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THEORETICAL AND PRACTICAL TREATISE
ON
MIDWIFERY,
INCLUDING THE
via
  loo
  Cr
 1874
DISEASES OF PREGNANCY AND PARTURITION.
       "\                  BY
                   P.  CAZEAUX,
Member of Vie  Imperial Academy of Medicine; Adjunct P-ofessor in the Faculty of Medicine of Paris;
    Oievalitr of the Legion of Honor; Correspondent of the Society of Accoucheurs of Berlin;
         President of the Medical Society of the Department of the Seine, etc., etc.
    ADOPTED BY THE SUPERIOR COUNCIL OF PUBLIC INSTRUCTION.

AMD PLACED, BY MINISTERIAL DECISION. IN THE RANK OP THE CLASSICAL WORKS
         DESIGNED FOR THE USE OF MIDWIFE STUDENTS, IN THE
                 MATERNITY HOSPITAL OF PARIS.
        REVISED  AND  ANNOTATED
                           BY            --^  •"''*'*
                  S.  TABNIBB,
Adjunct Professor in the Faculty of Medicine of Paris; Hospital Surgeon ; Former Clinical Chief of the
      Lying-in Hospital; Member of the Surgical Society, and of Ike Anatomical Society.
i

nxtlx %mt\\icmx Ji[om  tint Jimntlt  (Jfrwrit (Edition.
            BY
WM.  R. BULLOCK, M.D.
TOfe (tint $jam&xe& awl £mtttjj-ftM ptotftattoiw.
        PHILADELPHIA.
LINDSAY  AND  B L A K I S T 0 N.
                1874. 
00.
           Entered according to Act of Congress, in the year 1868, by
                  LINDSAY  AND  BLAKISTON,
in the Clerk's Office of the  District Court of the United States, in and for the Eastern
District of Pennsylvania.
CAXTON PRESS OF SHEB.MAN 4  CO. 
NOTE BY THE TRANSLATOR.
   The translation of the seventh and last French edition of
  Cazeauxs Midwifery is now offered to the Profession.
   Since the death of Prof. Cazeaux the work has  been revised
  and  edited by Prof. Tarnier, in whose preface will be  found
'  indicated  the many and important alterations and additions
  which it has undergone.
   The copious index  accompanying  the present  Americai)
  edition will, it  is hoped, be found of practical utility.
                                       W. R. BULLOCK
      Wilmington, Del.,
            May 18, 1868. 
 
PREFACE  TO  THE  SEVENTH  EDITION,
    THE  sixth edition  of this work was  almost exhausted, when its
    author, in the full  strength of years and talent, was suddenly struck
down by the disease which  very soon proved fatal.   In departing,
Cazeaux left a name beloved of physicians and students, and respected
by all.   The success of his work on obstetrics had greatly contributed
to extend his reputation and scientific authority.  Inasmuch, therefore,
as the stoppage of its publication would deprive the medical public of
a work which, for a long time, has justly been ranked first amongst
classical  books, both Cazeaux's family and his  editor concurred in the
opinion that a new edition ought to be published.
  A classical book soon grows old in these days, and it was found im-
possible to bring out a new edition without subjecting it to the  altera-
tions demanded by the progress of science.  I was charged with its pre-
paration, and accepted the honor of the task with a full appreciation of
its difficulties.  I had never been Cazeaux's pupil, but his book was the
first from which I had  studied obstetrics, and I  had been accustomed  to
see  it in the hands of all my fellow-students, and, at a later period,  of
my pupils also.  Independently, therefore,  of my personal  observa-
tion, I was in a position to become acquainted with its character through
others.   Thus, together with merited praise, I  sometimes also listened
to criticisms of its details, and profited by all  I heard.
  I was  left at liberty to remodel the work according to my judgment,
to make the alterations which seemed to be required, to suppress some
passages  and  to  introduce new ones.   Out  of respect to Cazeaux's
memory, it was decided that the printing should be done in two kinds
of type; the larger for the old  text, and  the smaller for what I had
myself written.
  The reader will  readily distinguish what  belongs  to Cazeaux and
what to  myself, but the work has been .resolved into a homogeneous
body without contradictory  annotations.  This last result could not
                                                         xi 
xi i
PREFACE.
possibly have been attained without retouching the old  text, by which
a new direction and meaning has been sometimes given  to the original
ideas.  Should it be desired to know certainly what Cazeaux's opinions
were, it will, therefore, be necessary to consult an old edition.
  Especially have I  made  it a duty not to change the  spirit in which
the work  had  been conceived;  therefore I can say with Cazeaux, that,
" After a work lias passed through several editions, a preface is hardly
needed, for  its object is  then  sufficiently well known.   The present is
more particularly intended  for the use of students of medicine and mid-
wife-students,  although general practitioners may also, perhaps, gain
something by its perusal, for I have endeavored to make it a condensed
summary  of the leading principles established by the masters of our
art, and for that purpose  have drawn  from all  the works published
down to the present day.  My position in the  lying-in hospitals has
enabled me to test  the  value of the  doctrines put forth  by former
authors; and I have adopted as true all which my daily experience has
confirmed, and have rejected unhesitatingly, from whatever source they
came, all such as were disproved by the numerous cases brought under
my observation, confining  myself  to quoting, without comment, those
whose value I have been unable to determine.
  11 Although  this work resembles, in its general arrangement, most of
those published on the  same subject in France, it  differs from them
essentially in the main; for I have adopted almost wholly the views of
Professors Nsegele, P. Dubois, and Stoltz, which are not found clearly
expressed in any of our classical books.  I  have also extracted freely
from the  learned treatise  of Professor  Velpeau, whose vast erudition
has  greatly  facilitated  my  bibliographical researches; from  the  course
of my former  teacher, Professor Moreau; from the excellent articles of
Desormeaux,  of  Pages, and of Guillemot; from  the  classical  works"
of England and America, such as those  of Burns, Campbell, Merriman
Ramsbotham,  Dewees, Meigs, and Rigby; and from the treatises of Peu
Delamotte,  Levret, Smellie,  Baudelocque, Gardien, and  Capuron.   I
have also consulted with advantage the manual recently published bv
my friend, Dr. Jacquemier; also, the memoirs of Simpson, Tyler Smith
Depaul, Devilliers, &c.  I may be permitted also to express publiclv
my thanks  to  M. Coste, for his great kindness in allowing me to study
his beautiful collection in the College of France, and to borrow several
figures from the magnificent work which he is now publishing  Lastly
it will  be seen how highly I value the  eminently practical writino-s of
Madame  Lachapelle.  In  a word,  I  have selected from  all sources 
PREFACE.
xiii
whatever bears the impress  jf truth.   In the sciences of observation, a
new work is necessarily enriched by the labors of all antecedent writers;
and therefore, its  greatest merit consists in collecting its scattered ma-
terials, and forming out of them a body of doctrine, which it illustrates
in the clearest and simplest  manner possible.  Such is the end  I  have
endeavored to attain;  and the medical public, and students especially,
must judge whether I have succeeded in the attempt.
   " But few quotations have  been made, though  their number might
have been greatly increased;  but I wished to avoid the charge  made
by most students against one of our best classical  works.  However, I
have felt bound to refer to  living authors whenever I have introduced
a new theory, or any particular procedure, which emanated from them;
and  besides, as  the professorate may be deemed a mode of publicity, I
have  respected  the  right to  the  original ideas which  I have heard
emitted by Professor Dubois; and his name  will be found scrupulously
associated with all the opinions emanating from him.
   " Notwithstanding a spurious copy published in Belgium, and several
translations into foreign  languages, the large editions of the work first
published were rapidly exhausted.   So favorable a reception made it
obligatory upon me to neglect nothing which could render this edition
worthy of the reputation of its predecessors.   I have, therefore, reviewed
and corrected all parts of it with scrupulous care."
   The plan of the present edition has been so greatly modified that it
may be regarded as altogether new, the order followed being that which
I  long since adopted  for my course of lectures, as the most natural and
the best.  The chapters are grouped  into eight principal parts.  Part
first is devoted to  the female organs of generation.  The pelvis is first
studied by describing separately each of its component parts, afterwards
considering them as  a whole, and pointing out carefully whatever  pecu-
liarities it may present as  to  form,  direction, and size ; then we pass
immediately to the anatomical description of the external and internal
organs of generation.  It will be seen that I have here profited by  M.
Sappey's recent researches in regard  to the structure of the ovary, and
those of Dr. Helie (of Nantes) in regard to the structure of the uterus.
The physiology of the genital organs is now so  intimately connected ,
with  their anatomical arrangement  that it is  impossible to describe
them fully without speaking "at the same -time of their functions.  The
phenomena which they exhibit at certain  periods are also very properly
regarded as the preludes of generation, making  their preliminary  study 
jdv
PREFACE.
indispensable to all who would  understand the changes which these
organs undergo during the puerperal condition.
  The genital apparatus of the female having been studied in the non-
pregnant condition, we examine, in the second part, those very numerous
and important changes which they undergo during gestation, and shall
often  have occasion to quote  the  many  works of Robin on  the uterine
mucous membrane,  the  decidua, and  the placenta.  AYe afterwards
study the first cause of all of these changes, to wit, the  foetus and  its
appendages, which are traced through the various stages of their devel-
opment.   From this examination we deduce the signs of pregnancy.
  Having acquired these  preliminary notions,  we are in a condition to
enter  upon the subject of labor in the third part of the work.  In the
process of parturition we distinguish two  orders of phenomena:  one
purely physiological and expressive of the vital action called  into play
in order to expel the foetus;  the  others, purely mechanical, and consti-
tuting the mechanism by which this expulsion takes place.
  We have given great latitude to the description, and especially to the
explanation of the mechanism of natural labor, and think that we have
succeeded in explaining certain  facts which, hitherto, had  only been
pointed out.  New views have  also  led  us to describe six  principal
stages in the mechanism of all  the  presentations.  After the  labor,
properly so called, comes the study of the delivery of the after-birth,
and of the puerperal state; this  part including afterward the subject
of the attentions to be given to the woman during and after labor, as
also an article devoted to apparent death of new-born children.
  I have also greatly extended the  pathology of pregnancy, to  which
the entire fourth part is devoted.  Chapters entirely new will be found
in it on the diseases of pregnancy, the alterations to which the placenta
is subject, and  the death of the child during intra-uterine life.   Thus
I hope that I have supplied an omission that was to be regretted.
  In  the fifth  part, which  is devoted  to difficult  labor, we treat in
detail of deformities of the pelvis and all other causes of dystocia  the
way in which each operates, their situation  in the mother, the child or
its appendages, the signs whereby their  presence  may be detected  the
indications which they present, and the  means of remedying them.   In
the study of the accidents which are  liable to complicate  labor, I have
profited  by all the works published of la'te years, and in the account
of hemorrhage, puerperal convulsions, and the indications which they
present, will be found  some new considerations.  To fill  up properly 
Missing pages
   XV- XVI 
 
TABLE  .OF  CONTENTS.
                        k  PART  I.

       OF THE  FEMALE ORGANS OF  GENERATION.
                                                                 PAGE
CHAPTER I. —Of the Pelvis,........33

    Article I. — Of the Bones of the Pelvis,.....      34
       g 1. The Sacrum,..........34
       g 2. Coccyx,..........      36
       g 3. Coxal Bones, or Ossa Innominata,......37
    Article II. — Articulations of the Pelvis,......39
       g 1. Articulation of the Pubis,.......40
       g 2. Sacro-Iliac Articulations,........41
       g 3. Sacro-Coccygeal Articulation,......42
       g 4. Sacro-Vertebral Symphysis,.......43
       g 5. Sub-Pubic Membrane,........     44
    Article III. — Of the Pelvis in general,......44
       g 1. External Surface,........44
       g 2. Internal Surface,.........44
       g 3. Superior Strait,.........47
       g 4. Inferior Strait,.........49
       g 5. Cavity of the Pelvis,........     51
       g 6. Base of the Pelvis,.........53
       g 7. Differences of the Pelvis,.......     53
       g 8. Uses of the Pelvis,.........54
    Article IV. — Of the Pelvis covered by the Soft Parts,    ...    54

 CHAPTER  II.—Of the External Organs of Generation,   ...    57

    Article I. — The Mons Veneris,.......      58
    Article II. — The Vulva,.......         .58
            Labia Majora,.........      58
            Labia Minora,..........59
        9                                                   xvii 
XV111
CONTENTS.
                                                                      PAGE
            Clitoris........             •      60
            Vestibule...........61
            Urethra,...........      61
            Hymen,...........02
            Carunculse Myrtiformes,     ....•••      63
            Fossa Naviculars,.........    63

    Article III. — Secretory Apparatus of the External Genital Organs,   .    64
            Sudoriparous Glands,.........      64
            Sebaceous Glands,.........64
            Mucous Glands,  .........      64
            Vulvo-Vaginal Gland,........65

    Article IV. — The Perineum,........    67

CHAPTER  III. — Internal Organs  of  Generation,     ....    68
    .Article I. — The Vagina,      ........      68
    Article II. — The Uterus,  .........    71
        g 1. External Surface of the Uterus,   ......      73
              Body of the Uterus,........73
              Neck of the Uterus,........74
        g 2. Internal Surface of the Uterus,     ......    76
              Cavity of the Body,........      76
              Cavity of the Neck,........77
        g 3. Structure of the Uterus,.......      78
              Peculiar Tissue,.........    78
              Peritoneal Membrane,     .......      78
              Mucous Membrane,    ........79
        g 4. Ligaments of the Uterus......._          82
              Broad Ligaments,     .     .         .....    82
               Bodies of Rosenmliller,   .......      82
               Round Ligaments,     ........    84

     Article III. — The Fallopian Tubes,.......85

     Article IV. — The Ovaries..........86
         g 1. Structure of the Ovaries,.......      88
         g 2. Ovarian Vesicles,.........90
         g 3. Human Ovule,   .........      90

 CHAPTER IV. — Ovulation and Menstruation,.....93
     Article I. — Modifications of the Ovarian Vesicles, ....      93
               The Corpus Luteum,.......         9g

     Article II. — Menstruation,.......#        103

 CHAPTER V. —The Breasts,........H5 
CONTENTS.                           XIX
                            PAET  II.

                         OF  PREGNANCY.

                                                                       PAGB
CHAPTER I. —Conception,.........119

CHAPTER II. — Changes in the Maternal  Organism, ....    125

    Article  I. — Changes in the Uterus......  .    .    .      125
        g 1.  Changes in the Body of the Uterus,    •.....125
        g 2.  Changes in the Neck,........130
        g 3.  Changes of Structure,    .         ......136
               1. Serous Layer,    ........      136
               2.  Mucous Layer,      .     .    .     .    .    .     .    .    137
               3.  Middle LayeK,    .              .....137
                   a. Mad. Boivin's Structure,  ......    138
                   b. Deville's  Structure,......139
                   c. M. Helie's Structure,......142
               4.  Vascular Apparatus,   .......      145
    Article  II. — Properties of the Uterus (Changes of),  ....    148
             Sensibility of  the Uterus,   .......      148
             Irritability,..........148
             Contractility,.........149
             Retractility,    ..........    151
    Article  III. — Changes in the Parts adjacent to the Uterus,      .    .    152
    Article  IV. — Changes in the Breasts,......155
    Article  V. — Anatomical and Functional Changes in some Parts not
           concerned in Generation,   ........    156
        g 1.  Digestion,..........157
        g 2.  Circulation,..........157
        g3.  Urine,...........160
            Kyesteine,     .         ........161
        g 4.  Osteophytes of the Cranial Bones,......166
        \ 5. Pigmentary Deposits,........166

CHAPTER III. —Of the  Decidua,........167
             Old Theory,.........167
            Present Theory,.........171

CHAPTER IV. — Of the Human  Ovum after Fecundation,  .     .    .    179
    Afticle I. — Changes which the Ovule undergoes in the Fallopian  Tube,    180
           Disappearance of the Germinal Vesicle,.....180 
 XX                             CONTENTS.

                                                                        PAG*
           Condensation of the Vitellus,......180
           Polar Globules,        .......         .180
           Vitelline Nucleus and Segmentation of the Vitellus,     .     .     181

     Article II. — Changes undergone by the Ovule  from the time of its
           Arrival in the Womb to the Formation of the Allantoid,   .    .   182

     Article III. — Of the Foetal Appendages,.....187
        g 1. The Allantoid Vesicle,        .......187
        g 2. Umbilical Vesicle,........188
        g 3. The Amnion,..........190
        g 4. Waters of the Amnion, (Liquor Amnii),    ....     191
        g 5. Chorion,...........192
     Article IV. — Organs of Connection,.......194
        g 1. Placenta,..........194
        g 2. Umbilical Cord,.........207

 CHAPTER V. —Of the Fostus,      .    .  »......210
     Article I. — The Foetus during Intra-Uterine Life,  ....     211
     Article II. — Head of the Foetus at Term,......217
     Article III. — Position and Attitude of the Foetus,    ....   222
     Article IV. — Functions of the Foetus,     ......   225
        g 1. Nutrition,..........     225
        g 2.  Respiration,..........229
        g 3. Circulation,..........231
        g 4. Innervation,   ..........    236
        g 5. Secretions,  ..........     236

CHAPTER VI. — Diagnosis of Pregnancy,......237
     Article I.—Rational Signs,.......          237
    Article II.—Sensible Signs,     ......             242
        g 1.  The Touch,..........     242
              Vaginal Touch,.......             243
              Anal Touch,     ••.....               245
              Ballottement,     •••...                  245
        g 2. Abdominal Palpation,......               r>^~
        g 3.  Active Motions of  the Foetus,......        250
        g 4.  Auscultation.........          050
              1.  Sounds of the Heart,     ......        253
              2.  Souffle of the Cord........257
              3.  Uterine Souffle.      .......        258

CHAPTER  VII.—Twin  Pregnancy,.......269 
CONTENTS.
XX]
                          PAET   III.

                              OF LABOR.

                                                                       PAGE
CHAPTER  I.— Causes of Natural  Labor,......276
        g 1.  Efficient Causes,.........276
        g 2.  Determining Causes,   '........    280

CHAPTER  II. — Physiological Phenomena of  Labor,     .     .    .      284
        g 1.  Pain and Contraction,........288
        g 2.  Dilatation of the Neck',.......292
        g 3.  Glairy Discharges,  .          .......293
        g 4.  Bag of Waters,.........294
        g 5.  Duration of Labor,.........297
        § 6-  Effect  of Labor upon the Mother and Child,     ...      300

CHAPTER  III. — Mechanical Phenomena of Labor,   ....    304
     Article I. — Presentations and Positions,......      304
     Article II. — Presentation of  the Vertex,   .."...   314
         § 1. Causes,..........314
         g 2. Diagnosis,..........315
         g 3. Mechanism,  ..........      317
         g 4. Inclined or Irregular  Presentation of the Vertex,  .     .    .   331
         g 5. Prognosis,..........331
     Article III. — Face Presentation,      .......   335
         g 1. Causes,..........335
         g 2. Diagnosis,..........336
         g 3. Mechanism,      .........      338
         g 4. Inclined or Irregular  Presentations,     .....   345
         g 5. Prognosis...........345
     Article IV.— Presentation of the Pelvic Extremity,   ....   347
         g 1. Causes,.........• .    .     349
         g 2.  Diagnosis,      ..........   349
         g 3. Mechanism,  ..........      351
         g 4. Prognosis,..........357
     Article V.— Presentation of  the Trunk,......361
         g 1. Causes,...........362
         g 2. Diagnosis,..........363
         g 3. Mechanism,  .....    .....     366
               Spontaneous Version,  ........   366
               Spontaneous Evolution,   .......     368
         g 4. Prognosis,...........371 
Xxil                          CONTENTS.

                                                                    PAGB
    Article VI. — Recapitulation of the Mechanism of Labor in general, .   371

CHAPTER IV —Twin Labor,.........375

CHAPTER V. — Premature and Retarded Labor,.....377
    Article I. — Premature Labor,    ........   377
    Article II. — Retarded Labor,........379

CHAPTER VI. — Natural  Delivery of the Placenta,      .     .    .   381

CHAPTER VII. — Attentions to the Woman and Child during Labor,   388

    Article I. — Attentions to the Woman during Labor,  ....   388
    Article II —Attentions to the Child during Labor,   ....   399

CHAPTER  VIII. — Attentions to the Woman and Child  immediately
        after Labor,...........   405
    Article I. — Attentions to the Woman immediately after Labor, .    .   405
    Article II. — Attentions to the Child immediately after Birth,   .    .   406
        g 1. When the Child is healthy.......406
        g 2. When ,the Child is weak or diseased,.....409

CHAPTER  IX. — Phenomena of the Lying-in State,   ....   421
        g 1. After-pains,..........429
        g 2. Lochia,...........431
        g 3. Secretion of  Milk,.........435

 CHAPTER  X.—Attentions to the Woman during her Lying-in,    .   439
                         PAET  IV.

                  PATHOLOGY OF PREGNANCY.

CHAPTER I. — Diseases  which may exist during Pregnancy,    .     .   443
        g 1.  Epidemic Diseases,  ........        443
              Grippe or Influenza,........     44,"!
              Cholera,..........44^
        g 2.  Endemic Diseases,........445
              Intermittent Fever,.......        44c
        g 3.  Eruptive Fevers,.......%          44Q
              Variola............44g 
CONTENTS.
XX111
                                                                        PAGE
              Scarlatina,.........   447
              Roseola,..........448
        3 4. Various Sporadic Diseases,    .......   448
              Typhoid Fever,.........448
              Pneumonia,  ..........   448
              Various Inflammations,   .......     449
              Icterus,..........449
              Syphilis,..........451
              Saturnine Intoxication,     .......   453
              Phthisis,..........453
              Hysteria, Epilepsy, Chlorosis,......455
        g 5. Surgical Affections,........455
        g 6. Hypertrophy of the Thyroid Gland,.....457
        g 7. Ulceration of the Neck of the Uterus......457

CHAPTER  II.— Diseases of Pregnancy,......46i

    Article I. — Lesions of Digestion,     .......463
        g 1. Anorexia,..........463
        g 2. Pica, Pyrosis,..........464
        g 3. Vomiting,   ..........464
              1. Simple Vomiting,........465
              2. Intractable Vomiting,.......467
              3. Treatment of Vomiting,  .......470
                     a. Medical Treatment.......470
                     b. Surgical Treatment,......474
        g 4. Constipation ; Diarrhoea,.......477
    Article II. — Lesions of Respiration,.......478
    Article III. — Lesions of Circulation,......479
        g 1. Plethora; Hydraemia,........479
        § 2. Hemorrhage,.........486
        g 3. Varicose  Veins; Hemorrhoids,     .     .    .    •          •   487
    Article IV. — Lesions of the Secretions and Excretions,    .     .     .   488
        g 1. Ptyalism,..........     488
        g 2. Excretion of Urine,      ....         ...   489
        g 3. Albuminuria; Uraemia,     ...         ...     490
        g 4. Dropsy of the Cellular Tissue........500
        g 5. Ascites,..........502
    Article V. — Lesions of Innervation,.......505
        g 1. Eclampsia,..........505
        g 2. Vertigo ;  Syncope,.........505
        g 3. Various Forms of Neuralgia;  Odontalgia.....507
        g 4. Paralysis,..........507
        g 5. Intellectual Disorders.   Mania,......510 
XXIV                           CONTENTS.

                                                                       PAGE
    Article VI. — Diseases of the Skin,  .         .....512
        g 1.  Itching,       ..........512
        g 2.  Pigmentary Spots.........513
    Article VII. — Lesions of the Pelvic Articulations,    .     .    .     .514
        g 1.  Relaxation of the Symphysis,......514
        g 2.  Inflammation of  the Symphysis,     ......   516
    Article VIII. — Diseases of the Vulva and Vagina,    ....   517
        g 1.  Pruritus of the Vulva,........517
        g 2.  Leucorrhcea,..........518
        g 3.  Vegetations,..........519
    Article  IX. — Abdominal and Uterine Pains,.....520
        g 1. Abdominal, Lumbar, and Inguinal Pains.....520
        g 2. Uterine Pains,..........522
        g 3. Rheumatism of the Uterus,.......524
    Article  X. — Displacements of the Uterus,......528
        g 1. Prolapsus,..........528
        g 2. Retroversion,..........532
        g 3. Anteversion...........539
        g 4. Lateral Obliquity..........541

CHAPTER  III. — Diseases of the  Oyum,.......541

    Article  I. — Dropsy,..........541
        g 1. Dropsy of the Amnion,     .......     541
        g 2. Hydrorrhcea,..........545
        g 3. Dropsy of the Villi.of the Chorion, (Hydatiform Mole,)    .     547
    Article  II. — Lesions of the Placental Villi,.....549
            Fibrous Obliteration,........550
    Article  III. — Effusions of Blood in the Placenta,      ....   552
            Placental Apoplexy,   .    .     .    .    .     .     .    . .    554

CHAPTER  IV. — Diseases and  Death of  the Fcstus,    ....   556
        g  1. Diseases of the Foetus, .         ......55g
        g 2. Death of  the Foetus,........553

CHAPTER  V. —Abortion,.........56C
    Article  I. — Causes,........,        5gj
        g 1.  Causes of Spontaneous Abortion,  ......     56]
        g 2. Causes of Accidental Abortion,......»ggg
        g 3. Causes of Induced Abortion,......gg-*
    Article  II.  — Symptoms  of Abortion........gg^
    Article  III. — Diagnosis,  ....              .    ,        57! 
CONTENTS.
XXV
                                                                      tage
    Article IV. — Delivery of the Placenta in Abortion,     .     .          575
    Article V. — Prognosis,.........578
    Article VI. — Treatment,........579

CHAPTER  VI. —Extra-Uterine Pregnancy,......585
            Pathological Anatomy,........591
            Symptoms,..........594
            Progress,...........596
            Causes,..........598
            Treatment,..........601
                           PAET   "V".

                               DYSTOCIA.

CHAPTER  1  -Deficient or Excessive Expulsive Power,  .     .    .   605

    Article I. — Tedious Labor,........605
        g 1. Feeble Contractions,    ........   607
        g 2. Lessening of Contractions,  .......     609
        g 3. Irregularity of Pains,   ........   611
        g 4. Effect of the Contraction of the Walls of the Abdomen,    .     612
    Article II. — Too Rapid Labor,  ........613

CHAPTER  II. — Deformities  of the Pelvis,......616
            Pelvis too Large,.........617
            Pelvis too Small,.........618
    Article I.—Pathological Anatomy,.......619
        g 1. Smallness without Deformity,......619
        g 2. Smallness with Deformity,.......620
    Article II. — Causes and Mode of Production,      ....     625
        g 1. Absolute Contraction,........626
        g 2. Rachitis,..........626
        g 3. Osteomalacia,..........629
        g 4. Oblique Oval Pelvis,........630
        g 5. Previous Deformity of another Part of the Skeleton,    .    .   634
              a. Inflection of  the Vertebral Column,    ....     635
              b. Congenital Luxations  of the Femur,     ....   635
              c Non-Congenital Luxations,......640
              r Lesions of the Lower  Extremities,.....640 
XXVI
CONTENTS.
Article III. — Effect of Deformity of the Pelvis  upon Pregnancy and
        Labor,..........,      641
Article IV. — Diagnosis of Deformities,......   649
    g 1. Rational Signs,.........649
    g 2. Sensible Signs,.........653
Article V. — Indications afforded by Deformities  of the Pelvis,     .     668
    g 1. Indications in  Pelves of 3| Inches at least,    ....   669
    g 2. Indications in  Pelves of from 3| Inches to 2f Inches,  .    .     671
    g 3. Indications in  Pelves below 2£  Inches,.....673
CHAPTER  III. —Bony Tumors,
        g 1. Exostoses,
        g 2. Enchondroma,
        g 3. Osteosteatoma,
        g 4. Osteo-sarcoma,  .
        g 5. Irregular Callus,  .
674
675
676
676
676
676
CHAPTER  IV. — Extreme Resistance of the External Genital Parts,   677
        g 1. Smallness and Rigidity of the Vulva,
        g 2. Rigidity of the Perineum,  ......
            Rupture of the Perineum,    .....

CHAPTER  V. — Deformities  of  the Vulya and Vagina,
        g 1. Adhesion of the Labia Majora and Minora,
        g 2. Persistence of.the Hymen,  ......
        g 3. Deformed  Cicatrices,      ......
        g 4. Deformities of the Vagina,.....
        g 5. Inversion of the Vagina,  ......

CHAPTER  VI. — Tumors of the Vulva and Vagina,
        g 1. QMema of the Labia  Majora,.....
        g2. Thrombus,'.........
        g 3. Various Tumors,    .......

CHAPTER  VII. — Difficulties due to the  Neck of the Uterus,
        g 1.- Agglutination of the External Orifice,
        g 2. Complete Obliteration of the Cervix,
        g 3. Rigidity of the Cervix,   ....
        g 4. Spasmodic Contraction of the Cervix,  .
        g 5. Obliquity  of the Orifice,  ....
        g 6. Tumefaction of the Anterior Lip,
        g 7. Abscess of the Lips of the Cervix,  .
        g 8. Thrombus of the Lips of the Cervix,   .
        g 9. Fibrous Tumors and  Polypi of the Cervix,
677
678
680

681
681
681
681
683
685

686
686
686
695

696
696
697
698
699
702
703
704
705
7oe 
CONTENTS.
XXV11
g 10. Fungous Tumors of the Cervix,  .
g 11. Encysted Tumors of the Cervix,  .
g 12. Induration and Hypertrophy of the Cervix,
g 13. Cancer of the Cervix,
CHAPTER  VIII. — Difficulties  due to the Body  of  the Uterus,
§1.
§2.
§3.
Obliquity of the Uterus,  .
  1.  Anterior Obliquity,
  2.  Posterior Obliquity, .
  3.  Lateral Obliquity,
  4.  Treatment of Obliquity,
Hernia of the Womb,  .
Prolapsus of the Womb,
        g 4. Tumors of the Body of the Womb,.....

CHAPTER  IX. — Tumoks of the Parts adjacent to the Pelvic Canal
          and  of the Cellular Tissue of the Cavity of the  Pelvis,
        g 1. Tumors of the Ovary,.......
        g 2. Tumors of the Fallopian Tube,     ....
        g 3. Tumors of the Rectum,.....
        g 4. Tumors of the Bladder,......
        g 5. Hernial Tumors,  .......
        g 6. Tumors of the Cellular Tissue,      ....


CHAPTER  X. — Rupture of the Uterus and Vagina,   .

    Article I. — Rupture of the Uterus,.....
        g  1. Causes,.........
        g  2. Symptoms,     ........
        g  3. Prognosis and Termination,      ....
        g  4. Pathological Anatomy,   ......
        g  5. Treatment,........
    Article II. — Rupture of the Vagina, .    .    .     .    .
PAGE
 710
 710
 711
 711

 713
 713
 713
 714
 718
 718
 719
 720
 72]
 723
 723
 725
 725
 72G
 728
 731

 732
 732
 733
 737
 739
 741
743
745
CHAPTER  XI. — Puerperal Hemorrhage,

    Article I. — Causes of Puerperal Hemorrhage,
        g 1. Predisposing Causes,   ...
        g 2. Determining Causes,
        g 3. Special Causes,    .
              Abnormal Insertion of the Placenta,
              Rupture of  the Vessels of the Cord,
              Rapid Retraction of the Uterus,  .
747
748
748
753
754
754
758
762
Article II. — Symptoms of Puerperal Hemorrhage, .
r63 
 xxviii                        CONTENTS.

                                                                      PAGB
    Article  III.—Diagnosis,.........   765
        a. External Discharge,     ......         .      765
            Hemorrhage from Abnormal Insertion of the Placenta,  .    .   766
            Hemorrhage from Rupture of the Umbilical Vessels,  .    .      768
        B. Internal Hemorrhage,     ........   769
    Article IV. — Prognosis,   .........    770
            Prognosis of External and Internal Hemorrhage,     .    .      770
            Prognosis of Hemorrhage from  Abnormal  Insertion of the
              Placenta,..........773
    Article V. — Treatment,   .........   775
        g 1. General  Therapeutic Measures,    ......      776
        g 2. Special Therapeutic Measures,     ......   776
              a. Slight Hemorrhage within the three last Months of Ges-
                  tation,  .......    ...    776
              b. Serious Hemorrhage within the three last Months of Ges-
                  tation,  ..........777
              c. Slight Hemorrhage during Labor,    ....      783
              d. Serious Hemorrhage during Labor, .....    783
        g 3. Treatment of Hemorrhage from  Abnormal  Insertion of the
              Placenta,  ..........      785
        g 4. Recapitulation of Treatment........    786

CHAPTER XII.—Eclampsia,.........78s
        g 1. Causes,...........791
        g 2. Symptoms,       .........796
        g 3. Termination,   ..........    802
        g 4. Diagnosis,   ..........      804
        g 5. Prognosis,..........805
        g 6. Pathological Anatomy,     .......      808
        g 7. Nature,...........810
        g 8. Treatment,   ..........      812
              1. Preventive Treatment,   .......    812
              2. Curative Treatment,   .......      814

CHAPTER XIII. — Diseases which may Complicate Labor,  .    .    .    824
            Hemoptysis ; Hematemesis, .......      824
            Aneurismal Tumors,     .......        825
            Asthma,     .........    #      825
            Hernia,...........g25
            Syncope...........    .      82g
            Exhaustion,    .........        g2g
            Emphysema,     .........827
            Fracture of the Sternum,     ••••..        828

CHAPTER XIV.—Dystocia due to the Fostal Appendages,     .        go^ 
CONTENTS.
xxix
    Article I.—Prolapsus, or Falling of the Cord,
    Article II. — Shortness of the Cord,

CHAPTER XV. — Difficulty due  to the Fcetus,
    Article I. — Extreme Size,    .
             Too  Great General Size,   .
             Too  Great Size of the Head,
             Too Great Size of the Shoulders,
PAGE
 828
 834
839
839
839
839
839
Article  II. — Irregular or  Complicated Presentations and  Positions:
         Anomalies in the Mechanism of Labor,.....
         Inclined Positions of the Vertex:  Irregularities of Mechanism,
         Inclined Positions of the Pelvis:  Irregularities of Mechanism,
         Inclined Positions of the Face: Irregularities of Mechanism,
         Presentation of the Body,.....
    21..
    2 2.
    2 3.
    H-
    §5.
Article
    21-
    2 2.
    2 3.
    2 4.
    2 5.
Article
Article
    21.
    2 2.
Complicated Presentations......
III. — Diseases of the Foetus,      ....
Hydrocephalus,......
Hydrothorax ; Ascites ;  Retention of Urine,   .
Emphysema of the Foetus,   ......
Various Tumors,.......
Anchylosis of Articulations of the Foetus:  Gibbosities,
IV. — Foetal Monstrosities,.....
V. — Dystocia due to Multiple Foetuses,  .
Multiple and Detached Foetuses, .     .     .     .    .
Multiple and Adherent Foetuses,    ....
CHAPTER  XVI. — Artificial  Delivery of the Placenta,
    Article I.—Difficulties in the Delivery of  the Placenta,  .
        g 1.  Inertia of the Womb,     .         .
        g 2.  Extreme Size of the Placenta.....
        g 3.  Weakness of the Cord,......
        g 4.  Irregular or  Spasmodic  Contractions of the Womb,
        g 5. Abnormal  Adhesions,......
        g 6.  Retention of a Part or of the Whole of the Placenta,
    Article II. — Accidents in the Delivery of the Placenta,
        g 1.  Hemorrhage,    ......
               a.'  Causes,.......
               B.  Symptoms,  ......
               c.  Diagnosis,      ......
               D.  Prognosis,  ......
               e.  Treatment,......
        g 2.  Secondary Hemorrhage,    ....
        g 3. Hemorrhage from the Umbilical Cord, 
A.X.X                          CONTENTS.

                                                                     PAGE
        g 4. Inversion of the Womb,......          902
        g 5. Rupture of the Womb,........906
        g 6. Eclampsia...........906
                          PAET   VL
                          THERAPEUTICS.
CHAPTER I. —Ergot,..........907
CHAPTER II. — Of  the Effect of Bleeding and  a Debilitating Regi-
        men upon the Development of the Child,.....911
                         PAET   VII.

                   OBSTETRICAL OPERATIONS.

CHAPTER I. — On the Use of Anaesthetics in Obstetric Practice,   .   915

CHAPTER II. — The Tampon,........927

CHAPTER III. —Version,.........929
    Article I. — Version by External Manipulation.....930
    Article II. — Pelvic Version,........93g
        g 1. Precautions to be Observed, .......     937
        g 2. Needful Conditions,.........938
        g 3. General Rules of the Operation,......939
        g 4. Difficulties of Version,........945
        g 5. Appreciation of  Version,.......952
        g 6. Version in the Various Presentations,    .....   953

CHAPTER IV. — The  Forceps,.........959
    Article I. — Preliminary Precautions,   ......     954
    Article II. — General Rules,.......m   ggg
    Article III. — Special Rules,  .......#     971
        g 1. When the Head  is at the Inferior Strait,      ...        gyi
        g 2. When the Head is at the Superior Strait,   ....     977
        g 3. When the Head  is above the Superior Strait,  .    .     #        970
        g 4. Application of the Forceps in Face Positions,    .     .    #     gog
        g 5. Application of the Forceps  upon the  Head after the Body is
             Delivered,   .........        ggg
        g 6. General Considerations upon the Use of  the Forceps,  .          935 
CONTENTS.
XXXI
CHAPTER  V. — The Lever, or Vectis,.....            995
CHAPTER  VI. — Premature Artificial Delivery,    ....    1000
    Article I. —Cases requiring Premature Delivery,    ....  1002
    Article II. —Modes of Operating,  .......    1007
        a. External Stimulation of the Body of the Womb,     .    .     .  1008
        b. Stimulation of the Periphery of the Os Tincse,     .    .     .    1009
        c. Dilatation of the Cervix,        .......101]
        D. Irritants introduced between  the Walls of the Uterus and  the
            0vum............1015
        e. Puncture of the Membranes,.......1019
          Appreciation,..........1021
CHAPTER VII. — Production of Abortion,......1022.
CHAPTER VIII. — Symphyseotomy,.......1025
CHAPTER IX. — Cesarean Operation,.......1030
        g 1.  Caesarean Operation on the Living Female, ....    1031
        g 2.  Caesarean Operation post-mortem.......1038
CHAPTER X. —Embryotomy,........1040
    Article I. — Craniotomy,.........1040
    Article II. — Cephalotripsy,........1045
    Article  III. — Section of the Neck and of the  Body,  ....  1058
                        PAET VIII.
 HYGIENE  OF  CHILDREN FROM  BIRTH  TO  THE  PERIOD
                           OF  WEANING.
CHAPTER I. —Lactation,.........1062
CHAPTER II. —Nursixg  of Children.......1069
    Article T. — Nursing by the Mother,.......1069
    Article II.--Weaning,   .........    1080
    Article III. — Regimen of Nursing Women,     .....  1082
    Article IV. — Difficulties and Accidents of Maternal Nursing,     .    1083
    Article V. — Mixed Nursing.........1093
    Article VI. — Nursing by a Nurse.......    .    1095
    Article VII. — Nursing by a Female Animal,.....1102
    Article VIII. — Artificial Nursing,  .             ....    1103
CHAPTER III. —General Hygiene of Children,.....1104 
\ 
A
TREATISE   ON  MIDWIFERY,
                         PAET  I.

        OF  THE  FEMALE OKGANS OF GENERATION.

   THE  female organs subservient to generation are:  the ovaries, the prin-
    cipal function of which is the secretion of the ovule or female germ;
the Fallopian tubes, designed to receive the ovule, and conduct it into the
cavity of the uterus; the uterus, a kind of receptacle, whose office it is to
contain  the fecundated  germ  during its period  of development, and to
expel  it immediately afterward; finally, the vagina, a membranous canal
extending from the neck of the uterus to the external genital parts.  Most
of these organs are situated within a large cavity, the walls of which are
composed of  bones  and soft parts; the cavity is  termed  the cavity of the
pelvis, or pelvic cavity. On account of the importance  of the pelvis as an
organ both of protection and transmission, we shall, with it, begin the study
of the organs of generation.
                        CHAPTER  I.

                         Or THE PELVIS.                      ,

  The basin, in  Latin, pelvis, is a large, irregular, bony cavity, a sort of
curved canal, which  terminates the trunk inferiorly, and sustains it by its
posterior  part.  It is placed  directly upon the lower extremities, which
afford it points of support, and to which, in the -erect posture, it transmits
the weight of the upper portions of the body.  Its position in an adult of
ordinary stature is, in general, about the central part of the whole  trunk.
In the infant at term, and  more especially during the intra-uterine life, it
is much below this point; and at a certain period of foetal existence, when
the  lower  extremities resemble as yet but little nipples, it even occupies
the inferior portion of the body.  Especially should the accoucheur study
      8                                                 33 
34
FEMALE  ORGANS  OF  GENERATION.
the pelvis in its totality and in its relations with  the great function which
it subserves.   Now as the best way of understanding a whole is to decom-
pose it, and study separately its constituent parts, we shall proceed at once
to consider individually the bones which enter into the composition of the
pelvis.

                          AKTICLE  I.

                        BONES  OF THE PELVIS.

  The bones which together constitute the  pelvis are:  the sacrum, ami the
coccyx, both placed behind and on the median line, and the ossa innominata
or coxal bones.  These last are  in pairs, being situated at the sides  and
articulating with each other in front.

  § 1. Or  the Sacrum.
  This is a symmetrical, triangular bone, which is curved forward at its
lower part, and is placed at the posterior part of the pelvis, where it appears
like a wedge, forced in between the two ossa innominata, immediately below
the vertebral column, and directly above the coccyx.   It is traversed longi-
tudinally by the sacral  canal (a continuation of the vertebral canal), and,
relatively to the axis of the  body, it is  directed from  above downwards,
and from before  backwards; hence the column represented by it forms an
obtuse angle with the lumbar vertebrae, being salient  in front, and receding
behind.   This point is  called the promontory,  or the sacro-vertebral angle.
Besides  this direction, the sacrum is curved upon itself from behind for-
wards, so as to present  an anterior concavity,  'the hollow of the sacrum:
this curvature is generally much  more marked in the female than in the
male.
  Anatomists  describe the bone as having two faces, two  borders, a base,
and an apex.
  1. The spinal,  or posterior face,  is convex, rough, and very irregular, pre-
senting on the median line three, four, or five prominences, the  longest of
which are  above, and continuous with  the ridge formed by the series of
spinous processes of the vertebrae;  lower down, the sacral canal is terminated
as a triangular gutter, being bounded laterally  by two tubercles, called the
comua of the  sacrum; upon  each side of,  and  close to the median  line a
large  furrow  exists,  at  the  bottom of  which  the  four  posterior  sacral
foramina are  seen, communicating  with  the vertebral canal,  and serving
to transmit the  nerves of the same  name.   Outside of these foramina Ave
find a series of elevations, apparently analogous to the transverse processes
of the vertebrae; and above them two irregular fossae, into which the pos-
terior sacro-iliac  ligaments are inserted.
  2. The pelvic,  or anterior face, is  smooth  and concave, and  is traversed
by four  prominent  transverse lines, the  remnants of the sutures  between
the different pieces that  composed the bone in early infancy,  and which
served to  separate some superficial, transverse, and  quadrilateral grooves
found there, from each other.  Sometimes the first of these prominent lines 
OF  THE  PELVIS.
35
is  so well marked  as to be mistaken, when practising the  touch, for the
Bacro-vertebral angle.
   The anterior sacral foramina, four in number, are found nearer the lateral
margins;  they communicate with the sacral canal, and transmit the anterior
branches  of the nerves of the same name.  Beyond the foramina  is an
unequal surface for the attachment of the pyramidal muscles.
   3. The borders of the sacrum may be divided into two portions.  1. The
superior,  being very thick,  presents, on  its  anterior half, a  semilunar
articular  facet  for joining with the coxal  bone, and on its  posterior part
an excavation, and some rough projections for the attachment of the  sacro-
iliac  ligaments. The  other,  or  inferior  portion,  is quite  thin, and is
occupied by the insertion of the sacro-sciatic ligaments.
   4. The base is directed upwardly and a little  in front, and has its greatest
diameter  transversely.  An oval  facet, more or less inclined backwards,
surmounts it at the middle, whereby the bone  is articulated with the  last
lumbar vertebra.  Upon  each side is seen a smooth  surface, which is con-
cave  transversely,  and  convex from  before  backwards.  These surfaces
incline forwards and are  continuous with the iliac foss?e, being covered, in
the recent  subject, by the  anterior sacro-iliac  ligaments.  They are sepa-
rated  from the anterior face of the  sacrum by a rounded  border,  which
forms, as  we shall  hereafter learn, the posterior part of the superior  strait.
The two  surfaces  constitute  the icings of the sacrum.  Behind,  are  found
the upper orifice of the sacral canal, and the two articular processes of the
first piece of the sacrum.
   5. The apex  of  the sacrum is directed  downwards,  and  a little  back-
wards ; presenting  an oval facet for the articulation of the coccyx.
   6. The sacral canal, hollowed out  in the thickness of the  bone,  is the
termination of the  vertebral canal; being triangular and broad superiorly,
it  becomes  narrow and  flattened  at its inferior  part, where it degenerates
into a gutter, that  is  converted into a canal  by  the ligaments.  This lodges
the sacral nerves, and communicates  both with the anterior  and the  pos-
terior  sacral foramina.
                Fig. 1.                                Fio. 2.
                B     B
/!#^#

        Anterior surface of tho sacrum.                Posterior surface of the sacrum.
  Fio. 1.  A. Ala or wings of the sacrum. B. Articular processes.  C Anterior sacral foramina.  E. Point!
of attachment of the right pyramidal muscle.
  Fio 2.  A. ltidge formed by the spinous processes. B. Posterior sacral foramina. D. Articular processor

  The sacrum, although  quite  thick, is a very  light and spongy bone.
Besides, it  is pierced  by a great number of foramina, and  traversed by a
central cavity,  which serve to diminish its weight  still more. 
36
FEMALE  ORGANS  OF  GENERATION.
   It is formed of five principal pieces (false sacral vertebrae), sometimes of
six, and in  one  case, seven  were  observed (Pauw).  In Scemmering'a
cabinet are three specimens which present but four pieces.
   The development of the sacrum is analogous to that of the vertebrae, and
takes place from thirty-four or thirty-five points of ossification, arranged in
the following manner:
   1. Five  of  them,  placed one  over the other, occupy the  anterior and
middle  parts.  2.  In  each of the interspaces which  separate these, two
small osseous laminae are developed  some time  after birth, which  seem to
form  their articular surfaces.  3. Ten are situated in front and upon each
side of the latter, that is, one  for each lateral  portion of the four or five
primitive bones.   4. And  behind them six others are developed, between
which:  5. There appear three or four that  correspond Avith  the  spinous
processes, or their laminae;  and 6. Lastly, there is one upon each side above
the iliac surface, for the articular facet.

  § 2. The Coccyx.
  This  name  is given  to an assemblage of three or four, occasionally five
little bones, united with each other  on  the median  line of the body, and
apparently suspended  at the point of the saorum, of which, indeed, they
appear  to be only a movable appendage,  continuing its line of curvature
forwards.
                Fig. 3.                                Fig. 4.
                  A.                                  A
        Posterior surface of the coccyx.               Anterior surface of the coccyx.
    Fig. 3.  A. Cornua of the coccyx. B. Apex.     Fig. 4.  A. Cornua of the coccyx.  B. Apex.

  M. Cruveilhier declares that he has known it, in some cases, to form a
right angle or even an acute one with the sacrum.  As a whole, the coccyx
represents a triangular and symmetrical bone.
  1. Its spinal, or posterior face, is convex and irregular, and is only
separated from the skin by the posterior sacro-coccygeal ligament.
  2. Its pelvic,  or anterior face, is smooth  and slightly concave, and  lies in
contact with the termination of the rectum, which rests upon it.   Like  the
preceding bone, it is marked by certain transverse grooves, corresponding
with the intervals which had, for a long period, separated its different  pieces
  3. Its two lateral borders are quite irregular, and  are occupied  by  the
attachments of the anterior sacro-sciatic ligaments, and the ischio-coccyp-e-il
muscles.
  4.  Its slightly  concave  base  presents, above, an  oval surface  which
articulates with the apex  of the  sacrum, and  behind, two little tubercles
called the cornua of the coccyx.
  5. The apex is rounded, irregular, and sometimes bifurcated, affording
attachment to the levator ani muscle.
  The coccyx is developed from four or five centres of ossification that is
one for each of its parts. 
OF THE  PELVIS.
37
  § 3.  The Cox at. Bone, Haunch Bone, or Os Ixxomixatum.
  Tliis  is a non-symmetrical, quadrilateral bone, curved upon itself, as if
twisted  in two  different directions, contracted in its middle, and of a very
irregular  figure.  The pair occupy the lateral  and anterior parts of the
pelvis.  It  presents an internal and  external  face, and four  borders, for
our consideration.
  1. The external, or femoral surface,  is turned  outwards, backwards, and
downwards, at its superior part, while  inferiorly, it looks forward.
  At its  superior and posterior portion is  seen  an unequal, narrow, and
convex surface, affording origin to the gluteus  maximus muscle, and ter-
minated below by a slightly elevated circular  ridge, called the superior
curved  line.   Beneath  this, there is  a larger  surface, which  is concave
behind, narrowed in front for the  insertion of the gluteus  medius  muscle,
and bounded by a slight ridge below, called the inferior curved line; still
lower, there is a third extensive and convex  surface, serving for the attach-
ment of the gluteus minimus muscle.  All that portion of the femoral face
just described forms a large fossa, alternately concave  and convex, bearing
the name of the external iliac fossa.
  Towards the front, the external face presents the cotyloid cavity or the
acetabulum, at its superior part; and  a little more in  advance and below,
the  sub-pubic,  or obturator foramen.   This opening  is  triangular, with
rounded angles; its long diameter  is inclined  downwards and  outwards,
and its circumference  is sharp and irregular,  presenting above a groove,
directed obliquely from behind forwards and from Avithout inwards, through
which the obturator vessels and nerves pass out.   A fibrous membrane that
subtends  the foramen is attached to its periphery, except in the immediate
vicinity of the groove.
  Upon the upper side of the obturator foramen, between it and the median
line, there is a concave or nearly plane  surface for the  origin of several
muscles.
                                  Fig. 5.
                       External surface of the os innominatum.
 A External iliac fossa. B. Crest of the ilium. C Anterior superior spine of the ilium.  1). A iterior in-
r.Tior spine of tho ilium.  E. Horizontal branch of the pubis.  F. Posterior superior spine of the ilium,
B. Posterior Inferior spine of the ilium. II. Cotyloid cavity. I. Ischium.  K. Sub-pubic or obturator foramen.
M. Ischio-pubic ramus.  0. Descending branch of the pubis.
       •1 
38
FEMALE  ORGANS  OF  GENERATION.
Fig. 6.
   2. The abdominal, or internal face, is directed forwards at its upper part,
and backwards at  the  lower.   It may be divided into two  portions, the
superior of which is characterized by a large excavation, called the internal
iliac fossa, by a semilunar  articular surface found just behind this fossa,
and called the auricular facet, and still  more posteriorly, by some rugosities,
analogous to those found on the articular faces of the sacrum.
   The superior portion is  terminated below by a  large, rounded,  and con-
cave line, which separates it from the other moiety.  The latter, or inferior
portion,  presents  behind a nearly triangular plane surface,  which  corre-
sponds  to the  cotyloid  cavity  and  to  the body of the ischium;  near its
middle, we find the  obturator  foramen, and  in front, the internal face of
the pubis and of the ischio-pubic ramus.
                                   3. Borders.   These  are four in number.
                                 The  posterior  one  has a very  irregular
                                 shape,  being  oblique  from  above  down-
                                 wards, and  from  without inwards.  The
                                 posterior superior spinous process is found
                                 at its junction with the  superior border.
                                 This prominent, well-marked eminence is
                                 separated by a rough margin from another
                                 though  less voluminous one, called the
                                 posterior inferior spinous process.
                                   Below this  last apophysis, the student
                                 will observe a very deep notch, which con-
                                 tributes to the formation of the great sciatic
                                 foramen, and  is  terminated  below by a
                                 triangular, pointed projection, bearing the
                                 title of the spine of the ischium.   This pro-
                                 cess is more or less prominent in different
                                 individuals, and is sometimes directed in-
                                 wards.  A groove is seen just beneath it,
                                 in which the tendon of the  obturator in-
                                 ternus muscle plays; this groove is a part
                                 of the lesser sciatic notch; and lastly, this
border terminates at the tuberosity of the ischium.
   The anterior border is concave, oblique above, and  nearly horizontal in
front.  The anterior superior spinous process is formed by its union with the
superior border.  A considerable depression  exists under this apophysis
which  separates  it  from another one, called  the anterior inferior spinous
process.  Then we find a groove just under this elevation, for the gliding
of the conjoint tendon of the psoas magnus and the iliacus internus muscles*-
which groove is bounded, in front and below,  by the ilio-pectineal eminence.
And lastly, the border is  terminated by  a triangular  horizontal surface'
which is directed  downwards and forwards, and is broader externally than
internally, and by the spine and angle of the pubis.
   The superior border  or  crest of the ilium is thick, convex,  and inclined
outwards, excepting at its posterior part, where it looks slightly inwards__
Internal surface of the right os innominatum.
  A. Internal iliac fossa. B. Anterior superior
spinous process of the ilium. C Crest of the
ilium.  D. Posterior superior spinous process
of the ilium.  K. Posterior inferior spinous
process of the  ilium.  F. Articular surface.
G. Spine of the ischium. II. Tuberosity of the
ischium. I.  Sub-pubic or obturator foramen.
K. Ischio-pubic ramus.   M.  Ilio-Tpectineal
eminence. N. Spine of the pubis. 
OF THE  PELVIS.
39
 being twisted, in its course, somewhat like an  italic/.   Anatomists have
 subdivided it into the external and internal lips, and the intervening space.
 The anterior superior spinous process  bounds it in front, and the posterior
 superior one behind.
   The inferior border is shorter than either of the others; it presents, how-
 ever, three parts for study.  There is an oval  surface above, for articulating
 with its fellow of the opposite side, forming the symphysis; below, it is
 terminated by the tuberosity of the ischium, and in the middle, we find  the
 ischio-pubic ramus;  this is a sharp ridge, formed superiorly by the descend-
 ing branch of the  pubis, and inferiorly by  the ascending portion of  the
 ischium.
   The coxal  bone is developed from  the principal centres of ossification,
 which appear at  the same time  in the iliac  fossa, the tuberosity of  the
 ischium, and  in the pubis.   Owing to this  mode of  growth, it  has been
 customary to  divide the  os innominatum into three  portions: the superior
 one, styled the ilium, forms, in a great measure, the contour and prominence
 of the hip;  the pubis, beings interior, supports the genital organs; and  the
 inferior  one, which sustains the body when seated, is named the ischium.
   Several years after birth,  an osseous lamina  resting upon the superior
 border of the bone, is developed to form  the iliac  crest, whilst a similar
 layer embraces  the tuberosity of the ischium, and extends to its ramus; at
 the same time, a third centre of ossification appears for the anterior inferior
 spinous  process  of the ilium, and a fourth forms  the angle of the pubis.


                            ARTICLE   II.

                     ARTICULATIONS OF THE PELVIS.

   [The four bones just described are united by four articulations peculiar to  the
 pelvis; one in front for the  two pubic bones, two behind for the iliac bones and  the
 sacrum,  and that of  the coccyx with  the  sacrum.  All these articulations  are
 usually termed symphyses ;  thus the articulation of the two pubic bones is styled  the
 pubic symphysis, the junction of  the iliac bone with the sacrum is called the sacro-
 iliac symphysis, and the connection of the sacrum and coccyx the sacro-coccygeal
 symphysis.
  It should be  observed, however, that  the  symphyses or amphiarthroses  are
 characterized by flat  articular surfaces, united by a layer of fibrous  tissue  which
 allows a bending  motion without any sliding of the  bones upon each other.   Now
 this  sliding motion exists in the pelvic articulations of the female.  It is, there-
 fore, a  mistake to classify them amongst the amphiarthroses, and only by an abuse
 of language can they continue to  be called symphyses.  Lenoir's  researches prove
 that some anatomists were  near  the  truth in considering them as arthrodia.  In
 twenty-two female subjects between the ages of eighteen  and thirty-five  years,
Lenoir  found that the four  pelvic articulations are  formed by the contact of sur-
faces covered with cartilage and lined  with synovial membranes ; they present,
therefore, all the characteristics of arthrodia, and have a simple, sliding motion.
  To the four articulations proper, of the pelvis, it  is well to add in this connection.
the articulation of the sacrum with the spinal column.  Here we have really one
of the amphiarthroses  or symphyses.
  The description of the sub-pubic ligament completes the history of the liga-
mentous connections of the pelvis.J 
40
FEMALE  ORGANS  OF  GENERATION.
   § 1.  Articulation of  the  Pubis.
   This articulation  is formed by the approximation of the oval surfaces
 occupying the upper part of the lower border of the coxal bones.  These
 surfaces are slightly convex and unequal, and are covered with a cartila-
 ginous lamina which fills up the inequalities.  The convex  shape and  the
 direction of their faces are such, that they only come into contact for an
 inconsiderable extent at their internal or posterior part, and hence they
 leave  above, in front, and  below, an open  space, which is  the more con-
 siderable, in proportion to the distance from the centre of  the joint.  The
 articulating surface of the two cartilages is a little facet, about six or eight
 lines in its vertical diameter, by two or three in its  transverse one.  This
 facet is smooth, and  furnished  with a synovial  membrane, which  is  the
 more lubricated with synovia as the female approaches the period of labor.
 A considerable thickness of the interpubic ligament fills  up the interval
 which exists between the other points of these articular surfaces.
   This interpubic ligament is formed of a very dense fibrous  substance.  It
 has the form of a wedge, with the point forced down between the bones and
 the sides adhering to the rough  surfaces  fronting the articulation.  Two
 planes of fibres are discoverable in it; the  deeper ones, which pass from one
 iliac bone to the other, and  are  shorter in proportion to their depth, are
 crossed, and disposed in several layers.   They constitute the interpubic liga-
 ment  properly so called.   The  others, which  are  more  superficial, are
 parallel, and pass obliquely from within outwards  and from above down-
 wards.  Beginning at the upper part of  the articulation they spread  in
 descending, until they are finally divided into two bundles,  which become
 lost in front of the branches of the pubic arch by mingling with the peri-
 osteum of the bones and the tendons of the muscles inserted  in  the vicinity.
 These form the anterior pubic ligament.
   The uppermost portion of the  anterior pubic  ligament seems to take  its
 origin in the fibrous  cord which is inserted on the spine of  the pubis, and
 which cushions, so to speak, the upper edge of that bone, in  such a way as
 to efface its inequalities.   It constitutes the superior pubic ligament.
  Lastly, at its lowest part,, the anterior pubic  ligament  assumes the form
 of a thick triangular bundle occupying the summit of the pubic arch and
fixed by its lateral edges to the upper and internal part of the two branches
thereof.  This  ligament, called the triangular, or sub-pubic ligament pre-
Fio. 8.
Hori rontal section through the articulation of thepubis.   Posterior view of the articulation of the
 Fio. 7.  A. Synovial membrane. B. Articular cartilages. C Inter-pubic ligament. D. Section of t
 Fia. 8.  A. Posterior projecting pad.  B. Sub-pubic ligament.  C. Section of horizontal branch
D. Section of ischio-pubic ramus.
 
OF  THE  PELVIS.
41
Bents a rounded base, which completes the arch of the pubes by giving it a
regular curve calculated to facilitate the exit of the foetus.
  Thus, we have three anterior pubic ligaments, a  superior pubic  and a
Bub-pubic ligament, all of them representing a spreading out of the inter-
osseous ligament.   Behind the symphysis, the fibro-cartilaginous substance
forms a sort of projecting  pad, which occupies the middle part only, and
disappears from above downwards.
  Finally, the ligamentous  arrangement of the  articulation is completed
by the posterior pubic ligament, composed of fibres extending transversely
from one pubis to the other, above the projection just noticed.   This liga-
ment, which  is very thin, and of  moderate strength, forms the posterior
lining'of the synovial membrane.

  § 2. Sacro-iliac Articulations.
  This articulation is formed by the junction of the semilunar facets, which
were pointed out in describing the border of the sacrum  and the internal
face of the ossa ilia.
  Both these facets are  covered  with a diarthrodial  cartilage, which is
closely adapted to the inequalities they present; that, however, which per-
tains to the sacrum,  being  always  much  thicker  than the layer which
belongs to the iliac bones.  The latter is so thin, that its existence has been
denied.  These cartilages are covered with a synovial  membrane, which
secretes  quite  abundantly a viscid  and transparent  synovia.  But, when
the female has passed the  prime of life,  this fluid  often  concretes, and
becomes disposed  in isolated flakes  upon the articular  surfaces, — a fact
which has caused its true nature to be misunderstood.
  A very limited sliding motion is all of which this articulation is suscep-
tible.   The bones are held together by the following ligaments:
   1.  The posterior, or great sacro-sciatic ligament, is  found at the posterior
inferior part of the pelvis.  It  is triangular, thin, flattened, and narrower
in the middle than at the extremities.  It arises by a large  base from the
posterior inferior spinous process of the ilium, the sacro-spinous ligament,
the last of the posterior tubercles  of  the sacrum, and from the inferior part
of the margin of this bone and border of the coccyx, and running outwards,
downwards,  and a little forwards, is  inserted into  the  tuberosity of the
ischium.   Its  fibres are  arranged in such a way, that  the internal  ones
cross the external  about their middle.
   2.  The lesser sacro-sciatic ligament is smaller  than the  preceding, though
nearly of the same form, and situated more in front.   Within, it is broad,
beino- partially confounded  with  the other, but  arising a little more ante-
riorly upon the sides of the  sacrum and coccyx; thence,  it passes forwards
and outwards to be inserted  into the spine of the ischium.
   The sacro-sciatic ligaments convert the two sciatic notches into foramina.
They not only serve to unite the sacrum to the ilium, but also contribute to
the formation of the parietes of the pelvis.
   3.  The posterior sacro-iliac ligament  is  a  collection of yellow,  elastic,
fibrous bundles, intermixed  with fatty  pellets, which fill  up  the rough
• 
42
FEMALE  ORGANS  OF  GENERATION.
   Pelvis with its ligaments; the anterior portion removed.
 A. Internal iliac fossa. B. Section if the bones.  C Origin of
the great sacro-sciatic J:gament.  D. Great sacro-sciatic ligament.
E. Lesser sacro-sciatic ligament.  F. Great sacro-sciatic foramen.
G.  Last lumbar vertebra.  II. Ilio-lumbar ligament.  I. Sacro-
vertebral ligament.

                    Fig. 10.

B S? B'
        Pelvis with its ligaments.  Posterior view.
 A. Great sacro-sciatic foramen, through which  is  seen the
horizontal branch of the pubis.  B. Great sacro-sciatic ligament.
C Tuberosity of the ischium.  D. Posterior sacro-iliac ligament.
E. Posterior superior spinous process of the ilium.  F. Inferior
Bacro-iliac ligament.
excavation observed behind
the cartilaginous  surfaces;
very short, numerous,  and
interlacing  in every direc-
tion, they become almost in-
timately blended  with  Vui
sacrum  and  coxal  bones.
On account of their strength,
they greatly consolidate this
articulation.
   4.  The anterior sacro-iliac
ligament is a  simple fibrous
lamina, extended transverse-
ly from the sacrum to the os
innominatum.  It  is  rather
an expansion of the perios-
teum of the  pelvis  than  a
true ligament.
   5.  The superior sacro-iliac
ligament is a very thick fas-
ciculus, passing transversely
from the base of  the sacrum
to the coxal bone.
   6. The inferior sacro-iliac
ligament (vertical sacro-iliac
of  M.   Cruveilhier)  arises
from the posterior  superior
spinous process of the ilium,
and is inserted just below the
third sacral foramen into the
tubercle found at the termi-
nation  of the  border of the
sacrum;  and  behind, into
the great sacro-sciatic liga-
ment.
   § 3. Sacro-coccygeal Articulation.
   This articulation, which for a long time was supposed to resemble tho«e
between the bodies  of the vertebrae, differs from them materially in beino- a
true arthrodia.  It is formed by the opposition of the  oval surface of the
point of the sacrum to that of  the  base of the coccyx; the middle of the
former is projecting, and  corresponds to a depression in  the centre of the
latter.  The long  diameter of  the  articular face of the  coccyx is directed
transversely.   The  cartilages covering  these  surfaces are rather thinner at
the centre  than at the  circumference.   They are provided in the  ad  It
female with a synovial membrane, which  is supposed by M. Lenoir  t  ^
only developed by  the movements of the coccyx upon  the  sacrum  s°i  ^
he.has failed to meet with it in subjects under eighteen years of use ' S1UC6 
OF  THE  PELVIS.
43
  1. The  anterior sacro-coccygeal ligament consists of a few  parallel  fibres,
which descend from  the anterior part of the sacrum to the corresponding
face of the coccyx.
  2. The posterior  sacro-coccygeal ligament  is flat, triangular, broader
above than below, and of a dark color.  Arising from the margin  of the
inferior orifice of the sacral canal, it  descends to, and is  lost upon, the
whole posterior surface of the coccyx.   It also aids  in completing the canal
behind.
  In investigating upon the dead body the anatomical arrangement to
which the motion of the coccyx on  the sacrum is due, it was ascertained by
M.  Lenoir that the  motion takes place almost as  frequently in the  sacro-
coccygeal articulation,  as in that of the second piece of the coccyx with
the third.  Sometimes  it happens  simultaneously  in both, whilst in few
cases only does it occur in the  connection  of the second  piece with the
third, or of the third with the fourth.
  These  inter-coccygeal articulations   are similarly constructed.   In  all.
cases, in fact, in which  the points of motion of the coccyx were changed,
M.  Lenoir discovered a more or less complete anchylosis of the articulation
between  the  sacrum and coccyx,  and  of those between the bones  of the
coccyx  itself, at points above  and below  the one which preserved  its
mobility.   Then, also,  wherever situated, the movable articulation  was
constructed  as follows:   1. Of articular surfaces  irregular in  form but
corresponding exactly, which were incrusted with diarthrodial  cartilages
and provided with a synovial membrane.  2. Of lax peripheral  ligaments
formed at the expense of the layers of  fibrous substance covering the bones'
of the coccyx.   3. Lastly, motion was possible in every direction.
  It is to  be observed that  ossification  is more frequent and rapid in the
joint between the sacrum and coccyx  than  in that between the first piece
of the  coccyx and  the second;  the third and fourth  become  fused very
early.  It is therefore  easy to understand how the great  mobility  of the
sacro-coccygeal  articulations renders luxation possible in  labor, whilst in
cases of anchylosis, either  fracture or  a  sudden separation of the  united
bonos might occur.
  During pregnancy, the  ligaments of the pelvic  articulations become so
softened and swelled by imbibition  of fluid, as to render the  mobility of the
articular  surfaces very evident.    This softening  is  very  considerable in
some cases, and may make walking, or  even  standing, impossible.  (See
Diseases of Pregnancy.)

  § 4. Sacro-vertebral  Symphysis.
  This is produced  by  the junction of the sacrum with the fifth lumbar
vertebra.  It is a true amphiarthrosis, as are all the vertebral articulations.
It takes place at three different points, viz., between the oval facet, seen at
the middle of the base of the sacrum,  and the inferior surface of the body
of the last  vertebra; and at the  two  articular surfaces found near the
entrance of the  sacral canal.
  The modes of connection are, a fibro-cartilage (which is much thicker in 
44
FEMALE  ORGANS  OF  GENERATION.
front than behind), the termination of the two anterior and posterior verte-
bral ligaments, the interspinous  ligament,  and lastly, the sacro-vertebral
ligament, a short,  very strong, fibrous  bundle,  which descends obliquely
from the anterior inferior part of the transverse process of the last vertebra,
downwards and outwards, towards the base of the  sacrum,  where it is
inserted.
  Further, a synovial, membrane is found in the articulation  between the
oblique process of the sacrum and those  of the vertebrae.
  To these must also bo added the ilio-lumbar ligament, which passes from
the apex of the transverse process of  the  fifth lumbar  vertebra  to the
thickest portion of the iliac crest; and  the ilio-vertebral ligament formed
of two  fibrous  bands, the superior of which arises from  the  middle and
lateral part of the  body of the last lumbar vertebra, and the inferior, from
the inter-sacro-vertebral space; both are then spread out on the coxal bone.

  § 5.  Obturator Membrane.
  The obturator membrane still  claims  a description, in order to finish the
history  of the  ligamentous  apparatus of the pelvis.   This, as has  been
remarked by  M.  Cruveilhier,  like the  sacro-sciatic  ligaments  already
spoken of, is rather an aponeurosis serving  to complete  the pelvic  walls,
than a true ligament.
  These resisting membranes are  probably intended to diminish,  in the
hour of labor,  the compression of the mother's soft parts, included between
the infant's head and the osseous parietes of the  pelvis, as also to favor, by
their elasticity, the passage of the head through the pelvic excavation.
   Obturator membrane.—This membrane subtends the foramen thyroideum,
excepting at its superior part, where an opening  exists, which converts the
groove, intended for the passage of the obturator vessels and nerves,  into a
complete canal.  Being inserted by its external semi-circumference into the
corresponding part of the periphery of the obturator foramen, it is attached
by  its  internal half to  the  posterior face of the ascending ramus of the
ischium.  Its surfaces afford origins for the  two obturator muscles.   This
membrane is composed of  aponeurotic fasciculi, which  cross each other in
every direction.  (Cruveilhier.')


                         ARTICLE  III.

                     OF THE PELVIS IN  GENERAL.

  Studied in its general aspect, the pelvis represents a cone, slightly flat-
tened from before backwards;  the base of. which, being above  is  at the
same time inclined forwards, whilst the  apex is directed downwards  and a
little backwards.

  § 1.  External  Surface of  the Pelvis.
  Anatomists have divided this  surface into four  regions: the anterior of
which  exhibits, on the median line, the front  part of the symphysis  pubis 
OF  THE  PELVIS.
45
which is directed from above downwards and from befc re backwards, at an
angle with the perpendicular of some 15° to 20°; next (passing outwards)
is a smooth surface, from which several muscles of the thigh arise, then the
external obturator fossa, occupied in the recent subject by the muscle of the
same name, and finally by the anterior half of the edge of the cotyloid cavity.
  The posterior, bounded by the hinder  part of the  iliac  crest, presents, on
the median line, the ridge of the sacral spinous processes, the inferior open-
ing of the vertebral canal, the union of the sacrum with the coccyx, and
the posterior face  of this  latter bone.
  The ten posterior sacral foramina, transmitting the  nerves of the  same
name, are found in two deep gutters, on the sides.   These grooves prolong
the spinal gutters, and are occupied in the  recent state by the commence-
ment of the sacro-spinal muscles.  The lateral regions may each  be divided
into two parts: one, the superior, is the external  iliac  fossa; the other, or
inferior, offers, behind,  the posterior aspect of the  sacro-sciatic  ligaments,
and the plane of the notches or foramina bearing the same  name;  and, in
front, the cotyloid cavity and the external face  of the  tuberosity of the
ischium.

  § 2.  Internal Surface.
  The internal surface or cavity of the  pelvis has been aptly compared to
the basin of the ancient  barbers.  ( Vcsalius.)  In  fact, like those  vessels,
it has a superior part which spreads out freely, and is called the great, the
superior, or the abdominal pelvis; and  an  inferior one, more  contracted,
bearing the title of the little pelvis, or pelvic excavation.
  1. The great pelvis has a very irregular  figure, and  forms a  species  of
pavilion to the entrance of the pelvis.   Its walls are three in number: the
anterior one is deficient in the  dried skeleton, but in the living state it is
supplied by the anterior abdominal muscles; its posterior parietes  exhibit
a notch in  its middle, that is  ordinarily filled up by the projection of the
last lumbar vertebra?, which are usually  left in connection with the pelvis,
although in reality not forming any part of  it.  Two gutters are found on
the sides of this eminence, occupied by the psoas muscles;  further outwards,
the anterior part of the sacro-iliac symphyses appear, which constitute the
boundaries between the posterior and lateral regions: these  latter are con-
stituted by the internal iliac fossae, covered by the iliacus internus muscles.
  2. The lesser pelvis, or  basin.  This  forms a curbed canal, larger in the
middle  than at its extremities,  and slightly bent forward.  If all the parts
described as appertaining to the great pelvis be removed by the  saw, as
recommended  by  Chaussier, a species of ring will  remain, whose circum-
ference, being narrow  in  front and much  broader  behind, will furnish a
correct  idea of the  shape of the pelvis.  Four regions are  found  in this
cavity also:
  The anterior one is concave transversely, and is inclined upwards, having
the  posterior part of the pubic articulation near its middle: this is generally
prominent, assuming the  form of a longitudinal  pad, which may in some
cases project to the extent of from two to three-eighths of an inch.  Towards 
46             FEMALE ORGANS OF  GENERATION.
the sides a smooth surface appears, and then the internal obturator, or sub'
pubic fossa, having, at its upper external part, the inner orifice of the sub-
pubic canal, through which the external obturator vessels  and nerves pass
out from  the pelvis.
  It is not at all uncommon for females to complain during labor of severe
cramps in the muscles of the upper internal part of one thigh.  These pains
result from the pressure made by the child's head upon those nerves, as it
glides over this portion of the excavation.
  The posterior region — constituted  by the front face of  the  sacrum and
coccyx — is directed downwards, and is concave from above, downwards.
It consequently exhibits those peculiarities already noticed when describing
the sacrum.
  The lateral regions present  two quite distinct  portions: the anterior one
is wholly osseous, corresponding to the back part of the cotyloid cavity, and
to the body and tuberosity of the ischium.   It is directed from above down-
wards, from behind forwards, and from without inwards.
  The posterior one is formed by the internal face of the greater and lesser
sacro-sciatic  ligaments, and by the internal aspect of the  great and small
sciatic notches, converted by  them  into foramina; it has an  opposite direc-
tion to the former.  One of these foramina is larger and situated higher  up
than the other, and is of an  oval form.  The other is triangular, smaller,
and more inferior.  The pyramidal  muscle, the great sciatic nerve, gluteal
artery, and the internal pudic vessels and nerves, escape from the pelvis
through  the great sciatic  foramen.  The small sciatic hole is filled up  by
the obturator internus muscle, and the internal  pudic vessels and nerves,
which re-enter the pelvis in order to supply the  perineum.
  If two vertical  sections be  made, the one extending on  the median line
through  the sacrum and  the pubis, dividing  the pelvis  into two lateral
halves, and the other at right  angles to the first, dividing it into anterior
and posterior  halves, four equal  parts or quarters of the pelvis  will  be
thereby produced, which  accoucheurs have designated as the anterior and
posterior inclined planes.   Desormeaux included only the lateral regions  of
the excavation, which he divided into two  equal  parts, in the composition
of these, planes: according to him, the anterior  inclined  planes are con-
tinuous with the anterior region; the  posterior, with  the front face of the
sacrum;  and the spine of the  ischium is found at the point of union of these
two.  The direction of tft inclined planes  is always the same, whatever  be
the manner in which  they are formed.  That is, the  anterior are directed
from without inwards, from above  downwards, and from behind forwards •
the posterior,  from without  inwards, from above downwards  and from
before  backwards —in a word, in such a way as to resemble somewhat the
four sides of a lozenge which is  slightly  curved  in  its leno-th.   By mo^t
authors, these inclined planes are supposed to play an important part in the
mechanism of labor: for they imagine that their direction has an immediate
influence upon the movements which the head of the foetus performs in the
excavation.
  In anticipating that the description of the mechanism of labor hereaft 
OF  THE  PELVIS.                        47
given will invalidate this assertion, we shall simply observe that the move-
ments of rotation  executed by the head, take place more frequently whilst
the latter  is strongly bulging out the  perineum, and is so far  below  the
inclined planes as scarcely to feel the influence of their direction, and further,
that these motions often occur in an opposite direction.
  The great and the lesser pelvis are separated from each other by a kind
of horizontal circle, which has been designated by accoucheurs as the abdom'-
inal, or superior strait, the isthmus, or margin of the pelvis.   Finally, the
apex of the  pelvis  presents  an opening that is limited by a circle, partly
osseous, partly ligamentous,  to which the name of the inferior strait  has
been applied.  Consequently, these two straits are the extreme limits of the
pelvic excavation.

  §  3. Of the Superior Strait.
  The superior strait  is formed, behind, by the sacro-vertebral  angle,  and
the anterior border  of the wings of the sacrum: outwardly, by the rounded
margin that bounds the internal  iliac fossa below; and in front, by the  ilio-
pectineal eminence  and  the horizontal  ramus of the pubis, terminating at
the symphysis  of  this  bone.  The abdominal strait has been variously com-
pared to an ellipse,  an oval,  and  to the heart of a playing-card.   AVe may
assert, however, with Chaussier, that  its shape  is  that of a curvilinear
triangle, the angles  of which  have been rounded off, and  having its base
behind and  the apex in front.
  It constitutes the entrance to  the lesser pelvis, and is therefore the  first
part of the narrow canal which the foetus has to traverse.  Hence, the pains
taken by accoucheurs to study this osseous opening can readily be conceived.
  All the  modern authors since the days of Deventer, have endeavored to
fix precisely the degree of inclination of its plane and axis, to  ascertain the
direction the  foetus should  follow in engaging in the  pelvic canal, and to
determine carefully the  dimensions of the latter, and their accordance with
those of the body, which is to pass through it.
   The plane of the superior strait is inclined obliquely from  above down-
wards, and from behind  forwards; but writers are far from being unanimous
in regard to the degree of its inclination; that is, in determining the angle
formed by the  sacro-pubic line, at the point where it  meets a horizontal  one,
drawn from the superior part of the symphysis pubis  towards  one of the
points on the anterior face of the  sacrum.   Although originally placed at
45 J  by J. J. Mtiller (174o),  this  angle lias successively been  fixed at  35°
by  Levret; at 75°  by Camper,  and at  bo° by Saxtorph; and still more
recently, Professor  Xsegele,  after a great number  of researches,  has  con-
cluded to  consider  it as an  angle of 60° (1819).  It is now generally ad-
mitted that the degree of inclination in the plane of the  superior strait is
from oo° to 00° in the erect position of  the female.
  The direction of  the plane being once understood, it is an easy matter to
ascertain that of  its axis; for the latter being a line which  falls perpen-
dicularlv upon the  centre of  this  plane, it  must evidently form  with the
vertical the same  angle that the  plane itself does with the horizontal line, 
48
FEMALE  ORGANS  OF  GENERATION.
Fig. 11.
and  consequently must have just  the same  degree of inclination.   Being
thus understood, the axis of the superior strait is a line (a b, Fig. 12) which,
commencing near the umbilicus of the female, would pass directly through
the centre of'this strait, and fall upon the point of union of the upper two-
thirds of  the coccyx, with  its  inferior third.  Hence, it  will be directed
from above downwards, and from before  backwards.   Further, the inclina-
                                    tion of this  plane varies  according to
                                    the woman's position.  Thus, it is al-
                                    most  nothing  when recumbent, and
                                    sometimes in  this position the  plane
                                    of the superior strait instead of being
                                    directed forwards  and upwards, even
                                    looks upwards  and  backwards (Du-
                                    bois) ; when the trunk is bent strongly
                                    forwards, the  inclination of the plane
                                    is diminished and becomes more nearly
                                    horizontal;  towards  the end of gesta-
                                    tion, on the contrary, the inclination
                                    increases, especially when, in order to
                                    restore equilibrium, the upper part of
                                    the body is  carried much backwards.
                                      As the figure which represents the
                                     circumference  of the superior strait is
                                     not a  perfect  circle, its  dimensions,
                                     taken at different points, are, of course,
                                     unequal, and, accordingly, writers have
admitted several diameters for it, thus:
   There  are three principal ones (Fig.  2), namely, an antero-posterior or
sacro-pubic diameter a a, which extends from the  sacro-vertebral angle to
 c h. The plane of the superior strait prolonged
beyond the pubis, c e. The plane of the inferior
strait prolonged beyond the pubis, c d. Shows the
departure of this plane' from the horizontal line.
a b. The axis of the superior strait, gf. The axis
of the inferior strait.
the upper  part of the symphysis pubis
four and a half inches in length.   2. A
 a a. The antero-posterior, or sacro-pubic diameter, b b.
The transverse diameter,  c c. The two oblique diameters.
% c. The sacro-cotyloid intorval.
it  is from four and a quarter to
transverse one, b b, passing  from
 the middle of the rounded border
 that terminates the iliac fossa of
 one side, to the  same point on
 the  opposite side;  this is five
 and  a  quarter   inches   long.
 3. An oblique diameter, c c, ex-
 tending  from the  anterior  part
 of the sacro-iliac  symphysis to
 the ilio-pectineal  enfinence of the
 opposite side; this is found on
 both  sides, and  is  four  and
 three-quarters  inches long.
    Lastly, M. Velpeau admits a
 fourth diameter, called by him
 the  sacro - cotyloidean ;  before
 described,  however,  by Burns
 under the  more exact name of 
OF  THE  PELVIS.
49
the sacro-cotyloid  interval a c, existing between the promontory and the
posterior  part of the cotyloid cavity.   This  interval,  according to the
examinations  of the  French surgeon, is from four to four  and one-eighth
inches in extent; but from the results of Noegele and Stoltz's researches it
is much less,  being scarcely three and a half inches (the  mean  obtained
from ninety pelves).  The circumference of this  strait varies from thirteen
to seventeen inches; Levret taught, that it equalled one-fourth of the female's
height; but to establish such an approximation, the development of the
pelvis should  always be in direct proportion to the stature of the individual,
which is certainly not the fact.

   § 4. Of the Inferior Strait.
   The inferior strait — the perineal strait — or  apex of the pelvis (as it is
variously called), is more irregular in shape than the superior one.  Its
outline presents, in fact, three tuberosities or osseous projections, separated
by as many deep  notches.
   If,  however, the advice of Chaussier be followed, and a sheet of paper be
placed over this opening, so as to trace its outline with a crayon, it will be
found to have an oval figure, the smaller  extremity of  which is in front
and the larger one, looking backwards, is broken  in upon by the prominence
of the coccyx.  This point, disappearing at the moment of the  head's pas-
sage,  offers no obstacle to the delivery;  and, therefore, the strait may be
considered as  nearly an oval.
   The periphery of the  pelvis at its apex is formed by the inferior part of
the symphysis pubis, the descending branch of this bone, the ascending
branch and tuberosity of the ischium, the inferior margin of the great sacro-
sciatic ligament, and  by the border and point of  the coccyx.  Hence, three
triangular projections are found in it: the two  ischia upon the sides, and
the coccyx behind.  The first two are immovable, but the last,  on the con-
trary,  is effaced at the  period of  delivery, as  just  mentioned;  for  the
mobility of the sacro-coccygeal articulation allows the coccyx to be pushed
downwards  and backwards by the  foetal head, as it traverses  the inferior
strait.   The two lateral prominences, made by the tuberosities of the ischia,
are placed on  a plane somewhat lower than the point of the coccyx; and
consequently,  in the sitting posture, the weight of the body rests solely on
those  tuberosities, and not at all upon the coccygeal extremity.  This cir-
cumstance furnishes us a reason why transverse  contractions of the pelvis
are far more frequent at the inferior strait than the antero-posterior ones.
  The three notches also require a passing  notice; thus, the tw7o  postero-
lateral ones are very deep, but when the sciatic  ligaments  have been pre-
served, they are comparatively superficial; the third is found  anteriorly;
its apex corresponds to the inferior part of the symphysis pubis, its base to
a line drawn  between the anterior  parts of the  tuberosities of the ischia,
and its sides  are formed by the ischio-pubal rami.   The term arch of the
pubis has been applied to this notch.  The columns of the arch are distorted
outwardly, as  if a  rounded body had been forcibly expelled from the pelvis,
whilst the bones were soft, and had pushed them before it;  and this arrange-
       4 
50
FEMALE  ORGANS OF  GENERATION.
ment, which is more marked in the female than the male, favors the descent
of the head.  The arch is three and a half to three and three-quarter inches
broad at the base; but only one  and a quarter to one and a half inches at
its apex ; in height, it is about two-, to two  and a half inches.   Hence the
area of the inferior strait will not present a uniform  plane (should it be
desirable to ascertain  the irregularities it exhibits), because all parts of its
margin are -not upon the  same  level.   However, to obviate  the difficulty
met with, in determining the direction of this plane, Duges has divided the
strait into two nearly  equal portions, the one  anterior, and the other pos-
terior, meeting  at the tuberosities of the ischium, and each  presenting a
distinct plane and  axis; but  as this method  of proceeding uselessly com-
plicates the question, we prefer considering the terminal plane of the pelvis,
as represented by the  coccy-pubal line, thus leaving out the lateral projec-
tions  altogether.
  The question is then reduced to these terms:  What is the direction of the
line that extends from the  point  of the  coccyx to the inferior part of the
symphysis  pubis?
  Writers, likewise, variously  describe this; for instance, according  to the
majority of the French accoucheurs, the plane of the inferior strait is slightly
oblique, from below upwards, and from  behind  forwards, so that it would
unite with that of the  superior  strait (if prolonged) in front of the symphysis
pubis.  On the other hand,  M. Naegele  concludes, from his numerous
researches, that the inclination of the antero-posterior diameter of this strait
is from 10° to 11° from  the horizon, and that the point of the coccyx is
found, as a mean, from a half  to three-quarters of an inch higher than the
summit of  the pubic  arch;  and,  therefore, the coccy-pubal line is a  little
oblique from above downwards,  and  from  behind  forwards.   The  lower
extremity of the axis of this plane of the  inferior strait would cut the coccy-
pubic diameter at right angles, and terminate  above at the sacro-vertebral
angle.  As a further  result of his labors,  he has found that, in five hundred
                                   well-formed persons, of different stat-
              FlG-13,                ures, four hundred and fifty-four have
                                   the point of the coccyx more elevated
                                   than the inferior portion of the sym-
                                   physis;  in twenty-six it  was  lower,
                                   and in twenty individuals both points
                                   were on  the same level.  M. Velpeau
                                   remarks, as we think with some reason,
                                   that, at the moment  of delivery, — the
                                   only time, after all, when it is requisite
                                   to  form  an  idea of the direction of
                                   this plane, —the point of the coccyx,
                                   being  pushed downwards  and  back-
                                   wards  by the passage of the head, is at
                                   least on a level with, if not lower than
                                   the inferior part of the symphysis.
                                     The assertion of M. Naegele,  there-
 c d. The horizontal line, c e. The plane of the in
ferior strait (during lab %r). a 6. The axis of the in
fcrior strait 
OF  THE PELVIS.
51
fore, although true as applied to the  female* not in labor, fails  during
parturition; and it must be admitted that th«j plane of the inferior strait is
then oblique from below upwards, and from behind forwards.
  The axis of this strait is represented by a line (a b, Fig. 13) directed from
above downwards, and from behind forwards, which, starting from the first
piece of the sacrum, falls at  a right  angle upon the  middle of the bis-
ischiatic space.   The remarks  made upon the variations hrthe  direction
of the plane, apply with equal force to its axis.  The latter crosses the axis
of the superior  strait  in the excavation, forming with  it an obtuse angle,
the sine of which is in front.
  It is also very important to know  the dimensions of the perineal strait,
and hence obstetricians describe three principal diameters at that point,
namely — 1.  The  antero-posterior or
coccy-pubal diameter  (a a, Fig. 14),                 Fl°-14-
running from  the point of the coccyx                   ,
to the  summit of the pubic  arch ; it
is usually four and a quarter inches
long, but  may increase  to four and
three-quarter inches during labor, by
the retrocession of the coccyx. 2. The
bis-ischiatic,  or  transverse diameter,
b b, is  four  and a  quarter inches in
length, and goes from one tuberosity
of the ischium to the other.   3. The
oblique diameter, c c,  commences at
the middle of the great sacro-sciatic
ligament, and crosses to the point of
union of the ascending branch of the
ischium, with the descending ramus
of the pubis,  and is four and a quarter  inches long, but may become one-
quarter of an inch more during labor, from the elasticity  of these ligaments.
  All the diameters of the inferior strait are, therefore, in the dried pelvis,
about  four and  a quarter inches in length, though their dimensions are
susceptible of great variation during labor.

  § 5.  Of the  Excavation.
  The excavation is that space comprised between  the superior  and the
inferior straits, and it is in this cavity that the  foetal head executes its prin-
cipal movements; and it is somewhat surprising, that, until quite recently,
this canal was scarcely mentioned in the majority of the classic works, not-
withstanding the importance of a knowledge of its dimensions, as a^o of
the direction of  its plane and axis.
  Its dimensions comprise both  the height and width at the different points:
thus the height in front, is one and a half inches;  upon the sides, three and
three-quarter  inches; whilst  it  is four  and  a  quarter inches  behind, if a
Btraight line be  drawn  from  the sacro-vertebral angle to the point of the
coccyx, and five inches and a quarter, following the curve of the sacrum.
 a a. The antero-posterior or coccy-pubal diameter.
b b. The transverse or bis-ischiatic diameter, c c. Tha
two oblique diameters. 
52
FEMALE  ORGANS  OF  GENERATION.
  Three diameters are also described for this cavity (like the straits), so as
to appreciate its extent in the different directions.  All of them are taken
at the centre of the excavation, and they consist of an antero-posterior one,
of four  and three-quarters to five and one-eighth  inches in length, a trans-
verse diameter four  and three-quarter inches long, and an oblique one, of
the same length; consequently, all  the  diameters of this cavity  are very
nearly four and three-quarter inches each.
  If the canal forming  the  excavation were a cylinder, it would only be
necessary to divide  it by a plane, perpendicular to  its walls, in  order to
represent the opening of this cavity; but a simple  division, thus made, would
not give a  just conception of the excavation, for two reasons.  First, the
canal is not cylindrical,  because its sides are not  parallel, and the anterior
                                         face of the  sacrum  presents  a
                 fig. 15.                   well-marked curvature;  the pubic
                                         wall being nearly straight,  and
                                         the lateral parietes very oblique
                                         from without inwards,  and from
                                         above downwards.  Consequently,
                                         to furnish an exact idea of the
                                         general arrangement of the pelvic
                                         excavation, it seems necessary to
                                         divide  the canal (see Fig. 15) by
                                         a  series of  planes, all passing
                                         from the  point  c  (the  point of
                                         intersection of the  planes of the
                                         superior and inferior straits) to
                                         any point  whatever, p q r s t, on
                                         the  anterior face of the sacrum.
                                         Each  of these planes will show
                                         the opening of the pelvic cavity
                                         at  the level  where it  is found.
                                         Now,  to  determine, with   cer-
                                         tainty, the direction of the  gen-
                                         eral axis of this excavation, it is
 requisite to raise a perpendicular line from  the geometrical  centre of each
 of these sections, and to draw a line g k through the base of  each.
   This line g k (which, as the student will observe, is not straight) is called
 the general axis of the pelvis.
   It is now  readily  understood  that this line  is nearly parallel to  the
 anterior face of the sacrum, and its extremities correspond with the axes of
 the superior and the inferior straits; hence, this curve exactly represents
 the whole axis of the pelvis, or, in other words, the line  which  the foetus
 must follow in traversing the pelvic excavation.
   It would be wrong to consider the line, representing the entire axis of the
 excavation, as a simple  curve; for M. Naegele  has  well observed, that  it
 cannot be composed of two straight  lines, as often taught, nor is it a simple
 arc of a circle.   In fact, the anterior face of the bodies of the first  two bones
 a b. The plane of the superior strait, i d. The plane of
the inferior strait,  c. The point where these two planes
would meet, if prolonged,  in n. The horizontal  line.
tf. The axis of the superior strait,  g lc. The axis of the
excavation, p qr s t. Various points taken on the sacrum
to show the plane of the excavation at each point. 
OF  THE  PELVIS.
53
 of the sacrum forms a straight line;  the sacral curve embracing only the
 last three bones.  Consequently, the central line, which is evidently parallel
 to this, will consist of a straight and a curved portion — straight, for that
 part of the  excavation corresponding to the two superior vertebrae, and
 curved  in the  space, which  is bounded behind  by the last  three sacral
 vertebrae, and in front by the anterior pelvic walls.

   § 6.  Base of the Pelvis.
   The base of  the cone, represented  by the  pelvis, has  its circumference
 directed upwards and in front; it exhibits, behind, a notch,  into the bottom
 of which the base of the sacrum projects, and which is further filled up by
 the  last lumbar vertebrae (generally left in situ to complete the  posterior
 wall of the greater  pelvis), by the ilio-lumbar ligaments, and by t,he qua-
 dratus lumborum muscles ; 2, outwardly, the anterior two-thirds of the iliac
 crest furnishing  attachments to the external  and the internal  oblique and
 transversalis abdominis muscles; and 3, in front, the anterior superior and
 inferior spinous processes of the ilium, the groove for the passage of the con-
 joint  muscles—the  psoas magnus and  iliacus internus, the ilio-pectineal
 eminence, the superior border of the horizontal branch of the pubis, the
 spine, and lastly, the upper margin of the symphysis of this bone.

   § 7. Differences of the  Pelvis.
   1. According to the sex.  Considered as a whole, the pelvis  in the male
 is smaller but deeper, the bones are thicker, and the muscular  impressions
 more marked, than in the female.  The superior strait being  more retracted,
 resembles the figure  of a heart on a  playing-card.  The  excavation is not
 so wide, though it is deeper, especially in front, owing to the greater length
 of the symphysis pubis;  the arch of the pubis is straight, nearly triangular
 in shape, and is not  widened  in front.   The  coccyx is early joined to the
 sacrum, and the articulations of the pelvis are much sooner anchvloscd
 than  in  the female.  In the  latter, we may add, that the  iliac fossa? are
 larger and more warped outwardly  (whence the prominence of  the haunch
 bones), and the iliac crest less twisted in the form of an italic/;  the interval
 separating the angle of the pubis from the cotyloid cavity is more consider-
 able, causing, in part, the projection of the  great  trochanters, and a wider
 separation of the femurs ; the superior strait is larger and more elliptical;
 the curve of the sacrum deeper and  more regular;  the tuberosities of the
 ischium are farther apart; the pubic symphysis shorter; the foramen thyroi-
 deum more triangular;  the arch of the pubis  broader, more rounded, and
 more curved, and the lateral  borders, formed by the  ischio-pubic ramus,
 more contorted  outwardly.
  2. According to the age.  At birth, the pelvis is extremely  narrow and
 elongated, and  of such  inconsiderable dimensions, that its cavity  will  not
 contain several of the organs  afterwards  found  in it;  from which circum-
stance, the protuberance of the belly,  observed in the foetus and in  children
 at term, in great measure results; the excavation has the form of a cone,
 the abdominal  strait  being strongly inclined downwards;  the sacrum is 
54
female  organs  of  generation.
nearly flat, and so much elevated that a  horizontal line diawn from the
superior part of the pubis would pass beneath the coccyx; the coxal bones
are narrow, elongated, and  nearly straight at their superior part, and the
cartilaginous iliac crests are not twisted.
  From this disposition it necessarily happens that the greatest diameter of
the pelvis extends from the sacrum to the pubis.   Burns declares that  this
form changes by degrees as  the little girl advances in age: thus, the—
Antero-posterior diameter measures . Transverse diameter measures, . . .	At 9 years.	At 10 years.	At 13 years.	At 14 years.	At 18 yearej l
	2% inches. 2% inches.	3J^ inches. 3 in. 5 lines.	3% inches. 3% inches.	3% inches. ■i inches.	3% inches. ±% inches.
  [3. According to Races.  This subject, studied by Vrolick and  Dubois, has been
recently taken up by Joulin, who published  an important memoir on it, in which
he proves that there is nothing characteristic in the differences to be observed in
the pelves of the three races, Aryan, Negro, and Mongol;  in the two latter espe-
cially, the resemblance is so strong that it is impossible to distinguish them.   The
same author states that, contrary to what has been said, in all human  races the
transverse diameter of the superior strait is  greater than the  antero-posterior;
but that the oblique diameter of the superior strait of the pelvis of the Negress and
Mongol  female differs from the transverse by a few millimeters only, whilst in the
Aryan female the difference amounts to a centimetre and a half.   The pelves of the
Negro and Mongol are, besides, less capacious than those of the  white race; they
have less depth, and the pubic arch is wider by several degrees.]

  § 8.  Uses of the Pelvis.
  The pelvis  constitutes the base of the trunk, and,  according to Desor-
meaux, it forms a complete ring, that may be reduced to two arches; the
posterior and superior of which receives the wdiole weight of the trunk,
whilst the anterior and inferior one serves as a buttress to it.
  The two lower extremities are attached to the lateral parts of this circle,
and support, in the erect posture, all the weight of the superior part of the
body.   This use of the pelvis  satisfactorily explains to the accoucheur the
vicious  forms the cavity often assumes when ossification  is retarded, or when-
ever any disease alters and softens the bones.
  Another function of the pelvis is to  inclose and protect  the bladder
rectum, and seminal vesicles of the male; the uterus, Fallopian tubes  and
ovaries  in  the female.   During gestation,  it sustains  and  gives  a proper
direction to the womb; and in labor, it affords a passage to  the child.


                          AETICLE   IV.

            OF  THE PELVIS,  COVERED BY THE SOFT  PARTS.

  It will not suffice to study the  pelvis as found in the skeleton alone for
the changes produced in its form and dimensions in the livino- female bv
the arrangement of the soft parts, also require our special attention. 
OF THE  PELVIS.
55
   Being continuous above with the abdomen, the great pelvis incloses and
 supports the mass of the intestines, and atibrds points of attachment by its
 walls to two orders of muscles.  The one destined to form the inclosure of
 the belly fills the large opening exhibited in front, and thus constitutes the
 anterior  abdominal wall;  the extensibility of which,  in comparison with
 the resistance of the posterior plane, accounts readily for the tendency of
 the uterus to incline forward in
 the advanced stage of gestation.
 The others,  two in number, are
 placed in the iliac fossae;  they
 are the iliacus interims, and the
 psoas magnus  muscles, which,
 from being situated on the late-
 ral parts of the abdominal strait,
 change  both its form  and di-
 mensions.   The first  of these
 has radiated fibres, and occu-
 pies the iliac fossae; the second
 descends from the sides of the
 lumbar vertebrae, and after hav-
 ing been joined to the preced-
 ing, is inserted  into the lesser
 trochanter  of the thigh bone.
 These two muscles, surrounded
 and confined by an aponeurosis
 {fascia iliaca), may be regarded
 as a sort of  cushion, forming a
 convenient  support to  the de-
 veloped  uterus, and destined to protect it by the elasticity of the soft parts
 against the  shocks and concussions continually produced  by locomotion.
 Notwithstanding the presence of these muscles, the  strait still resembles a
 curvilinear  triangle in shape, the  base, however, of the triangle being in
 front instead of behind, as it was in the dried pelvis; the transverse diam-
 eter is diminished  half an  inch by  their presence; the antero-posterior one
 is, perhaps, a little abridged  by the thickness of the vesical walls, uterus
 and soft  parts that line  the posterior face of the symphysis and anterior sur-
 face of the sacrum, the oblique diameters alone remaining unchanged; the
 location  of  the  rectum, however, on the left, shortens  slightly the  corre-
 sponding diameter.
  The modification of the transverse diameter, produced by the psoas mus-
 cles, is always much less when these are in a state of relaxation from the
flexure of the thighs.  Finally, as  Baudelocque has remarked, the bis-iliac
diameter is diminished  in  length, in proportion to the thickness of these
muscles,  and the antero-posterior one being more contracted, the strait be-
comes  more elliptic  or rounded.   Two muscles are also  found on each side
of the excavation,  covering the obturator and ischiatic foramina; namely,
the obturator intern us, and  the pyramidales.  Flamand attributes the move-
Fio. 16.
    Pelvis, with the soft parts seen from above.
 A. A section of the  aorta.  B. The  vena cava inferior.
c. The internal iliac artery, arising together with D, the ex-
ternal iliac, from the primitive iliac trunk. E. External iliac
vein.  r. The iliacus internus, and G, the psoas magnus mus-
cles, n. The rectum,  i. The uterus with its appendages.
K. The bladder, the fundus of which is depressed so as to
bring the womb into view. 
56
FEMALE  ORGANS  OF  GENERATION.
ments of rotation, executed by the head in the pelvis, to the action of these
muscles; but the same reasons that caused us to reject the influence of the
inclined planes on this process, equally deter us from entertaining  the
opinion of the  Strasburg Professor.   The pelvic cavity  is still further
diminished by the rectum, bladder, and cellular  tissue;  more  especially
when the latter is loaded with fat.  Consequently, the foetal head descends
with more difficulty in very corpulent women than in others.
  The perineal strait, although open in the  dried skeleton, is here occupied
by a sort of contractile concave partition, which sustains the viscera of the
pelvic and abdominal cavities.  This floor, so to speak, is composed of two
muscular planes ; the interior of which, formed by the levator ani and coccy-
geal muscles, is concave above;  and the other, having its concavity below,
is constituted by the sphincter ani, the transversus perinei, the ischio-cavern-
ous, and the  constrictor vaginae muscles.   The internal pudic vessels and
nerves, a large amount of cellular tissue, the skin, the  pelvic aponeurosis,
and  an inter-muscular  aponeurosis complete  this floor, which, in the hour
of labor, ought to become thin and distended, but which occasionally offers
such an obstacle to the spontaneous delivery of the foetus as to require the
intervention of art.
  The extent  of the perineum,  in its ordinary condition, is three inches,
namely: from the point of the coccyx to the anus, there are one and three-
quarter  inches, and from the anus to the vulva, one and one-quarter inches;
but at the instant of the passage of the head through the genital  fissure it
becomes so distended, that  the interval separating  the anterior commissure
from the coccyx, is increased  from four to four and  three-quarter inches.
  It must now be evident that the terminal outlet of the pelvic canal, in the
pelvis, covered with its  soft parts, is  not  at the point  of the coccyx, but
rather at the anterior commissure of the  perineum ; in fact, the latter is so
greatly distended in the last moments of labor, that its anterior border goes
beyond  the inferior part of the  symphysis  pubis, thereby prolonging very
considerably the posterior wall of the pelvic  excavation, and, as a conse-
quence, the canal  to be traversed by the foetus.  Wherefore, the direction
in which the head is ultimately disengaged is not represented by the axis of
the inferior strait, but by that of a plane which  may be drawn  from the
lower part of the symphysis to the anterior commissure of the  distended
perineum.
  Hence, in order to form an exact idea of the line traversed by the foetus
from its entrance into the superior strait until its final exit from the vulva
it will be necessary to continue  the  operation already pursued  upon the
anterior face of the sacrum (see page 52) over the curve represented by the
anterior face of the distended perineum:  that is, to make a series of planes
from the point c (Fig. 15)  to the divers parts of the perineal curve; and
from the centre of each, raise a perpendicular, so as to  form by their union
a complete  axis, the upper extremity of which is  the axis of the superior
strait; the middle part, a  curved line, having its concavity anterior and its
convexity parallel to the  front face of the sacrum and  perineum  and the
inferior extremity directed  from  before backwards, and slightly from above
downwards. 
              EXTERNAL  ORGANS OF  GENERATION.              57

  It must not, however, be forgotten, that the direction just described  be-
longs to the vertical posture,  and that it becomes remarkably altered in the
various attitudes assumed by the  female.  Thus, whilst lying upon  the
back, as is usual in France during labor, the plane  of the  superior strait
instead of looking upward  and forward will  be turned upward and back-
ward, and its  axis directed  from above downward and from behind forward.
At the same time, the plane of the inferior strait, which before looked back-
ward and downward, will be  turned almost directly  forward, its axis  also
passing directly from before backward.  Finally, the terminal orifice formed
by the contour of the vulva  presents another plane,  which at the moment
of delivery (the horizontal position being still maintained)  is directed up-
ward and forward.   In short, the central line followed by the foetus during
                                 Fig. 17.
    Position of the pelvis and the direction of its axis in the dorsal attitude assumed by the female
                                during labor.
 a b. Total axis of the excavation, being a continuation of d b, the axis of the superior strait, c v. Peri-
neum as distended at the moment of the passage of the head. r. Anal orifice,  e v. Terminal plane of the
pelvis.

its expulsion is a strongly-marked curve, whose concavity is turned almost
directly upwrard (Fig. 17).
                          CHAPTER   II.

            OF THE  EXTERNAL ORGANS OF GENERATION.

  The genital apparatus of the female is much more complicated than that
of the male,  and  is composed of organs  situated  in  the  interior of the
pelvis, and  of parts attached to its exterior.   The former  are the ovaries,
Fallopian tubes, uterus, and vagina, and the latter, the mons veneris, vulva,
and  perineum.  We commence by describing  the external organs of gen-
eration. 
58
FEMALE  ORGANS  OF  GENERATION.
AKTICLE  I.
MONS VENERIS.
  The mons veneris is a rounded eminence, a species of relief, more or les9
prominent according to the embonpoint of the individual, situated in front
of the pubis, and surmounting the vulva;  this eminence is partly produced
by the bones, and  partly by the  subcutaneous adipose  tissue; the skin
covering it is very thick and elastic, but  being little extensible, it cannot
aid in the enlargement of the  vulva, as  asserted by M. Moreau, at the
period of delivery.  In the adult female,  it is covered with  hair, and con-
tains a great number  of sebaceous follicles.


                          ARTICLE  II.

                                VULVA.
Fig. 18.
  The vulva  is a longitudinal opening  or fissure, situated  on the median
line at the base of the trunk;  being bounded in front by the mons veneris,
behind by the perineum, and laterally by the external labia.
  We shall comprise in its description,  as properly appertaining thereto,
all the parts included between the labia majora.
                                 1. The labia majora, or labia externa, are
                               two cutaneous  folds, flattened transversely,
                               and thicker in front than  behind,  which
                               bound tne opening of the vulva externally ;
                               commencing at  the  mons  veneris, they
                               gradually recede from each other, as they
                               pass  backwards, nearly to  their middle,
                               where they  again approach, so  as to unite
                               at the posterior extremity,  and form there
                               a bridle  or commissure  called  the four-
                               chette, which is generally lacerated during
                               the first labor.
                                 The labia externa  present an  external
                               or cutaneous surface, which is covered with
                               hair  after  puberty ;  and an internal one,
                               moist, smooth,  of a rose color, and formed
                               by a mucous membrane that  is provided
                               with a  considerable quantity of  sebaceous
                               glands and  papillae.
                                 In young girls,  the external  lins are
     .  D. Labia minora. E.  Orifice of       i    ?• ?   t_        .        ^    XtJ
urethra, f. Orifice of vagina,  h. Poste-  somewhat thicker above, and approach each
rior commissure of the vulva.  I.  Perineum.  otner  closely ; but in  females  who have
                               borne children they are separated, and have
                               lost their regularity.
        External genital parts.
 A. Mons veneris.  B. Labia majora.  C
Clitoris
J. Anus. 
               EXTERNAL  ORGANS  OF  GENERATION.             59

  They consist  of a cutaneous  and  a  mucous layer, between which is a
fibrous partition, a continuation of the superficial fascia of the  perineum.
Between  this aponeurosis  and  the internal surface of the integument, is
found a very thick layer of cellulo-adipose  tissue, filling  up a peculiar
pouch hitherto unknown to anatomists  until discovered by M.  Broca.

  [This pouch is constituted by a membranous sac situated  between the skin and
the superficial aponeurosis:  its bottom is directed towards the fourchette, where
it becomes  blended with the fascia superficial of the parts on each side of the
anus.  It  has a  long and narrow neck, which is  directed  toward the external
inguinal  rin<r, and receives into its  opening a portion of the fibres of the round
ligament.   Its ctivity is filled with  cellulo-adipose tissue,  varying in quantity with
the embonpoint of the individual.  The pouch forms of itself the greater part of
the thickness of the labia majora.
  The fibres of which the pouch is composed are derived chiefly from the fascia
superficialis of the thigh and abdomen, but s<.ui<> proceed directly from the spine
of the pubis; the most external are attached to the rami  of the pubes  and  ischia,
whilst the most internal unite and become blended with  the  suspensory ligament
of the clitoris.
  According to M. Broca, this sac  is the analogue of the dartos of the male; M.
^appey, however, believes that it  is comparable only to the  suspensory ligament
of the scrotum and penis.  The microscope proves it to be composed of interlaced
fibres of elastic tissue.                          '
  The arteries of the labia  majora are  derived from  the perineal artery, itself a
branch of the internal pudic or of  the external pudic or epigastric.
  The veins for the most part accompany the arteries, some, however, pass back-
ward and form a plexus, which communicates with the  bulb and vaginal veins.
These veins, which-are very numerous, often become dilated during pregnancy.
  The nerves proceed from the genito-crural branch of  the  lumbar  plexus, and
from the perineal  branch of the internal pudic nerve.  The  lymphatics all  pass
into the inguinal glands.]
  2.  The nymphce, or labia interna,  are  brought into view, by  separating
the external lips, under the form of two mucous folds, resembling the comb
of a young cock.  Contracted behind, where  they are continuous with the
internal  face .of the labia externa, they spread out in  front  as they con-
verge towards each other.  These lips scarcely descend to  the  middle of
the external ones, but they mount up in front as high as the clitoris,  where
thev bifurcate;  the inferior branch of this  bifurcation is  lost in the clitoris;
but  the  other surmounts  it, joins its fellow of the opposite side, and forms
above this body a little fold in  the  shape of a hood, called the prepuce of
the  clitoris.   At birth, the nvmphae project beyond the  external lips,  but at
puberty they are  concealed by the latter.   Again, they become visible in
child-bearing women; rather,  however,  by the  separation of  the  labia
majora than by their own prominence.
  Further, their dimensions are very variable in different individuals, and
in various climates ;  thus, in certain countries of Africa,  they are very long,
and constitute the famous apron  of the  Hottentots.  Besides, as Velpeau
has  remarked, these parts are  so extensible that, under the  influence of
continual tractions, they may become very much elongated.   I  have met
wi'.h  a young female,  in  my own practice, who was afflicted  with an ex- 
60
FEMALE  ORGANS  OF  GENERATION.
cessive itching at the vulva at the  commencement of her pregnancy.  To
relieve this, she was in the  habit of scratching continually, and in her im-
patience  dragged on  the right nympha, so that, in less than a fortnight,  it
had become twice as long as its fellow.

  [The internal labia are covered with tesselated epithelium, below  which are
papillae whose sensibility is especially exercised during copulation.  The papillae of
the internal surface have a greater development than those of the external surface,
and their  size is found to increase as they approach the orifice of the vagina.
  The blood-vessels of the internal labia are supplied by those of the labia majora
A portion of the veins  anastomose largely  with  those  of the bulb and  of the
vagina.
  The nerves come from the perineal branch.  The lymphatics proceed  to the
inguinal glands.]

  3. The Clitoris.— Under  this name,  a little erectile tubercle, resembling
the corpus cavernosum of the male (except in volume), is described. Its free
extremity appears at the front part of the vulva, about half an inch behind
the anterior commissure of the labia externa,  and its body is attached by
two crura to ischio-pubic rami; these roots ascend, converging and increas-
ing in size, to the level of the symphysis, where they unite to form a  single
cavernous body, flattened on its sides, which after a course of two or three
lines  in  front of the  symphysis, becomes detached and curved forward so
as to present a convexity above  and  in  front, at the same time growing
more and more slender towards the free extremity, which is called the glans
clitoridis.
  During the first months of the intra-uterine  life it is difficult to make
out the distinction of the sexes, because the clitoris is as long as  the penis;
even in the earlier years of existence its dimensions are quite considerable,
but  after this period it  ceases to  grow, and,  in some females, apparently
diminishes.   Again, in certain rare cases, it acquires a  great length ; for
instance, M. Cruveilhier has seen one whose free  extremity  measured  two
inches, and a case is on record where it reached from four and a  quarter to
five  inches.  Most of the pretended hermaphrodites may be referred to
anomalies of this kind.
  Henle  gives a representation of a case so singular and rare as  to deserve
mention.  It is  a congenital division of the clitoris occurring in a girl of
seventeen years of age, in which  the body of that  organ was completely
divided through the middle so as to form two nipples, each invested with a
prepuce.   The halves of the prepuce thus divided, are prolonged respec-
tively toward the corresponding nympha, from which it  is separated by a
notch, and is lost, above, in the frenum clitoridis.
  The clitoris,  like the penis, has  a suspensory ligament, and an erector
muscle;  the canal of the  urethra in the female passes  between the  two
branches of the cavernous body, as  it does in the male.

  [The structure  of the clitoris is. in all respects, precisely that of the corpus cav«
ernosum of the male, except in point of size.   It presents the fibrous envelope the
muscular  trabecular, and  the  helicine arteries, all characteristic of the erectile 
               EXTERNAL  ORGANS   OF  GENERATION.             61

tissue.   During coition, blood  accumulates in  it,  dilates it, and  thereby causes
its erection.
  The arteries of the clitoris come from the perineal artery, and are distributed as
in the male,  presenting therefore the cavernous artery, which on each  side enters
the corresponding corpus cavernosum, and the dorsal artery, which is  disti ibuted
to the mucous membrane known as the prepuce  of the clitoris.
  The veins  form a plexus arranged in two planes, the most superficial of which
furnishes the dorsal vein, whilst the deeper communicates with the veins of the
bulb, of the  vagina, and of the bladder.
  The nerves proceed from the perineal branch of the internal pudic; tht y send
branches to the corpus cavernosum, and terminate in  the prepuce, which is the
principal seat of voluptuousness in the female.]

  4. The vestibule is a small triangular space  placed at the upper pxrt of
the vulva.  It is bounded above  by the clitoris, below by the urethra, and
laterally by the nymphae.
  5.  The Urethra. — The meatus urinarius  is  situated just below the ves-.
tibule, about an inch from the  clitoris, and immediately above the promi-
nent enlargement of the anterior  part of the vagina.  The orifice is usually
more  contracted  than the  canal,  but the tubercle, or enlargement  just
alluded to,  enables us to sound females without uncovering  them, for it is
only necessary to recognize  it by the  finger in order to direct the instru-
ment properly.  In my estimation,  the following is the most simple method
of introducing the catheter without uncovering the patient;  1  first intro-
duce my finger into  the  orifice  of the vagina, and rest its  palmar  face
against  the anterior vaginal wall;  I then slide the instrument  along this
palmar  face  until  it  is arrested by the fold already  alluded to ; then  I
depress  the extremity so as to elevate the point of the instrument one or
two lines, and in the majority  of cases, the  canal  is easily entered in this
manner.

  [If the first attempt should fail, it may be tried again in  another way.  Tho
point of the forefinger  finds  the clitoris, and passes from above downwards to tire
middle of the vestibule; the first inequality met with is the orifice of the urethra,
into which the instrument  can then be inserted.  I have often succeeded in this
way, after having failed by the ordinary method.
  In some women, those especially who have borne children, the  parts  adjoining
the meatus  are so deformed, that it becomes  absolutely necessary to expose the
parts in order  to introduce the catheter; even then it is by no means  easily done,
and I have seen the most skilful foiled in  attempting  it. It may be accomplished
with  certainty by  separating carefully the greater  and lesser labia,  and then
Bliding the extremity of the catheter from above downward along the median line
of the vestibule below the clitoris, which is the  chief rallying point.  During this
movement the instrument falls, so to  speak, of its own accord into the orifice of
the urethra ; but if  slid either to the right or left,  it will be sure to go astray.
We shall learn hereafter (article Pregnancy) the cause of the difficulties met with
in catheterizing pregnant women.]

  The  urethra, a  continuation  of the meatus urinarius, just  described,
varies in the female from one to one  and  a half inches  in  length.   It is
large, conical,  and slightly curved.   Its inferior portion  is confounded 
62
FEMALE  ORGANS  OF  GENERATION.
with, or  at  least intimately united to, the anterior vaginal Avail, and  its
anterior parietes, separated in front from the  pubis by some cellular  tissue
only, is located on a level with the symphysis, under the junction of the
two crura of the clitoris.
  The canal of the urethra is muscular and erectile, having a thick lamina
of muscular fibres, which  seem to be a continuation of those of the blad-
der ; another thick layer formed by a venous plexus, lies subjacent to the
mucous membrane.
  Occasionally, this canal is enormously dilated.   Flamand met with a case
that  permitted the introduction of the finger, and Meyer,  with another,
which eventually admitted of coition !
  6.  The  Hymen. — The irregular opening of the vagina is found  beneath
the meatus  urinarius;  it  is of variable  dimensions after coition, and  in
females who have had children ;  but in virgins, it is provided with a mem-
brane by which the orifice is diminished.  This  membrane  is the hymen,
a species  of diaphragm, interposed between  the internal organs  and the
external genital apparatus  and the urinary passages.   It resembles a crescent
in shape (Fig. 19), the concavity being anterior; sometimes the horns  of
the crescent are  prolonged  enough to join each other, thus forming a com-
plete circle, perforated in the centre (Fig. 20); its free  margin is thin and
concave; the convex one is continuous with the membrane of the vagina or
vulva, and as fhis blocks up the posterior and lateral parts of the vagina,
a notable difference will exist in the extent of the orifice, dependent upon
the greater or less size of the hymen.
  Sometimes the hymen forms a complete imperforate membrane.   Though
often thin, transparent, and very fragile, it is  occasionally found thick and
resisting.
Fig. 19.                                Fig. 20.
 Fig. 19.  Ilymen in the form of a crescent.
 a. Clitoris. B. Labia externa, c. Labia interna. D. Orifice of the urethra,  e. IlymeD
of the vagina. G. Posterior commissure of the vulva.
 Fig. 20.  This figure exhibits the hymen in the form of a circle, e. The hymen, p. '
oreni-i? somewhat elongated. 
               EXTERNAL ORGANS OF GENERATION.             63

  The two forms just mentioned are not  the only ones which the hymen
may assume; other varieties have been described by M. Velpeau, as follows:
1.  In the semicircular species, the hymen may form such a narrow and
solid  fold as  to permit copulation without being ruptured.  2. In the cres-
centic variety (Fig. 19) the concave border approaches more or less towards
the urethra, in such a way as to contract the vagina  behind, and  hence it
almost always gives way in coition.  3. In the circular variety, the free
border is much thinner than the other (Fig. 20% often being fringed, as it
were, and leaving an opening which is sometimes round, sometimes slightly
elongated, though in general situated somewhat nearer to the anterior than
the posterior  wall of the vagina.  4. Again, Ave find a disk or complete
diaphragm, that is ordinarily pierced by a number of small holes like those
of a Avatering-pot, and at other times is  Avithout the least aperture.   5. In
Bome instances a species of bridle, or a  small cord attached under the urethra,
or on the concave border of the hymen, supplants  both the valve and  the
circle.  6. Lastly, a second hymen occasionally exists above the first.

  [Full details of the anatomy of this membrane may be found in the thesis of M.
Ledru, defended before the Faculty of Medicine, Paris, 1855.
  The hymen is formed by a fold of the vaginal mucous membrane, between  the
layers of which are cellular tissue fibres, some muscular fibres, vessels, and nerve
filaments.]

  This membrane is  regarded as the seal of  virginity;  and yet,  as just
shown, it is often found after a fecundation; and, on the other hand, numer-
ous causes besides coition may destroy it.   It is generally ruptured  at  the
first sexual  approaches,  and of its debris  are  formed tAvo or  three little
tubercles, bearing the name of  carunculce myrtiformes.
  The hymen is composed of a  fold  of mucous  membrane, containing
between  its laminai  a few vessels and  some areolar tissue.
  7. The carunculoz myrtiformes are some little tubercles, two to five in
number,  Avhich appear to  be  the  debris of the ruptured hymen; the two
most  anterior ones, according to certain  physiologists, appertain to  the
median columns of  the vagina.
  In  consequence of oft-repeated friction, these  caruncles  may inflame,
degenerate, and even become the source of an abundant purulent discharge;
they have been mistaken under such circumstances for syphilitic vegetations,
and the patient subjected  to anti-venereal treatment, which, at least, Avas
useless.   Personal  cleanliness,  and some of the vegeto-mineral lotions  are
usually sufficient to cause  their disappearance.   M. Yelpeau has resorted,
however, in some cases, to excision.
  8. Fossa Xuvicularis. — This is a little depression, of half an inch only in
extent, bounded behind  by the fourchette, and in front by the  convex
border of the hymen.  It, like the fourchette, formed, as before stated, by
the junction of the inferior extremities of the labia majora, mostly disappears
after  delivery. 
64
FEMALE  ORGANS OF  GENERATION.
                            ARTICLE  III.

     OF  THE SECRETORY APPARATUS OF THE  EXTERNAL  ORGANS OF
                                GENERATION.

  [The  secretory apparatus of the female genital organs has been the  subject of
numerous investigations, but of late a fresh interest in the subject has given rise to
works by Robert,  Iluguier, Sappey, Martin, and  Leger, all of  which  are  placed
under contribution in the preparation of this article.
  Aside  from the piliferous  bulbs, the glands of the vulva may be arranged  in
three classes:   1. Sudoriparous glands;  2.  Sebaceous  glands; 3. Muciparous
glands and follicles.
  First class. — The sudoriparous glands are found on the penil and the external
surface of the  labia majora  ; they are mingled with the  sebaceous glands  and
surround  the bases of the  hair  bulbs.  Presenting the  same arrangement as  in
other parts of the body, they  are noticeable here on account of their great number.
  Second  class. — The  sebaceous glands of the Arulva  are extremely  numerous.
Those of the mons veneris and of the outer surface of the labia majora are remark-
able for their  size, having  an average diameter of -rjj5  of an  inch.   They are
generally composed of from four to six  lobules, each containing eight or ten culs-
de-sac.  They always open  upon a piliferous bulb.
  The internal  surfaces of the labia majora are also provided with sebaceous glands
to the extent of about forty to  every f of an inch square.  They are  still more
numerous upon both sides of the lesser  labia,  the inner surfaces of which  present
about one hundred and fifty to e\rery f of an inch square.  Martin and  Leger note
the fact, that these glunds, which are very apparent in  the adult female, become
atrophied after  the cessation of the menstrual function, and cannot be found at all
in the foetus.
  The sebaceous  glands are  also found on the fourchette and the prepuce of the
clitoris.   No trace of them, hoAvever, is to be discovered either in  the vestibule  or
around the orifice of the urethra.
  These glands secrete an oily matter, Avhich maintains the suppleness of the parts
to which it  is applied,  prevents them from contracting  abnormal adhesions,  and
preserves them  from irritation by the urine.
   Third class. — The muciparous follicles as described by M. Iluguier, present two
varieties: in the first, they are isolated or simply agminated, isolated or agminated
follicles;  in  the second they are enclosed in one envelope, and discharge into the
same excretory  canal, vuloo-vaginal glands.
  A. Isolated or agminated  muciparous follicles.  These follicles  exist, accordino- to
Huguier, upon  several points of the circumference of the Araginal orifice ; they are
sometimes absent  and always difficult to discover; their existence even has been
denied by some anatomists  (Sappey, Martin,  Leger).   Huguier  describes three
groups of them.
  1. — Eight or ten of them  are found  in the vestibule below the clitoris  where
they open by separate orifices, Avhich  are very small and  partly  covered by a  root
of valve  easily  raised by a  probe; [Vestibular follicles of Iluguier)  (fin.  21, A).
These follicles are mere depressions in the mucous membrane without a diverticu-
lum.  So  simple  is their structure, that Martin and Leger refused  to call them
muciparous follicles.]

   2. Others, termed urethral follicles  on  account of their situation,  are stated
by  M. Huguier to be less readily discoverable than the preceding, on Avhich
account they  Avere supposed  by M. Robert to be less numerous.  They are 
EXTERNAL ORGANS OF GENERATION.
65
f(Mtf'ji
of considerable size, and  are situated at a depth of from three-eighths to
four-eighths of an inch in the cellulo-vascular  tissue of the urethra (Fig.
21, c).  They are placed  beneath the  mucous membrane in a direction
parallel to the canal, and  discharge in close proximity to the orifice of  the
urethra upon the surface of the projection Avhich          fig. 21.
forms  the inferior boundary of  that  opening
in such a way as to form a semicircle, or some-
times even  an entire  circle, around it.  They
are closer together than those which  have been
just  described, and sometimes several of them
open  into the same  excretory cavity, so as to
produce the ramified arrangement Avhich Graaf
has figured and described.
   3.  Laterally, and at some distance from the
urethral  orifice, are several  small and  shallow
ones, Avith a common opening at the bottom of a
remarkable  conical  depression.   M. Huguier
states that these are  often absent, and  he pro-
poses calling them the lateral urethral  follicles
(Fig. 21,  b).
   4.  Besides these, some two, three, or four large
follicles are found in  some females upon the
lateral parts of the vaginal orifice, immediately beloAV the hymen  or  the
upper carunculse myrtiformes (Fig. 21, d) ; they are the  lateral follicles of
the orifice  of the vagina.   Their openings ordinarily correspond neither in
number, situation, nor arrangement, with those of the opposite side; some
are slightly projecting whilst others are not so, and some are readily visible
whilst others are hidden beneath the myrtiform caruncles.
   B.  Vulvo-vaginal gland. — This gland had been completely lost sight of by
modern anatomists, although described by Caspar Bartholin ; and attention
has only recently been  called to it by M. Huguier.  It belongs to the class
of conglomerate  glands.  There are tAvo vulvo-vaginal glands, one on each
side,  where thev form peculiar bodies whose position it is important to define
Avith  exactness.  They are situated at the limits of the vulva and vagina,
upon  the lateral and posterior parts of the latter, about three-eighths of an
inch  above the upper surface of the hymen or of the myrtiform caruncles,
ia the triangular space formed on  each side  by the juxtaposition of  the
lectum and vagina,  upon the latter  of Avhich  they  repose.  They lie at a
distance of from  three-eighths to five-eighths of an inch from the internal
surface of the ascending rami of the  ischia, and  from three-quarters of an
iach  to one and a quarter inches from the external labia.
   The vulvo-vaainal gland has someAvhat the  shape of an apricot-kernel,
resembling  in  this respect the lachrymal gland;  like the latter, its  two
surfaces are flattened, and it is besides  slightly lobular and mamelonated.
According to M. Huguier, it is  much  flatter  in  women Avho have borne
children, which he attributes to the species of separation which its granular
elements  must undergo from the  enormo\is distention of the vulva during 
66
FEMALE ORGANS OF GENERATION.
Fig. 22.
labor.   The gland of the right side does not ahvays resemble that of the left:
it is indeed not uncommon to find one much more developed than the other.
  Its  size varies much according to age,  habits, and, adds M.  Huguier,
                                 according to the  development of  the
                                  ovaries,  Avhich appear  to  exercise a de-
                                 cided influence over it; for he has always
                                 found  the largest gland upon  the same
                                 side Avith  the most  voluminous ovary.
                                 It also  appears  larger in females Avho
                                 indulge  immoderately in  sexual plea
                                 sures.   Its size is greatest, in general,
                                 between the ages of sixteen and thirty-
                                 five years.  Its diameter  at this period
                                 of life is, on an average, from four-eighths
                                 to  five-eighths of an inch.  It is  very
                                 small at puberty, and becomes atrophied
                                 in old age.
                                    Excretory Duct. — Each of the gran-
                                 ules of Avhich the  gland is composed, is
                                 furnished with a minute duct, which, by
                                 uniting  with  those of the neighboring
                                 granules, gives rise to  three  separate
                                 ducts.   The  latter soon join to form  a
                                 single  canal,  Avhich  proceeds from the
                                 internal surface and vulvar extremity
                                 of the gland  (Fig. 22,  D), and opens in
                                 virgins, or in females in whom the hymen
                                 has been only  dilated, in the internal
                                 angle AArhich the great  circumference of
                                 this membrane  forms by  its  union Avith
the contour of the vulvar opening, and, Avhen the hymen has been ruptured,
at the base of the lateral and posterior  myrtiform caruncles (Fig. 22, E).
The orifice, Avhich is smaller  than the duct Avhich it terminates, is in  most
women surrounded by a vascular area, which serves, by its lively red color,
to distinguish it  from  the neighboring parts.  If required, it will only be
necessary to turn the caruncle imvard in order to render it conspicuous:
it  should however be distinguished from  three or four  minute  openino-g
found in the same furrow, and which belong to the lateral follicles of the
orifice of the vagina.
  The direction of the opening of the duct is perpendicular, but its oblique
orifice is directed upAvards and imvards.   Its external semi-circumference is
provided Avith a small falciform, valvular fold of mucous membrane, Avhich
increases the difficulty of its detection.  In the normal condition the diameter
of the orifice hardly exceeds the one-one-hundreth of an inch.
   The diameter of the duct varies  from the one-tAventy-fourth to the one-
eighth of an inch, and its length, Avhich lessens  as the gland is  more volu-
minous  and  approaches  near the myrtiform  caruncles, is, on an average
about five-eighths of an inch.
        A'ulvo-vaginal Gland.
 A A. Sertion of the labia majora and of the
nympha?. showing the excretory duct and its
orifice.  B. The gland. C. Excretory duct. C
Stylet engaged in the orifice of the excretory
dnct.  D. Its  glandular extremity.  E. Its
vulvar extremity and orifice.  F. Bulb of the
vagina. G. Ascending ramus of the ischium. 
                EXTERNAL  ORGANS OF GENERATION.             67

   Organization. — The tissue proper, or glandular tissue, is of a ydlowish-
 vvhite color, and, Avhen examined by a magnifier, or even by the naked eye
 appears composed of  lobules, themselves  formed of granulations having a
 rounded and holloAv appearance.  The entire mass is surrounded by a fibro-
 cellular envelope, the thickness and transparency of Avhich varies in different
 individuals.   From the internal surface of the envelope are sent off a great
 number of fibrous prolongations Avhich serve both to connect and separate
 the granules of the organs.
   These  glands  are provided Avith arteries,  veins,  lymphatic vessels,  and
 nerves.   The arteries, two in number, are derived from the clitoric branch
 of the internal pudic; one of them is sometimes given off directly from the
 trunk of  the latter.  The veins, which form a sort of plexus  upon the sur-
 face of the  organ, empty partly into  the  pudic veins, and partly into the
 venous plexus of the vagina and the bulb.
   The lymphatic  vessels  proceed to the lymphatic ganglions  found in the
 cellular triangle  included  betAveen the lateral parts of the vagina and the
 rectum and not into the inguinal glands.
   The nerves are demred from the deep branch of the perineo-vulvar branch
 of the internal pudic.
   When the glands are incised, they are found to contain a glutinous, thick,
 and  unctuous  fluid, Avhich is generally colorless,  transparent,  or slightly
 burbid.  In some cases  it  is brownish or of a deep chestnut color, Avhich
 appearance is due to altered blood-corpuscles.
   Uses and Functions.—The vulvo-vaginal gland, like the entire generative
 apparatus of Avhich  it forms a part, acquires its full  development only at
 puberty.  This concordance alone, independently of observation, Avould lead
 to the supposition that the fluid Avhich it secretes is destined to bear a part
 in the generative act.
   The amount of its secretion is, in fact, variable.  It is especially increased
 during sexual intercourse, illicit contacts, and under the influence of lasciv-
 ious  thoughts, desires, and  dreams.   "When, during coition, the muscles of
 the perineum and  vulva are excited to involuntary and convulsive contrac-
 tions, it is expelled in  an  intermittent manner or by jets, as is the sperm in
 the ejaculation of the male.  According to M. Huguier, the use  of  this
 abundant secretion is to lubricate the external  parts, and thus render the
 first approaches less  painful, to maintain the humidity of the organs during
 the act, and thereby preserve their extreme sensibility.

                           ARTICLE  IV.
                               PERINEUM.
   9.  The  perineum is  a sort of  bridge, scarcely an inch to an inch and a
half long, Avhich separates  the  vulva from the anus; its inferior plane is
composed  of the skin.   But, for a more full description of the parts enter-
ing into its  structure, I must refer to the  treatises on anatomy.   (See  art.
Pelvis.  See also the first number of the Traite d'Accouchements of M. P,
Dubois, and the At bis Complimentaire de tous  les Traite* d' Accouchements, of
Lenoir). 
68
FEMALE  ORGANS OF GENERATION.
                         CHAPTER III.

            OF  THE INTERNAL  ORGANS OF GENERATION.

  The internal organs of generation are the vagina and the uterus, togethei
with its appendages, the Fallopian tubes and ovaries.

                           ARTICLE  I.
                           OF THE VAGINA.   *
  The vagina, or vulvo-uterine canal, is  a cylindrical membranous tube,
extending from the vulva to the uterus; it is situated in the pelvic excava-
tion betAveen the bladder and rectum; extending from  the vulva  to the
superior strait, it has of course the same direction as the general axis of the
pelvis: that is, it  forms a curve, the concavity of which is  anterior; the
walls are soft and yielding, flattened from  before backAvards, Avith their sur-
faces  in contact.  Its length varies  from  four and a quarter to five and a
quarter inches, though, according  to Professor Velpeau (Legons Orales), it
is much  less  than has been  generally imagined, or than he himself has
pointed out in his Avorks, being hardly tAVO and a quarter to two and three-
quarter inches long.  Although this remark may be true, if the length be
measured  in the dead  subject, Avhere the soft flabby walls of the  vagina
easily yield under their own Aveight and  that  of the uterus,  and in conse-
quence, the vertical extent of this cavity does not exceed three or three and
a half inches ; yet, the elasticity of these Avails will permit the introduction
of a speculum five or six inches long, and Avhen the uterus  is raised  com-
pletely above the superior strait, the estimate of the Professor of La Charite
is certainly below the truth.
  The length  of the vagina varies in different females ; thus, for instance,
the negress has it longer and more  spacious than the European, as a general
rule.  Professor Chomel informed me that he, had frequently remarked this
fact, and I have since  had occasion to verify its  truth ; nor  is the  vagina
uniform in its  size, in all  parts of  its extent;  for the inferior orifice is the
most  contracted, the superior  extremity is the largest, whilst the  middle
part, especially in Avomen who have had many children, frequently exhibits
a considerable extension.  The Avails apparently retract in aged females,
and  greatly diminish the area of  its cavity, returning very nearly  to the
same dimensions as are found in young girls.
  This canal  is sometimes  very short, reduced even  to one and a half or
two inches; but  this congenital brevity must not be confounded with the
apparent shortening produced by the descent of the uterus.
  M. Cruveilhier says these cases are daily confounded in practice, though
n othing, however, is easier than to distinguish  them from each other;  for
in the former one, the uterus cannot be raised, whereas, in the case of
descent, it yields without resistance to the pressure of the finger, and resumes
its natural position.
  Congenital shortening is a frequent cause of sterility, as well as of sharp 
               INTERNAL  ORGANS  OF  GENERATION.            69

pains in coition, and is a fruitful source of the  acute or chronic inflam-
matory engorgements of the uterus.   I have met with a case of considerable
shortening of the vagina, in which the os tincae had been sufficiently dilated
by the membrum virile, to admit the index finger.  In some instances the
repeated coition produces a sort of artificial vagina, behind the os uteri, at
the expense of the posterior vaginal Avail, and if the finger be then carried
under the neck of the Avomb, it will dip into a pocket, the anterior Avail of
which is  placed against the posterior  one of the uterus.   This artificial
vagina, produced by forcing up the posterior cul-de-sac, is sometimes longer
than  the  natural canal.
  The vagina is in relation by its external face: in front, Avith the bas-fond
of the bladder, to Avhich it is united by  some condensed  areolar tissue, and
also with  the canal of the urethra, Avhich indeed  appears to be channelled
out in its substance; behind, it is connected Avith the rectum, superiorly by
a double  fold of peritoneum, and inferiorly by areolar tissue, which is less
condensed than that existing in front.   Hence, the rectum is seldom draAvn
upon in the displacements of the uterus, Avhilst the bladder ahvays partici-
pates more or less in these  accidents.   The lateral borders  afford attach-
ment, above to the broad ligaments, and beloAv to  the  pelvic areolar tissue
and to some venous  plexuses.
  The internal face of the vagina is covered by a mucous membrane, con-
tinuous Avith that of the uterine cavity,  excepting that its epithelium is not
prolonged into the  orifice of the latter, but terminates by a sort of denti-
culated border, similar to the relation of the oesophageal epidermis Avith the
stomach ; the  internal surface  also exhibits some wrinkles or rather some
transverse elevations near the vulvar orifice.  A raphe, or prominent ridge
found on the median line, extends the Avhole length of the anterior Avail of
the vagina, affording origin to all those  rugae; but the raphe is not so Avell
marked on the posterior parietes as on the anterior; the term columns of the
vagina has been applied to these tAvo ridges.
  The transverse rugae are much better developed in young virgins and
aged  females;  but, on the contrary, during pregnancy, and for a short time
after  delivery, they are  nearly effaced.  These  transverse  rugae have by
some  physiologists been  regarded as organs of  special  sensation, and as
designed to increase friction by the irregularities  which  they present.

  [The upper extremity of the vagina embraces the neck of the uterus, to which  it
is attached, at the junction of the  lower Avith the middle third.  The  neck is thus
divided into two portions, an intra-vaginal and a supra-vaginal portion.  At the
point of insertion there is a true continuity of tissue between the vagina and uterus,
inasmuc/  as on  the one hand the vaginal mucous membrane is simply reflected so
as to form the mucous membrane of the os tincae, whilst on the other, the muscular
fibres  of the vagina are directly continuous Avith those of the uterus.]

  In  thus folding upon  itself in order to embrace the neck, the mucous
membrane of the vagina forms  a circular groove or cul-de-sac, described as
the anterior and posterior cul-de-sac.   The posterior one is, generally, deeper
than  the  anterior, owing probably  to the  insertion of the vagina behind,
upon  a more elevated point of the neck. 
70              FEMALE  ORGANS  OF  GENERATION.
  The inferior extremity, or vulvar orifice, presents, in  front, a transverse
rugous prominence, that seems to diminish the entrance.
  Structure of the Vagina. — [The walls of the  vagina  average in thickness from
one-eighth to three-sixteenths of an inch.  It  ia composed of three layers:  one,
external or cellulo-fibrous;  a middle or muscular one;  and the internal or mucous.
  The external layer is composed of fibres of both elastic and connective tissue; it
blends externally Avith the organs  surrounding the vagina, and internally with the
middle layer.
  The middle layer is composed of muscular fibres which are inserted in front upon
the branches of the ischium and pubis, and are continued upward to become blended
with the middle layer of fibres of the uterus. Some again disappear upon the utero-
sacral ligaments, whilst others cross each other in all directions, leaving interspaces
occupied by projecting veins.
  The internal or mucous layer is of a pale-red color, Avhich becomes violet  during
menstruation  and  especially during  pregnancy.   Its external surface  is  con-
founded with  the preceding layer, whilst its internal is  covered with tessellated
epithelium and abounds in folds analogous to papillae.   For a long "time this mem-
brane was supposed to be rich in mucous follicles, but anatomists now agree in the
opinion that the vagina is destitute of mucous glands.
  In great part, the Avails of the Aragina are composed of a tissue possessing all the
characters of spongy erectile tissue; that such is the case has been  proved beyond
cavil by the researches of M. Kobelt and Ch. Rouget.]
  According to Kobelt, this erectile tissue is composed of several superposed
layers of venous network which proceed from the bulb, the finest ramifica-
tions extending into the mucous membrane.   This true spongy body extends
continuously through the entire limits of  the vestibule and of  the vagina,
and  seems connected Avith the veins of the parenchyma of the uterus.  The
great vascularity of the walls of the vagina explains, to a certain extent,
the  dangers  consequent upon  their  rupture.    Surrounding the  loAver
extremity of the vagina  are  a feAv  muscular fibres, that constitute what is
erroneously called  (see below)  the  constrictor vaginae  muscle.  In some
females, this is quite strong and Avell developed.
  Finally, under  the name of  bulb of the vagina,  a  SAvelling  or cavernous
body is described, that separates the orifice of this canal from the roots of
the clitoris:  moderately thick in the centre, Avhere it is  placed betAveen  the
meatus urinarius and the junction of the crurae clitoridis, it gradually SAvells
out,  as it recedes from  this  point, and terminates  beloAv in an enlarged
extremity on the  sides of the vagina, being deficient, however  on   the
posterior wall of this canal.   The length of the bulb, when injected, is about
one inch and three-eighths of an inch; its greatest width, from one-half to
three-quarters of an inch, and its thickness from about  three-eighths of an
inch to one-quarter  of an inch.   (Kobelt.)    The bulb of the vagina is com-
posed of an erectile tissue analogous to that of  the bulb of the urethra in
the  male, and  communicates  freely, as shoAvn by M. Deville, Avith  the
cavernous tissue of the clitoris, by means of several veins of considerable size
  The bulb of the vagina is surrounded, as it Avere, by a layer of muscular
fibres (constrictor  cunni), in regard  to the arrangement of Avhich authors
differ.   According to Kobelt, there are  two constrictor  muscles.  It takes
its origin by a large  and flattened base from the aponeurosis of the perineum
almost directly at the middle of the space Avhich  separates the anus fron/ 
INTERNAL  ORGANS  OF  GENERATION.
71
 the tuberosity jf the ischium; thence it rises, becoming at the same  time
 narrower towards the clitoris, and  covers or rather embraces in the shape
 of a half cylinder the-entire length and width of the bulb of the vagina.
   A  closer examination, says Kobelt, shows that  this  muscle is composed
 of tevo flattened layers, the deeper of which glides in  between the upper
 border of the bulb  and the root of the clitoris, and so appears above the
 urethra to unite Avith the muscle of the opposite side;  the upper layer, on
 the contrary, which  is also flat, rises upon  the back of the clitoris, and is
 connected with its fellow by a flat and narrow tendon.
   This muscle, Avhich is, in fact, at a considerable distance from the vaginal
 orifice, has been  erroneously regarded as a sphincter of the vagina.   Xoav
 its poAver to diminish the orifice of the vagina is but momentary, and only
 by compressing the bulb when greatly distended at the  moment of coition.
 Its proper office is, in fact, that of a compressor of the bulb, Avhilst its upper
 extremity tends, at the same time, to depress the gfexnd of the clitoris  toAvards
 the vestibule.
   Vessels. — The vaginal arteries come from the hypogastric; the veins are
 very numerous and plexiform, and  discharge into the hypogastrics; the
 lymphatics empty into the ganglions of the pelvis, and the*nerves arise from
 the hypogastric plexus.
   The vagina serves in the  female  both as the  organ of copulation and as
 the canal for the passage of the menstrual fluid, and for that of the  product
 of conception.
                            ARTICLE  II.
                             OF THE UTERUS.
   The uterus is the organ  of gestation, in  Avhich  the ovum is destined to
 remain, from  the   period  of  its
 escape from  the Fallopian tube,
 until the moment of final  delivery.
   In  form,  it  resembles  a small
 gourd, or a  pear flattened from
 before  backwards, having its base
 turned  upAvards  and  the apex
 doAvmvards.
   The  organ  is divided  into tAvo
 parts, the superior of which, called
 the body, is the largest, and  com-
 prises more  than half  the total
 length ;  the  other, or inferior por-
 tion, styled the neck, is smaller;  a
 slight circular  constriction  serves
 to indicate externally the point of
 union of the body with the neck.
   The axis runs from above doAvn-
 wards, and from before backwards,
corresponding nearly with that  of
the superior strait.
   It is situated in the excavation,
         The Internal Genital Organs.
  a. The uterus, seen on its anterior lace. B. The intra-
vaginal portion of the neck of the uterus,  c C. The
Fallopian tubes.  D. The  pavilion, or fimbriated os
treniit;. of the tube, e e. The ovaries,  f. The ligain,m»
of the ovary, o G. The round ligaments, n. The vagina,
laid open.
  On the right, fhe fimbriated extremity of the tube ii
seen applied to the ovary. 
72
FEMALE  ORGANS  OF  GENERATION.
 usually on the median line, betAveen the bladder and rectum, being retainer!
 in position by the round  and the broad ligaments on the sides, and below
 by the vagina, upon Avhich it rests.

   [The situation of the uterus is affected by the fulness or emptiness of the bladder.
 When the latter is empty, the uterus is near the pubis and the neck directed hack-
 ward.  When the bladder is full, the uterus is pushed back, and its axis corresponds
 nearly with that of the vagina.]

   As we have said before, the neck of the uterus is embraced about its
 middle by the mucous membrane of the  vagina, being thereby divided into
 two portions, of Avhich the one situated above the insertion of the vagina is
 called the superior vaginal; and the other, Avhich  projects into the  upper
 part of that canal, is termed  the inferior vaginal portion of the neck.
  The connections of thekuterus are very loose and extensible;  it therefore
 exhibits  a great  degree  of mobility, and  may easily be  moved  in  every
 direction.
  Its volume varies with  age, being quite small prior to the fifteenth  year,
 but augmenting rapidly at this  era;  the womb never resumes completely its
 primitive dimensions in  Avomen Avho have borne children, and finally, in
 advanced age, it often appears  to waste aAvay, and to dAvindle doAvn to the
size it had prior to the fifteenth year.  Its dimensions after puberty are as
 folloAvs, viz.: The vertical diameter varies from tAvo and five-eighths to two
 and three-quarter inches;  the transverse  one, at the fundus, one and three-
 eighths to one and a half inches.  Certain physiological  conditions produce
a  great  augmentation in its  volume.   For  instance, I have  frequently
observed at the approach of the monthly  courses,  that  it presented  twice
the ordinary size at least, and in some Avomen  the increase in volume is so
marked at this period as to be mistaken for the commencement of a preg-
nancy.  (See Diagnosis of Pregnancy.)
  The  uterus  likewise varies in situation at different epochs; thus it sur-
 mounts the superior strait in  the foetus, and rests in the  abdominal cavitv,
so that the Fallopian tubes and ovaries  occupy the iliac fossae,  the fundus
 uteri corresponding  to the fifth lumbar vertebra.   After birth,  in conse-
quence of the development of the pelvis, it appears to sink gradually into the
excavation, and, at ten years, the fundus is on a level Avith the superior strait.
 but subsequently gets beloAV this point.   The  womb is generally inclined
 to the right or left in aged females, or is turned backAvards on the rectum.
  The  axis of the uterus  approaches that of the inferior  strait  in  manv
 women, especially in  those having a short vagina.   It must  further be
 observed, that the direction described by us as normal, is far from  being   •
 constant  in all women ; thus, in some cases, the fundus  may be throAvn so
 far forwards as  to render the anterior wall the most inferior  part, thereby
 constituting what pathologists  have described as an anteversion; in others
 the superior border  is thrown  towards  the  most  inferior  portion of the
 Bacrum, the neck being carried  behind the posterior face of the pubis, thus
producing a retroversion;  again, it  is often turned  towards one side of the
 excavation, the neck being directed to the opposite side: this is lateral version. 
INTERNAL ORGANS OF GENERATION.
73
   Another  singular  anomaly in  the relative direction of the axis  of the
 body and that of the neck of the uterus  remains to be described.  In the
 normal condition, the axis of the neck seems to be identical Avith that of the
 body, and to be  simply a continuation of  it.   Now, in some subjects, the
 body of the uterus is found to form with the  neck an angle which approaches
 more or less to a right angle, as though one  of these parts had been strongly
 bent  upon the other, like the body of a retort upon its beak.  This inflexion
 may  take place  anteriorly, posteriorly, or  laterally,  and has been styled
 accordingly, anteflexion, retroflexion, and  lateroflexion.
   This alteration  in the relation of the  axis of the body Avith that of the
 neck of the  womb  may occur accidentally, and Ave  have  several  times
 observed it as a consequence of anteversion or retroversion, but certainly it
 is often congenital, and then, should it remain after puberty, and especially
 should it increase in extent, it might become a cause of sterility.
   [It is by no means  uncommon to  find a uterus presenting a curvature with con-
 cavity directed in front, the curve being most marked at the junction of the body
 Avith the neck.  This flexion, which in the  adult is exceptional, is the normal con-
 dition in the foetus at term.  The researches of Boulard, Verneuil, and Follin, have
 proved  this  to be a fact which  may be verified at any time.  The  question then
 arises, Is this inflection inherent to the uterus itself, or is it  due to  the form of the
 neighboring organs?  The discussions  upon  this point have been resumed by M.
 Sappey, who thinks that the curvature varies  according as the bladder is full or
 empty,  the uterus merely moulding itself upon  it as it were.  When the bladder is
 empty,  the abdominal viscera  press upon the  fundus of the Avomb and bend it
 forward.  Should death  supervene under these  circumstances — the uterus is over-
 taken, so to speak, by  the cadaveric rigidity whilst in its deviated condition, and at
 the autopsy presents an  inflexion apparently permanent and inherent in the organ
 itself, but which disappears if the bladder be filled by injection, having first taken
 care to place  the body for some  time in Avarm water so as to restore suppleness to
 the tissues.]
   The  Aveight of the womb, in girls at puberty,  is from six to ten drachms;
 but in Avomen avIio have had children,  it ranges from an ounce and a half
 to tAVO  ounces; and from one to two  drachms in very aged females.
   The  uterus exhibits an external and an internal surface.

   § 1.  External Surface.
   In the study of the external surface Ave should recognize the division into
 the body and the neck.
   Of the Body of  the Lterus.—The external  surface presents for our
 study tAvo faces, two borders, a base, and  an apex.
   The anterior face of the body is slightly  convex, is  covered by the  peri-
 toneum on its superior three-fourths, and  lies in a mediate relation Avith the
 posterior face of the  bladder, from Avhich  it is frequently separated by some
 folds  of the  small intestine;  whilst, at  the  inferior fourth, it is  in  contact
 with the bas-fond of the bladder, to which it is united by some loose cellular
 tissue.  This  latter connection explains  the frequent  participation  of the
 bladder in the uterine displacements, hoAvever  inconsiderable they may be,
as also how in certain cases vesico-uterine  fistulas may be produced after
difficult labors. 
74              FEMALE  ORGAN'S OF GENERATION.
  The posterior  face is much more  convex  than  the  preceding,  being
covered throughout its Avhole extent by the peritoneum ;  it is in a mediate
relation Avith the anterior surface of the rectum, the intestinal convolutions,
hoAvever, often separating them; it  may be readily examined through the
rectum.  The lateral borders are slightly concave, affording an  attachment
to the broad and  the round ligaments ; but,  as  M. Cruveilhier remarks
these  ligaments are attached to the anterior edge of the borders, and  hence
all the thickness of these margins is found behind the broad  ligaments, and
consequently the latter are on the  same plane as the anterior  face of the
womb.
  The base, fundus, or superior border of theAvomb is convex, looking upAvards
and fonvards, and covered by the convolutions of the small intestine.  It never
attains the level of the superior strait in the unimpregnated state, and* there-
fore it is only possible to feel it through the inferior abdominal Avail, by using
great  pressure.
  At  the junction of this base Avith the lateral borders of the body the tAvo
angles are formed, from  Avhich the Fallopian tubes and ligaments of the
ovary arise.
  The apex  or inferior angle is continuous with the neck, which  next claims
our attention.
  Of  the Neck of the Uterus.—Very remarkable differences are found
between the  neck  of the uterus in  a woman who  has borne children, and
that in one  who has never been a mother; we shall, therefore, consider it
successively in each, because the modifications it undergoes  during pregnancy
can only be  appreciated after, a careful study of the ordinary condition.
  1st. In the woman who  has never been a mother, the neck of the uterus is
from an inch to an inch and three-eighths in length, and  is separated from
the body by a narrow, constricted portion, which can easily be distinguished,
even on the  exterior of the organ.  At  the central part, Avhere  it is a little
enlarged and fusiform, it is about three-quarters of an inch in the transverse
diameter, and half an inch in the antero-posterior one.  Near the junction
of the superior third Avith the inferior  two-thirds, it is  embraced by the
upper end of the vagina, which descends a little loAver on the anterior than
on the posterior face, Avhence the subvaginal portion of the neck  is some-
what  longer behind; but  the contrary is true for that part above the vagina.
  The cervix is terminated  by an  extremity that  is  less voluminous than
the other portions of its extent, so as to present a conical form to the finger.
This extremity bears the name of the os tincce, or  tench's  mouth.  The os
tincae  presents two lips, separated by a small  transverse  fissure, someAvhat
swollen in the middle, called the external orifice of the neck.  The  orifice
is sometimes difficult to find  in a young marriageable girl.  But, accordinc
to Dubois, if the index encounters it, we may recognize the part  by compar-
ing the sensation then experienced with that produced by applying the pulp
of the finger upon the extremity of the nose, and feeling the depression  be-
tween the alae nasi.  The anterior lip is the thicker, though both are very
nearly of the same length,  the anterior one,  perhaps, descending a  little
lower  than the other.  Most  authors teach that the anterior lip  of the neck 
INTERNAL  ORGANS  OF GENERATION.
75
descends loAver than  the  posterior.   In detaching  the uterus from  a dead
body, no great difference, however, is observed in  this respect, but, on the
contrarv, if we touch a female, the distinction is much better marked.  I
believe  this results solely  from the fact of the  neck being directed a  little
posteriorly, so that the surface of the  os tincae is not horizontal, but inclined
backAvards; and, therefore,  the  anterior lip is necessarily somewhat loAver
than the posterior.  Besides, the finger in passing from beloAV upAvards, and
from  before backwards, must first encounter the anterior lip, and  is then
obliged to go higher and further behind to reach the posterior one.   These
lips are smooth and polished throughout, neither  presenting any inequali-
ties nor any depressions ; in fact, the  Avhole external surface of the neck is
equally smooth, and Avithout elevations.
  The cervix, as already stated, is slightly directed baekwards, so that, if
prolonged, it Avould terminate near the coccyx, or the  most inferior part of
the sacrum.  It  is situated in  the upper half of  the excavation, yet the
finger can  easily reach and  pass over its Avhole exterior surface.
  2d. In the female who has had several children, the neck has not the same
aspect,  and the length is so  variable that  it is not possible to announce it in
advance; though we may say, in general  terms, that it is shorter in propor-
tion to the larger number of children the Avoman has borne,  a  portion of it
seeming, as it Avere, to have been destroyed at every labor.
  Two  females, one of Avhom had seventeen, the other nineteen children.
have  been  under my care; the  neck in  each of them was  completely de-
stroyed, in its intra-vaginal  portion.  No  prominence Avas found at the
superior part of this canal, and the finger only encountered tAvo little tuber-
cles, as large as a lentil, separated by an  open orifice, by Avhich latter alone
the neck could be recognized.
  This  diminished length of the intra-vaginal portion of the  neck in women
who have borne many children, is due to  the strong traction upon the upper
extremity of the vagina in the preceding pregnancies, produced  by the ele-
vation of the  uterus; in consequence of this traction,  and the laxity of its
adhesions with the middle part  of the neck, the vagina becomes detached
from  it at that point, and adheres to it only at its inferior extremity. When
this has occurred, it is plain that the portion Avhich projects into the vagina
must  be much less considerable than  before.  Although it still preserves a
certain length, the regular form that it previously  had is Avanting, for it  is
no  longer  a fusiform body,  Avith  an exterior surface polished and  smooth
everyAvhere, but  a kind  of  irregular teat, covered  on its external face by
more  or less numerous elevations.
  Sometimes  it is more  SAVollen at the inferior portion, Avhilst the upper
part appears to be holloAved out in its whole circumference by a deep exca-
vation.
  The orifice of the os tincae is sufficiently patulous to admit the extremity
of the finger, or even one-half of its ungual portion may occasionally be
introduced. The lips are  unequal, presenting a variable number of notches
Beiin-- rarely found on the middle part of the lips, these depressions are con-
tinually met Avith about the level of the commissures, and more frequently 
76               FEMALE  ORGANS  OF  GENERATION.
on the left side than the right.  They result from the lacerations that have
occurred  in  former  labors, at the moment when the  head  cleared the os
uteri;  and the lochial  discharges  have  prevented  the lips  of these little
wounds from uniting, and they have cicatrized separately.  The depressions
are sometimes  so numerous as to subdivide the lips into six or eight small
tubercles, separated  by as many fissures of variable depth.
  In case the Avoman has not  had children for several years, and more espe-
cially if she has had but one  or two of them, these characters are much less
determined,  the  orifice is nearly obliterated, and the  neck  has gradually
resumed its primitive form ; nevertheless, the fissure of the orifice is ahvays
sufficiently marked,  as well as the inequalities on the lips, to indicate ante-
cedent labors.   These marks may become  more  and  more faint, but they
never disappear altogether.
  The frequency of these  depressions  on  the  left side may be,  I think,
readily explained.   When  the head  passes through the neck, it is evident
that, if a laceration  be produced, it will  be at the point which sustains the
greatest strain.   Now, the left occipito-iliac positions being much the more
frequent,  the occiput, Avhich constitutes the  largest extremity of the head,
will consequently correspond to the left commissure of  the neck.  Further,
the uterus is habitually inclined  to the right, so  that  the line of its con-
tractions is directed from right to left, and, therefore, acts more energetically
on the left side of the  cervix.  Hence  the greatest strains occur at  this
point.
  §  2.  Internal Surface.
  [The uterus has an internal surface Avhich  defines  its  cavity.   This cavity has,
in the virgin  condition, a longitudinal extent of about two and a quarter inches,
and of two and a half  inches after several labors.  We may distinguish the cavity
of the body and the cavity of the neck.  The length of the former is, in virgins,
rather less than that of the neck, whilst  in  multipara the two  dimensions  are
nearly  equal; — that of the  body being, perhaps,  rather  greater than  that  of
the neck.
  a.  The cavity of the  body is  triangular in shape, having two faces, three edo-es,
and  three  angles.   The  two faces are plane, and separated only  by a thin layer
of mucus,  so that they may be said to be in contact.
                                  Fig. 24.
                     Cavity of the Uterus and the Fallopian Tubes.
 A. Superior border or fundus of the womb.  b. Cavity of the womb. o. Cavity of the neck of the uterus.
D. The canal of the Fallopian tube cut open.  e. The fimbriated extremity or pavilion, likewise  laid open.
r F. The ovaries, one-half of which has been removed so as to bring into view several of the Graafian
resides.  G. Tho cavity of the vagina, h h. The ligaments of the ovaries,  q g. The round ligament. 
INTERNAL  ORGANS  OF GENERATION.
77
  Of the three edges, the upper extends from the orifice of one Falkpian tube to
the other, and the two lateral ones, from the orifice of each tube to  the  upper or
internal orifice of the neck.  In virgins, the three edges are curvilinear, with con-
vexity directed imvard ; in multiparae, they are  either rectilinear, or present a
slight curvature with concavity directed internally.
  The three angles are described as the superior or lateral, and the inferior.  The
two superior angles are at the extremities of the upper edge where it joins  the
lateral edges, and where are situated the very minute orifices of the Fallopian
tubes.  The inferior angle, formed  by the  convergence of the two lateral edges,
also presents an opening in the internal  orifice of the  neck, by which the cavity
of the body communicates with that of the neck.]
   In the state of vacuity, no cavity, to speak correctly, exists in the womb
for the uterine walls  are in contact throughout  their  extent;  the cavity
like that of the pleura for  example, has a real exist-
ence  only  when the walls become separated by a         fig. 25.
liquid effusion.   Fig. 25 will  afford an  idea  of the
dimensions of the uterine cavity when empty.
   The congenital  deficiency of a cavity in the body
is very  rare,  but yet  no  trace  of it existed  in a
uterus  presented  to  M.  Cruveilhier by M. Rostan,
although  that  of the  neck  remained.    In  aged
women, hoAvever, it is not very rare to  find the cavity
partly effaced by more or less extensive adhesions.
   B.  The  cavity of  the neck is fusiform, (see Figs.
24 and 25,) flattened from before backwards,  and
presents an assemblage of  rugae on its anterior  and
posterior Avails, Avhich  constitute  a median vertical
column upon  each Avail,  occupying the Avhole  length
of the  neck, and  from Avhich  a number of smaller
columns pass off  at  various angles,  representing a
fern  in relief.    The term arbor vitce has been applied  0f the cavity of the body
to these rugosities.   After delivery they frequently  of the neck of the womb in '
            °        .            ...     .               state of vacuity.
disappear, but Sometimes they Still persist.              A.  Mucous  membrane.   B.
                                                       Tissue proper.  c. Cavity ol
   [M. Guyon  observes very correctly, that the vertical  the body.  d. Cavity of the
column  situated  upon each of the walls is  not  exactly  neck'
upon the median line; that on the posterior wall being
a little to the left, and  that on the  anterior wall a little to the  right.  From  this
arrangement results a  complete  fitting or adjustment of  the two walls to each
other, Avhich is especially  observable at  the internal orifice.  Both  columns dis-
appear at the superior orifice of the cavity of the neck.
   The superior or internal orifice of the  neck is  not a narroAV ring, but is about
three-eighths of an inch  in extent, and might with great propriety be termed the
intermediate portion.  It forms, in fact, a sort of strait between the cavities of the
body  and neck.  M. Guyon, who has given a good description of this arrange-
ment, also states that after the menopause, the internal orifice often grows narrower,
and is sometimes entirely obliterated.]
   The  uterine  cavity  likewise exhibits a variable number  of  transparent
vesicles, mistaken  by  Naboth for  eggs, hence  they have been  called the
 This profile view gives an
exact idea of the dimensions
                   ant. 
78
FEMALE  ORGANS  OF  GENERATION.
ovula Nabothi.  These vesicles are nothing  more than  simple  muciparous
follicles, and they are particularly abundant in the neighborhood of the
neck.  They secrete a gelatinous mucus, Avhich may  accumulate  in  the
cavity of the neck, and so obstruct it as to render fecundation impossible.
  The internal surface of the uterus is much more vascular  in the body
than in the neck.  This  difference is particularly well marked in women
Avho have died during the menstrual period.   The cavity  of the body is of
a rose color, and  that of the neck of a pearly gray hue, which is probably
due  to the  slight vascularity of this part in  comparison  Avith  that of the
lining membrane of the body.

  § 3. Structure of the  Uterus.
  In the ordinary condition of the Avomb, this  structure is difficult to
make out, but it becomes much more evident during the period of gestation.
  The  constituent parts of  the  organ  are:  a middle or  tissue proper, an
external  peritoneal membrane,  and an internal mucous one, together Avith
numerous vessels and nerves.
  A. Tissue Proper. — This  tissue  is of a grayish color, and is very dense
in structure, creaking like  cartilage under  the scalpel.   In general,  the
neck appears less firm in consistence than  the body, resulting, as M. Cru-
veilhier supposes, from  the  former being the more frequent seat  of  san-
guineous fluxions.  It sometimes  happens,  as after  a suppression of the
menses, or just before or after menstruation, that  the  uterus  has  a more
decided red  color and its tissue is more supple.  (See Menstruation.')
  The proper tissue of the womb is composed of fibres disposed lengthAvise.
The nature  of these  fibres  has  led to numerous discussions, but at  the
present day they are  proven by the microscope  to be muscular, and since
this muscular nature becomes clearly evident toAvards the end  of gestation
(see Pregnancy), Ave must acknowledge  that, notAvithstanding  the fibrous
appearance of its tissue in the unimpregnated condition, the fibres composing
it are not the less muscular in  their structure.   This organization is  con-
cealed  by  the state  of  condensation;  of  atrophy, maintained  either by
inertia or Avant of action ; but which becomes distinct, in consequence of the
very considerable determination to the uterus, of its distention, and of the
development of its fibres during pregnancy.
  According to most  anatomists, the direction of these fibres in the  state of
vacuity is  very irregular, and  their inter-crossing is nearly  inextricable
as every  one must confess, in this particular condition, says M. Cruveilhier.
But as the structure of the uterus, except in gestation, is not of any conse-
quence (practically speaking)  to  the. accoucheur,  we refer to  the article
Pregnancy for the more particular study thereof.
  b. The External or  Peritoneal  Membrane.—The peritoneum  having
covered the posterior  face of the bladder, is  reflected upon the anterior one
of the uterus, covering only its superior three-fourths ; and having  reached
the  fundus  uteri, and gained the  posterior  wall, it covers this entire!v ia
prolonged on the vagina for a short distance, and is then reflected upon the 
                INTERNAL  ORGANS OF GENERATION.              79

rectum.  The broad ligaments are produced by the transverse  elongations
of this membrane; and its falciform folds, seen in the interval that separates
the  bladder  from the uterus, are called  the vesico-uterine, or the  anterior
ligaments;  and those formed by it, betAveen the rectum  and  uterus, are
called the  posterior, or the recto-uterine  ligaments.  The adherence of the
peritoneum is quite loose on the borders of the uterus, but it becomes more
intimate towards the median line.
  v.  The Internal or Mucous Membrane.—The existence of this membrane
was for a long time contested, and there  can be no doubt, that if a mem-
brane resembling the  majority of those Avhich line all the mucous cavities
be sought for in the uterus, it will be sought  in vain.   Still its  existence
is rendered very probable by the functions of the organ, for,  as  Cruveilhier
has remarked: 1st. Every organic cavity communicating Avith the exterior
is lined by  a mucous membrane.   2d.  Anatomy demonstrates  that the
vaginal mucous  membrane is continued  into the cavity of  the neck, and
then into that of the uterus.   3d. When  examined by a lens, the  internal
surface of the uterus exhibits a papillary disposition,  but the papillae are
imperfectly developed.  4th. This internal surface has  follicles or crypts
scattered over it, from which mucus can be squeezed out, and Avhich, if their
orifices be  obstructed  or  obliterated, become distended  by the  liquid, and
form  little  vesicles.  5th.  It is continually lubricated by mucus.  6th, and
lastly ; the  internal surface of the uterus,  like all other mucous membranes,
is subject  to spontaneous hemorrhages, to catarrhal secretions, and to the
mucous, fibrous, and vesicular vegetations called polypi;  and it is generally
admitted that, Avherever there is an identity of action, there is also an iden-
tity of nature.
  These physiological probabilities  are at present fully confirmed by ana-
tomical research, the numerous preparations in the possession of  M-. Coste
leaving no doubt Avhatever as  to the existence of the mucous  membrane.
I shall therefore borroAV from  this  able physiologist the principal facts
which pertain to its  description.
  The thickness of the uterine mucous membrane varies in different parts
of its extent.  Towards the  middle of the body, it forms one-fourth of the
thickness of the Avails of the uterus; that is  to say, its usual depth at this
point is from one-eighth to three-sixteenths of an inch, amounting to about
the  one-fourth of the thickness of the uterine parietes.   It thins off rapidly
towards the point of union of the body with the neck, as also toAvards the
apertures of  the  Fallopian tubes.  Its greatest thickness  in the neck does
not  exceed  the one twenty-fourth part of an inch.
  The thickness of the mucous membrane is clearly exhibited by the assist-
ance of a perpendicular section of the uterus.  It is then found to be in-
jected, and varying in color from a deep or bright red to a semi-transparent
reddish or  pearly gray:  the muscular tissue, on the contrary, is  almost
always of a reddish-gray color,  and is besides  easily distinguished by the
numerous vascular openings upon the surface of the section, and from which
blood may be caused to exude  by pressure.  In addition, there is always a 
80
FEMALE   ORGANS  OF  GENERATION.
 Avhitish line of demarcation betAveen the tAvo tissues, Avhich  becomes  most
 distinct when the injection of the mucous membrane is greatest.
   Its consistence is less than that of the tissue  proper of the uterus, being
 very friable, and easily crushed.
                                          It adheres very strongly to the
                  FlG-26                  substance of  the uterus, and is
                                        separated from it Avith great  diffi-
                                        culty :  it is also incapable of any
                                        gliding  motion  upon  the  parts
                                        Avhich it covers, on account of the
                                        entire absence of a sub-mucous cel-
                                        lular tissue.
                                          Its  internal  surface  presents a
                                        multitude of small  orifices, rather
                                        regularly arranged, Avhich, though
                                        barely perceptible to  the naked eye,
                                        become very evident- with the as-
                                        sistance of  a  lens.   About forty-
                                       five of them are contained in a space
                                        equivalent  to the square  of  one-
                                       eighth of an inch.   They  are the
                                       orifices of glands.
                                          M. Robin  has given an excellent
                                       description of the elements Avhich
                                       enter into the composition of the
                                       mucous membrane ;  they are :
                                          1. Embryo-plastic  nuclei; 2. Ele-
                                       ments  of laminated tissue ; 3.  Spe-
                                       cial cells, in very small amount
                                       except during pregnancy; 4. Amor-
phous connective matter; 5. Glands; 6.  Capillary vessels; 7. Epithelium
at first  prismatic  but becoming  pavimentous  during  pregnancy.  A feAV
words in regard to the uterine glands.
  Tavo species of glands exist in  this mucous membrane, one beino- found
only A\ithin the body of the uterus, Avhilst the other is confined to  the neck.
  1. According to M. Coste, Avho  Avas the first to describe them, the glands
of the body are especially visible Avhen death has occurred durino- menstrua-
tion ; they then appear as minute  canals of about the one two-hundred-and-
fiftieth part of an  inch in  diameter, placed vertically beside each  other.
They are, hoAvever, disposed so compactly, that the mucous membrane as  seen
by a lens appears to be formed of  them almost exclusively.  Their adherent
extremities terminate in culs-de-sac and  repose  upon the muscular tissue.
The bodies of the glands are rendered someAvhat  flexuous by the mucous
membrane  being too  thin,  as it Avere, in the state of vacuity, for the length
of the tubes.  They contain a Avhitish,  viscid fluid, Avhich may be squeezed
from them, especially at the menstrual  period.
 This figure represents the arrangement of the mucous
ti embrane and of the tissue proper of the uterus, as also
their relative dimensions.
 ,\. Cavity of the neck and arbor vitse. B. Cavity of
the body. c. Mucous membrane.  D. Intervening' mem-
brane. E. Represents the marked thinning off of the
mucous membrane towards the neck. 
INTERNAL  ORGANS OF GENERATION.
81
  2. The glands of the neck (glands, or ovula of Naboth) are found in all
the interval betAveen the line separating the cavity of the neck from that of
the body, and the neighborhood of the borders of the  os  tincae.  Their
orifices are readily seen upon, and especially between, the folds of the arbor
vitae.
  These glands have the form of a minute cylinder, terminating in a rounded
cul-de-sac, which is inflated into the form of a lentil or,vial, and inclosed in
the tissue of the  mucous  membrane, even  descending a little betAveen the
fibres of  the muscular structure.
  The excretory orifice is ahvays smaller than the glandular tube.  Pres-
sure causes the escape from it of a transparent, viscid, tenacious, and  com-
pletely homogeneous fluid.
  We shall treat hereafter of  the modifications Avhich these glands undergo
during gestation.

  [The epithelium of the uterine mucous membrane is cylindric, with vibratile cilia
moving from without inward.  It is therefore  impossible that the ciliary motion
should carry the  spermatic  fluid  toward  the openings of the tubes, as has  been
erroneously supposed.
  The entire cavity of the body and of the neck, to a point near the external ori-
fice of the latter, is covered with vibratile epithelium.  Below this point the mucous
membrane of the neck is furnished Avith the pavimentous variety.
  d. Vessels.—The arteries of the uterus proceed from the hypogastric and ovarian
arteries.  Both present many flexuosities in their course through the tissue of the
organ, and are  remarkable for their corkscrew form, recalling the arrangement of
the helicine arteries.  The neck is less vascular than the body.
  The veins are highly developed, anastomosing freely, and forming cavities, as it
were, in the muscular tissue.   They are  called uterine sinuses, and communicate
largely Avith the Aenous plexuses Avithin the folds  of the broad ligaments.  From
the latter proceed the uterine and ovarian veins which empty into  the correspond-
ing trunks.
  From the arrangement of  the uterine arteries and veins, surrounded as they are
everywhere by muscular partitions, it results, that the uterus is a true erectile organ,
as has been placed  beyond doubt by an excellent  memoir published by Professor
Rouget.   This  skilful anatomist has, in fact, shown that by injecting the veins of
the uterus the organ is put in a state of true erection, whereby it rises, swells, and
moves up toward  the abdomen.   Under these circumstances its volume is greater
by one-half than in the empty condition, and the walls of the cavity separate from
each other.  These  phenomena doubtless take  place during coition, and probably
facilitate the ascent of the spermatic fluid.
  The lymphatic vessels are  very abundant,  and pass into the pelvic and lumbar
ganglia.
  E. Nerres.—The nen^es are derived from the great sympathetic, some of them pro-
ceeding from the renal and others from the hypogastric plexuses; to the latter are
united some fibres from the sacral plexus.]

  It  is an  important practical remark of M. Jobert, that the entire intra-
vaginal portion of the neck is destitute of a supply of  nervous fibres, whilst
the portion above the insertion  of the vagina receives a great number of
them, which  form  species  of plexuses, furnishing  ascending  or uterine
        6 
82
FEMALE  ORGANS OF  GENERATION.
branches and descending or vaginal ones. The latter are extremely numer-
ous, and ramify to infinity in the substance of the vagina.
  This distribution, which would explain a number of physiological and
pathological facts, needs confirmation from neAv researches, for recent prepa-
rations deposited by M. Boulard in the museum of the School of Medicine,
give it a formal denial.
  Development. — Aacording to some authors, the. uterus is bifid in the em-
bryo as late as  the end of the third month, but  M. Cruveilhier  says he has
never observed this bifurcation.  During the intra-uterine life, the volume
of the neck surpasses that of the body, and at  this period its largest por-
tion corresponds to the vaginal extremity.   After birth it remains  nearly
stationary until puberty, and  then it acquires  in a very short time the
dimensions observed in the adult Avoman.  The organ often becomes atro-
phied in old age.

  § 4.  Ligaments of the Uterus.
  We have  already spoken of the  anterior and posterior ligaments. The
broad and round ones still remain to be described.
  The Broad Ligaments.—As  elsewhere stated, the double  lamina of the
peritoneum, which covers  the  anterior and  posterior faces of the uterus, is
prolonged transversely, the two folds resting against each  other, and  form-
ing by their union a transverse  partition, extending from  each side of the
uterus, which divides  the pelvis into  tAvo cavities; the anterior  of Avhich
lodges the bladder, and the posterior the rectum.  Outwardly,  and  beloAV,
these ligaments are continuous with the peritoneum that lines the excava-
tion ;  their superior border is free, and is extended from the  angles of the
uterus to the iliac fossae—presenting three folds, called  the wings. The
anterior wing is not admitted  by some anatomists ; it is  but  slightly devel-
oped,  and is occupied by the round ligament.   The middle one incloses the
Fallopian tube, and the posterior contains the ovary and its ligament.
  [Between the tAvo layers of serous membrane, whose apposition forms the broad
ligament, are found two muscular layers, discovered and described  by M. Rouget,
who represents them as formed of muscular fibres  making by their interla6ement
a network in a transverse direction.  The anterior of these two layers is continuous
with the superficial muscular fibres of the anterior surface  of the uterus, and is
directed outAvard so as to form a part of the round ligament.  The posterior mus-
cular layer is continuous with  the superficial fibres of the posterior surface of  the
uterus, and  is so directed outwardly as to  become attached for the most part to the
sacro-iliac symphysis.]
  The two serous folds that constitute  the broad ligament, are separated by
a loose  and very extensible lamellated cellular tissue, continuous with the
fascia propria of the  pelvis.   The broad ligaments disappear during gesta-
tion, their two laminae assisting to cover the anterior and posterior faces of
the developed womb.
  Bodies of Rosenmilller. — By the inspection  of  pieces  prepared  by  M.
Follin, we  have become assured of the existence of an  organ between the
two laminae of the broad ligament, which has  not been  even  noticed  by 
INTERNAL  ORGANS  OF  GENERATION.
83
           Bodice of Rosenmtlller.
A. Ovary.
B. Fallopian tube.
C Fimbriated extremity of Fallopian tube.
D. Culs-de-sac of the tubes.
E. Canaliculi proceeding to the ovary.
V. Point to which the tubes converge.
G. A'esii'lo appended to the Fallopian tube.
 French anatomists, but which certain German anatomists figure under the
 name of the organ of IiofenmuUer,  who  was the first to discover it.  Its
 general arrangement is not yet well understood,.its development is involved
 in obscurity, and the details of its histology had not hitherto been described.
 The researches undertaken by M. Follin  in reference  to this  subject show,
 that the organ is composed of
 seven  or eight  tubes folded                      Fw. 27.
 upon themselves, terminating
 in blind extremities,  and  all
 converging towards  the tube
 which serves as a point of en-
 trance for the  vessels of the
 ovary.   The tubes are gener-
 ally closely  approximated to
 each  other, so  that  their  in-
 flexions frequently correspond.
.When  examined  by  trans-
 mitted  light, the  assemblage
 of canals is distinctly seen in
 the broad ligament  near the
 fimbriated  extremity  of the
 Fallopian  tube.   Sometimes
 these tubes are not very appar-
 ent, and their number is much less, yet some are always to be  found.  They
 exist at all ages, but are much more readily distinguished in the broad liga-
 ments of the foetus, or  of children, for then the slight  development of  the
 blood-vessels does not obscure them, nor are  they  hidden from observation
 by the fat, which infiltrates the laminae of the broad ligaments in adults.
  The size of the tubes is variable: and they often present dilatations, and
 sometimes true cysts filled with a citrine fluid.
  M. Follin  has not been able to discover an excretory orifice to these  tubes,
 either in young girls or adult women.
  Their  structure  resembles  that of the  glandular  tubes of  many simple
 glands.  They are provided with  a central cavity, which presents the dila-
 tations so often  observed  in  tubes of  this class.  Externally, the tube is
 formed of cellular-tissue-nicmbrane Avith longitudinal fibres.   The internal
 surface of the tube is covered with pavement epithelium.
  Some observations  are calculated to produce the impression, Avithout how-
 ever confirming  it, that this assemblage of tubes has, in its origin, some
 relation Avith the corpora Wolffiana.
  Attached to the free edge of the broad ligaments, it is not uncommon to
 find five, six, or even more small  cysts.  They are  generally connected Avith
 the ligament  by a very slender pedicle,  of variable length,  but Avhich is
 sometimes so short, that the cyst appears to be sessile, and directly adherent
 to the  ligament.   < See Fig. 28.)
  It is difficult to  understand the mode of the development of these cysts.
 Thcv mav, perhaps, havB some relation with the tubes of Avhich the bodies 
84
FEMALE  ORGANS  OF  GENERATION.
of Rosenmuller are composed.   It has however seemed to us Avorth while to
call  attention to them particularly, as they are stated by M. Broca  to  be
present in the great majority of cases.
   The round ligaments, or supra-pubic cords, are evidently continuous Avith
the tissue of the uterus, to Avhich their proper substance is precisely similar;
arising from the lateral border of this organ, below and a little in advance
of the Fallopian tube, it runs upwards  and outAvards.   According to M.
Deville, this fringe, or ligament, is bent dowmvard in the anterior fold of the
broad ligament, and reaches the internal orifice of the inguinal canal, iato

                                  Fig. 28.
 The figure exhibits the small cysts appended to the free edge of the broad ligaments.  One of the Fallopian
    tubes is represented with a double fimbriated extremity, as in the case described by G. Richard.
 a. Uterus,  b. Fallopian tubes,  c. The additional fimbriated extremity,  d, e. The normal fimbriated
Bxtremities. F, G, H. The cysts described above.
Avhich it enters, accompanied by a prolongation of the peritoneum, bearing
the name of the Canal of Nuck.  It then divides into a number of fibrous
fasciculi, wdiich are lost  in the cellular tissue of the mons veneris and that
Avhich  fills the dartoid sac, described as existing in the  labia externa. Ac-
cording to Madame Boivin,  the round ligament on the right  side  is  the
shorter and larger of the tAvo.  They  contain a great number of veins,
which  are liable  to become varicose.
  These ligaments serve to retain the uterus in position, and to prevent its
displacements; and  it is probably to them that the  pains in the groins,
experienced by some women during chronic affections or displacements of
the Avomb, may be referred.   They are, in  a  great  measure, composed of
cellular tissue and vessels, but containing also some  muscular fasciculi, the
superior of which are prolonged from the uterus, and the inferior come from
the transversalis  muscle.  The  superior muscular fibres are  much  more
evident during pregnancy.
   Finally, the vesico-uterine and  utero-sacral ligaments, formed, as we have
stated, of folds of the peritoneum, which, after having covered the uterus,
are reflected upon the posterior surface of the bladder and the anterior sur-
face of the rectum; these ligaments are, so to speak,  reinforced, by collec-
tions of fibres which appear to be prolongations from the tissue proper of
the womb, and Avhich are attached anteriorly to the posterior surface  of the
bladder, and posteriorly to the anterior surface of the rectum. 
INTERNAL  ORGANS  OF  GENERATION.             85
                            ARTICLE  III.
                        OF  THE  FALLOPIAN  TUBES.
   The uterine or Fallopian tubes are tAvo canals, varying from four and a
 quarter to five inches in length,  and placed in the thickness of the superior
 border of the broad ligament.   They extend transversely from the  lateral
 angles of the  Avomb nearly to  the iliac fossa on the corresponding  side.
 Their volume is made more evident by inflating them.   (G.  Richard.)  It
 may then be  ascertained that beyond  the uterine parietes, the tube has a
 diameter of about three-sixteenths of  an inch ;  tOAvards the middle of its
 course it increases to about one-quarter of an  inch, and just before the
 ostium abdominale, to  five-sixteenths of an  inch.   Their calibre  is  verv
 variable at different points.  The elasticity of the Avails is hoAvever so great
 as to allow of their increase to an enormous extent, as is proved by the cysts
 which are frequently found in them.
   The internal orifice of the tube (ostium uterinum) is stated by M. Richard
 to be the one-sixteenth  of an inch in diameter ; from thence,  the calibre of
 the  canal increases gradually to its external orifice.  Near the free extremity
 it spreads out and becomes  fringed.  This termination constitutes the pavil-
 ion, or fimbriated extremity (the morsus diaboli).
   It is generally taught that one of these fringes, Avhich is longer than  the
 others, attaches itself to the extremity of the ovary.   On the contrary, M.
 Cruveilhier  believes that this adherence takes place through the interven-
 tion of a groove, the concavity of Avhich looks doAvmvards and backAvards,
 and facilitates the communication betAveen the ovary and the cavity of the
 tube.  All the fringed folds are attached to a small circle Avhich is more
 contracted than the part of the tubeAvhich it terminates.   This small circle
 is called the external orifice of the  tube.  The internal or uterine orifice is
 the name given to the one by Avhich it opens in the uterine cavity.

   [The Fallopian tubes are composed of three layers: an external or serous, a middle
 or muscular, and an internal or mucous layer.
   The external layer is a part of the peritoneum which lines the entire length  of
 the oviduct, and is extended to the  free edge of the fimbriated  extremity, where it
 ends  abruptly.
   The middle layer is composed of two planes of muscular fibres — the external
 being longitudinal, and the internal circular.  The tubes have often been described
 as prolongations of  the uterus, whereas M.  Robin regards them  as entirely dis-
 tinct.  A thin, cellular septum is,  in fact,  interposed between the  tissues of the
 r.Avo organs, allowing of their separation by the scalpel.
   The mucous layer is continuous internally with the uterine mucous membrane,
 and  terminates externally upon the free edge of the fimbriated extremity where it
 is connected Avith the peritoneal layer.  Thus affording the  only example  of a
 mucous membrane in continuity with a serous one.
  The mucous membrane of the oviduct is devoid of papilli and glands, but presents
 longitudinal folds so adjusted to each other as to transform the canal into numerous
 capillary tubes, Avell adapted  to convey readily the spermatic  fluid to the ovary..
 The mucous membrane is also covered  Avith a vibratile epithelium,  the motion  of
 whose cilia being directed toward the uterus are, doubtless, intended to impel the
ovuls toward the uterine orifice of the tube.] 
86
FEMALE  ORGANS  OF  GENERATION.
   A special artery, derived from the numerous branches  Avith Avhich  the
 uterus is supplied, and  two veins, Avhich join the  ovarian  veins, constitute
 the vascular apparatus  of the tube.   It  is provided Avith  nerves from  the
 spermatic and hypogastric plexuses.
   The Fallopian tube serves the double purpose of a canal for transmitting
 the fecundating principle of the male, and for carrying the germ furnished
 by the female from the  ovary to the uterus.
   The use  of the  fimbriated extremity is to embrace the ovary  at  the
 moment of fecundation, and probably also at  each  menstrual period, and
 to apply itself over the point from Avhence the germ is detached.  At this
 time, the vessels of the  Fallopian tubes are engorged — the mucous mem-
 brane assumes a well-marked red color—the walls are thickened, and  the
 canal is enlarged.   The tubes are at the same time affected with peristaltic
 contractions, which are probably intended to propel  the ovule into  the
 uterine cavity.
   The anomaly presented  by the existence of  supernumerary pavilions, or
 fimbriated extremities,  upon the same  tube, as described by  M. Gustave
 Richard,  is here deserving  of  notice.   In  the bodies of  twenty  Avomen,
 selected at random, he observed it five times.   One or several of them were
 found attached to the tube either immediately behind the normal fimbriated
 extremity, or at distances varying from three-quarters of an inch to an inch
 and a quarter beyond  it; all of them  were formed  like  the  one Avhich
 terminated the oviduct  by the fringe-like division of the mucous membrane.
 By floating the fringes  under water,  an opening was discovered  conducting
 into the tube, through Avhich a stylet might be introduced  and  brought  out
 through either the internal or external orifice of the tube.
   According to Dr. Hamilton, of Edinburgh, the Fallopian tube undergoes
 some modification during gestation,  to Avhich he attaches great importance.
 as a characteristic  sign of  pregnancy.  This change consists in the  forma-
 tion of a little pocket, or sac, about  an inch from the fringed extremity.
 This partial dilatation of the tube, previously described by Roederer under
 the name of antrum tuboz, is certainly an exceptional fact.  I have never
 observed  it; and M. Montgomery has encountered it but  once in fourteen
 uteri, examined in the state of gestation; so that it cannot  have all the  im-
 portance that certain authors wish to ascribe to it.

                           ARTICLE  IV.
                            OF  THE OVARIES.
   The ovaries (testes muliebres) are the analogues, in the female, to the testi-
 cles of the male: that  is, both of them secrete  a  product  indispensable to
 reproduction.   Two in  number, they are situated on the sides of the  uterus
 in that portion of the broad  ligament called the posterior Aving, just  behind
 the Fallopian tube.  They are maintained in  position by those ligaments,
 as also by a special one, denominated the ligament of the ovary.
   The. ovaries vary in situation, according to the age  of the individual, and
' the state of the uterus.  In the foetus, they  are placed, like the fundus uteri
 in  the lumbar region;  but,  during  gestation,  they rise  into the abdomen
 along Avith the body of the uterus, upon the sides of which they lie. 
INTERNAL ORGANS OF  GENERATION.             87
  Immediately after delivery the ovaries occupy the iliac fossa?, where they
Bometimes  continue throughout life; again, it is not  at  all uncommon to
find them turned backAvards, and adherent to the posterior face of the womb.
  The ovaries vary in size, both from age, from the plenitude or vacuity of
the uterus, and from health or disease.   Being proportionably larger in the
foetus than in adult  age, they diminish  after birth, augment in volume at
puberty, especially at  the monthly periods, and  dwindle away in old age.
During pregnancy and after delivery, they acquire in some cases quite a
considerable  volume.
                                 FlO. 29.
                      Ovary of the Young Female after Puberty.
    A. Body of the ovary.  B. Utero-ovarian ligament, c. Tubo-ovarian ligament. B. Fallopian tube.
                        E. Fimbriated extremity of the tube.

   Before the age of puberty, the external surface of the ovaries is of a light
rose color, and is smooth and  free from inequalities.   In women who have
menstruated for several years the surface is rough, fissured, covered Avith
small blackish cicatrices,  and  sometimes Avith ccchymotic spots.   Some of
these cicatrices are linear, others  are  triangular or radiated; they are of a
red color when  recent, but become broAvn in the course of a  few months.
Sometimes a complete union fails to take place between their edges, leaving
a small opening, Avhich communicates Avith the ruptured cavity.  After  the
period of life at which  the menses disappear, the external surface presents
numerous Avrinkles, Avhich are not, as has been  supposed, the result of  old
cicatrices, but are due simply  to the atrophy of the  ovaries, and the plica-
tion of the external envelope Avhich is the consequence.
  The ovaries are ovoidal in shape, a little flattened from before backwards,
and of a Avhitish color.
  The external extremity of the ovary is adherent, as Ave have said, to one
of the fringes of the fimbriated  extremity of the Fallopian tube;  the internal
extremity is attached to the  uterus by the ligament of the ovary, which is
inserted at the corresponding angle of that organ.
  The ligament of the ovary, Avhich Ave have already considered, Avas for a
long time regarded as a canal,  designed like  the Fallopian tube to convey
the fecundated ovule into the cavity of the uterus; modern  anatomy, hoAV-
ever, proves it to be solid.
  From the researches of Gartner, of Copenhagen, and of M. de Blainville,
it  appears that in  some quadrupeds, and especially the soav, a canal is
almost always to be found extending from its external orifice by the side 
88              FEMALE  ORGANS  OF  GENERATION.
of the meatus urinarius (corresponding with a similar orifice  on the othei
side of the meatus), through  the  substance of the muscular fibres of the
vagina to the neck of the uterus; here the canal becomes narroAver, but
continues on, following the body of the uterus  and imbedded in its fibrous
structure, and finally leaves it to pass in a direction parallel  to the  corre-
sponding angle into the substance  of the broad ligament.
  M.  Follin found, whilst injecting the duct of Gartner in the soav, that he
injected at the same time a long tortuous  tube, situated in the substance of
the ligament, at the point occupied in the human female, by the collection
of glandular tubes which I have described.  I have been  able to determine
the fact that in the soav this duct does  not open by a large orifice at the
lower part of the vagina, as has been  represented, but in reality by a very
narroAV one.  It is not terminated at its entrance  into the broad ligament
by a few brush-like divisions, as stated by M. de Blainville, but is continuous
with a very fine tortuous tube which  extends to the external extremity of
that ligament.  The duct of Gartner is furnished internally Avith  a pavement
epithelium, and communicates throughout its  course  Avith many glandular
tubes finer than itself.  (Follin.)
  We have sought for this duct of Gartner in the human  female, but found
nothing Avhich could be reconciled with the  description given by him of it;
however, we cannot avoid  remarking that since these  researches  N. C.
Baudelocque has observed  in a woman a canal  which seemed  to be pro-
duced by a bifurcation of the  Fallopian tube,  and  which,  after passing
through  the  entire uterine walls,  opened  into the upper part of the vagina
near the neck of the Avomb.   Madame Boivin  and some others havre met
Avith a similar canal, and Mauriceau  and Dulaurens  considered it of quite
frequent occurrence.
  The arteries Avhich supply the ovary  are the spermatics, and proceed
directly from the aorta.
  The numerous small venous branches found in the ovary unite below the
organ so as to form a plexus which gives origin to the ovarian veins; the
latter emptying into the vena  cava inferior, and into  the renal vein.
  The numerous lymphatic vessels with which it is provided contribute to
the formation of the spermatic plexus, which itself empties into  the lumbar
plexus, and thence passes to the thoracic duct.
  The nerves are derived from the great sympathetic.

  § 1. Structure  of the Ovaries.
  [The ovary consists of a special parenchyma  inclosed by two envelopes, one ot
which is serous, the other fibrous.
  The serous envelope is formed by the peritoneum and is closely attached to the
subjacent one.  It covers the entire gland except at its lower edge, Avhere the two
layers of peritoneum separate to allow passage for the vessels and nerves distributed
to the ovary.
  The fibrous  envelope  corresponds with the peritoneum by its external surface
whilst its  internal surface is blended with the glandular parenchyma.   It is much
thinner than the tunica albuginea of the testicle with which it has been compared
M. Sappey even denies  its existence, and regards the peritoneum  as the onlv
envelope of the organ; his opinion, hoAvever, is not yet adopted by most anatomists. 
                INTERNAL  ORGANS  OF  GENERATION.             89

  Within the envelopes mentioned,  is a special  tissue of a grayish-white color,
termed the stroma, which is formed in great part by the interlacement of muscular
fibres, some of which are peculiar to the ovary, whilst others are but a prolongation
of the same kind of fibres as constitute  the  ligament of  the  organ.  Other fibres
take their origin from the Fallopian tube.   The  existence of all these fibres was
Bhown  by M. Rouget in 1858.  With the muscular fibres are mingled  others of
connective tissue.
  Tlic arteries are situated  between the muscular fibres, are flexuous, and have a
spiral form.   The A'eins, contorted  in like manner, form  a  rich  network which
empties into a venous plexus immediately below the ovary.  The arteries and veins,
surrounded as they are by muscular fibres, form a true erectile organ, and the ovary
is regar led as such by  M. Rouget.
  Within the fibrous, structure of the  stroma  exist small cavities, called ovisacs or
Graafian vesicles, of a  size  varying  ordinarily from that of a millet-seed to that of
a hemp-seed.   Some of the more developed vesicles project from the surface of the
ovary, wherjb they acquire,  as Ave shall see hereafter, a comparatively large size.
  About fifteen or twenty vesicles may be readily distinguished in the adult female,
but with the microscope many more are observable, all of Avhich will be developed
when the first shall have disappeared.
  The ovisacs have hitherto been described as distributed through the substance
of the ovary at different depths, and as approaching the surface as they increased in
size.  Kolliker  had, indeed, observed that the Graafian vesicles occupied chiefly
the peripheral portions of the gland,  but M.  Sappey deserves the credit of having
determined clearly their true position.  Having examined his preparations illustra-
tive of the structure of the ovary, kindly shown  me  by  this skilful anatomist, no
doubt on the subject is left in my own  mind, and I can  vouch for  the correctness
of the following description.
  According to M. Sappey, a complete
Bection of the ovary made perpendicular
to the surface, Avill show the stroma  to
be composed of two distinct parts.
   1. Of  a central portion,  of a reddish
color and spongy texture, manifestly
composed of the stroma as j ust described.
The bulk of this portion is considerable,
forming almost the entire mass of the
ovary,   and  containing  no  Graafian
  r ^ .• *, 4                                   This figure represents a longitudinal section of the
                         .          . .   ovary, showing the arrangement and different degrees
   2. Of a superficial portion, of a white  of development 0f the Graafian vesicles.
color, firm consistence,  and homogeneous
appearance,  spread over the central portion.   In  this peripheral layer are  situated
 exclusively the ovisacs and ovules; it may, therefore, be  termed the ovigenic layer.
It is about the one tAventy-fifth of an inch in thickness.
   The ovigenic layer is composed of the fibres of the stroma, amongst  Avhich are
 found Graafian vesicles in abundance.
   M. Sappey's microscopical examinations  have shown  that in one healthy ovary
of  a Avoman of from eighteen to tAventy years of age, the number of ovisacs and
ovules is more than 300.00, making near 700,000 for the individual.  He therefore
 calculates, that if all  the  ova existing in  the surface of the ovaries of a young
 woman  Avere to be fecundated  and  uudergo all their phases of  development,  it
 would require  but one Avoman  to populate four such cities as Lyons, Marseilles,
 Bordeaux, and Rouen, and but two, to furnish inhabitants for a capital like  Paris,
 containing 1,600,000 souls.
   There are as mauy  ovisacs in  the foetus  as there Avill be at puberty, but as the
 
90
FEMALE  ORGANS  OF  GENERATION,
gland is then small, the vesicles conglomerated, but separate as the ovary develops.
After puberty, the number of ovisacs lessens ; in old women they disappear.
  § 2. Of the  Ovarian Vesicles.
  From birth to puberty the Graafian vesicles undergo  no change.  They have a
founded form and a diameter of jo^o" °f an inch.  At puberty some of them have
become developed, and, as stated, have attained the size of a millet-seed, of a hemp-
seed, or even of a pea.
  Each vesicle adheres firmly to the substance of the stroma in Avhich it is lodged,
and which forms for it a sort of retractile tegument.   The special structure of each
ovisac consists: 1, in a capsule or envelope; 2, of a contained body or nucleus.
  1.  The capsule or envelope is formed of a special, transparent,  extremely thin,
but resisting, non-contractile membrane.  It is vascular  and forms the vesicle con-
taining the nucleus.]
  2. The Nucleus.—The parts  entering into the composition of the nucleus
are: 1st, a granular membrane  which incloses  the  humor of the Graafian
vesicle; and 2d, a liquid produced by the aggregation of three humors of
a different aspect,  viz., a limpid mucosity, clear,  though a little oily, a
number of small rounded granulations, transparent  in their central cavity,
and slightly opaque  at their periphery, and some  oil globules.   3d,  and
lastly, an ovule  floating in the midst of this liquid.
  The  Granular Membrane  (see Fig.  31, g'). — A delicate membrane is
                                 found  applied on  the internal face of the
                                 Graafian vesicle,  formed of granules, or
                                 rather of cellules, and bearing the name
                                 of the granular membrane.   It tears Avith
                                 great facility, from its  extreme  tenuity;
                                 and  hence many  authors have denied its
                                 existence.  Upon  one part of the mem-
                                 brane (that corresponding to  the  free side
                                 of the vesicle)  the granulations, or cells
                                 producing it, are  more numerous or more
                                 compact, and  in  the centre of this com-
      Ovuie in the Graafian vesicle.        Pact mass> which has been called the pro-
  A. Ovule. B. Cumulus granulosus, c. Gran-  UgerOUS disk, the OVUle is found.
ular membrane, d. Cavity of the Graafian    rpi        -i  ,•          .   .
vesicle. E. Membrane proper of the ovisac.    ine grailUlatlOllS, Constituting  the  prO-
F. Stroma of the ovary. G Fibrous envelope  HgerOUS disk (see G, Fig. 31), are SO closely
Df the ovary,  h. Peritoneal laver of the ovary.    -jii.i    •,,     ,    ,       ,   .,   ,
                                 united both with each other and with  the
latter, that upon opening the  Graafian vesicle, even where the granular
membrane is destroyed, this portion remains adherent to the ovule, formino-
round it, as it were,  a  granular bed.   This membrane is entirely destitute
of vessels.
  § 3. The Ovule.
  Since the labors of  Graaf, the majority of authors agree Avith him  that
the  ovule is constituted by the vesicle just  described;  but the honor of
having first discovered the ovule, as a distinct organ in this vesicle  belongs
to  Charles Ernest  Baer.  The ovule  is  completely formed in the ovary
during the earlier years of life.  It  is imbedded  from  the period of its
maturity,  as stated  above,  in  the  midst of a mass of granulations which
are more compact than those which fill the remainder of the vesicle.
 
INTERNAL ORGANS  OF  GENERATION.
91
   It therefore occupies a fixed  position in the vesicle, and is almost  con
 Btantly met with at a  point opposite  to  that  Avhence the large  vascular
 trunks spread out  upon  the ovarian capsule, that  is to  say, at the point
 which  projects from the surface of the  ovary.  When examined with a
 lens, it appears as an opaque rounded body, at least more opaque than the
 liquid  inclosed in the same vesicle; it is extremely minute, although the
 diameter of the little sphere it represents is subject  to variations.
   "The largest human ovules I have seen  and manipulated," says Bischoff,
 "did not  exceed the tenth of a line, being barely perceptible to the naked
 eye."   When placed under a microscope, it is seen to consist of an exterior
 envelope,  called  the vitelline membrane (Coste), transparent zone,  cortical
 membrane, or chorion (Baer), of a substance  aptly  compared  to the  yolk
 of an egg, and  designated as the vitellus, and
 of another vesicle  (placed  within the latter)           Fia-32-
 called the germinal vesicle.
   A. Vitelline Membrane. — If  the ovule be
 examined by a  magnifying  glass of sufficient
 poAver, an obscure sphere will be brought  into
 vieAV, surrounded by a large  clear ring, the
 nature of Avhich it is difficult to make out.  M.
 Coste has  given the name of the vitelline mem-
 brane to  this ring.  It is  evidently a thick
 membrane, the  external  and internal outlines
 of Avhich assume the appearance of two circular
 lines inclosing a transparent  ring.  Many  per-
 sons have  merely considered  it as a layer of
 albumen  surrounding the yolk,  but any  one
 may easily convince himself  that it is at least
 a  resisting  membrane, by  cutting the ovule, or
 by compressing it by means of an instrument  called  the compressor; " for
 after proceeding in  this manner," says Bischoff, "there cannot be a doubt
 that the transparent zone is an  elastic,  thick, hyaline, and  transparent
 membrane, Avithout  a determinate texture."
   Though entirely destitute of cells and vessels, it is nevertheless a living
 envelope;  because, as soon as the ovum  in the  mammalia  arrives in the
 cavity of the uterus, it becomes the seat of an active vegetation, and pro-
 duces villosities  which are  more  or less  ramified.   The latter, as they
 become developed,  insinuate  themselves  into the  tissue of the  uterine
 mucous membrane, and  thus  attach the ovum to the place Avhich it is to
 occupy for the future.
   B. Yolk or Vitellus. — The cavity of the vitelline membrane is occupied,
in great measure, by a  granular liquid, that does  not adhere to the ex-
terior envelope, and even escapes from it readily Avhen the latter is broken.
   According to  Bischoff, the  yolk of a human ovum is formed of a coher-
ent, indistinctly  granular,  transparent,  and viscous  mass, Avhich does not
run out Avhen the egg is cut or crushed; each  portion of the zone reserving
its particular segment or yolk, or the latter escaping  altogether.
   "Tn certain cases," says  he, "the vitelline granulations are not united in
  A Non-fecundated Human Ovule.
  A. The vitelline membrane, or trans-
parent zone. B. The vitellus, or yolk.
0. The vesicle of I'urUinje, or the ger-
minal vesicle. D. The germinal spot. 
92
female  organs  of  generation.
 a single mass.   I have seen the yolk divided in two, and, on one occasion,
 into five parts of different volume."
  The vitellus usually fills the interior of the zone completely, and  has the
 same form, but sometimes the vitelline sphere is smaller than that destined
 to receive it.  Some authors likewise believe that a very delicate membrane
 exists, which incloses  and unites the  yolk  in a single mass: but  Messrs.
 Coste and Bischoff agree in  rejecting the  existence of this, and contend
 that the granulations of the vitellus are placed in juxtaposition Avith the
 transparent zone, Avhich forms its sole and only  envelope.
  c. Germinal Vesicle.—In  the midst of the vitellus, in very young girls,
 or on one of the neighboring points of the peripheral envelope in the matured
 ovules, a  small, perfectly transparent,  and  colorless vesicle  is seen like a
 clear spot, surrounded by a mass of a deeper yelloAV.  Purkinje had described
 it in the eggs of birds, and gave his own name to it; but M. Coste is entitled
 to the honor of having first demonstrated  its  existence  in  the ovum of
 mammiferse, and of thus having established the perfect identity between the
 latter and the eggs of birds.  This is the vesicle of Purkinje, or the germinal
 vesicle.  It is slightly  oval, and consists of a very delicate, transparent, and
 colorless membrane, which incloses a liquid that is frequently as limpid and
 transparent as itself, though it sometimes contains a feAv granules.  Notwith-
 standing its  extreme tenuity, this vesicle  still  offers a certain consistence,
 since it has been seen intact, after leaving the ovule, and being completely
 separated from the granular liquid in which  it was placed.
  It is  always very small, and  scarcely measures the sixtieth of a line in
 diameter.
  d.  The Germinal Spot. — If the germinal vesicle be attentively observed,
 an obscure rounded spot will be seen on some part of its periphery; this Avas
 first discovered by Wagner, who gave it the name of the germinal spot.   It
seems to  be  formed by the aggregation of fine small granules, or little
globules, the obscure hue of which is brought out by the  clear contents of
the  vesicle.  Wagner has sometimes met Avith two, or even more, germinal
spots in the mammiferse.
  Before fecundation, therefore, the ovule is  composed: 1st, of an exterior
envelope, the vitelline membrane, or transparent zone ; 2d, of a vitellus, or
yolk, contained  in this vesicle; 3d,  of  a little vesicle  inclosed in the  first
and SAvimming in the vitelline fluid — the germinal vesicle ; 4th, and  lastly,
of the germinal  spot.

                  EXPLANATION  OF   PLATE  I.
 antero-posterior section of the female  pelvis, of the genital
            organs, and of the defecatory apparatus.
                 (Taken from M. Richel's Treatise on Surgical Anatomy)
  The soft parts of the lesser pelvis and the contained organs have been previously fixed
 by two very sharp  metallic rods, one of which is passed above and the other below the
symphysis pubis and made fast in the vertebrae.  An examination of the drawing will
 show that the  section is slightly oblique  from the  median line in front, toward the
 right side  behind.  In other words, it has been so made that the instrument  after
 having divided the pubic  symphysis in  front, falls outside- of the right sacro-iliac
 symphysis. 
OVULATION AND  MENSTRUATION.
93
  1. Symphysis pubis.  2. Articular surface of the sacrum with the ilium.  3. 3. Sec-
.ion of the skin and of the subcutaneous cellulo-fatty layer.  4. Labia majora of left
Bide.  5.  Labia minora of same side.  6.  Orifice of the  vulva.   7. ''. Root of the
clitoris.—Clitoris.  8.  Bulb of vagina injected by the veins.  9.  Section of constric-
tor  vaginae muscle.  10.  Section of  transversus muscle.   11. Yulvo-vaginal gland.
12.  Anus.  13. Sphincter ani muscle.  14. Orifices of veins of prevesical plexus.  15.
Prevesical cellular tissue.  16.  Vesical orifice of urethra.   17. Vesical cavity, show-
ing  orifice of left ureter.  18.  Vagina.   19. Neck of uterus.  20.  Body of  uterus.
21.  Section of right Fallopian tube.  22. Section of  broad ligament.  Venous plexus
contained within  its  fold. 23.  Fallopian  tube and broad  ligameut of the left  side.
24.  Rectum and its ovoid  cul-de-sac; the longitudinal fibres of the bowels are shown.
25.  The same covered in its upper part by the  peritoneum.   2G. Vesico-uterine cul-de-
sac  of the peritoneum.  27. Recto-vaginal cul-de-sac of the peritoneum.  28.  Section
of Levator ani muscle.  29. Point of the coccyx.  30.  Pyramidalis muscle.  31. Retro-
rectal cellular tissue contained  within the  upper pelvi-rectal space.  32. Section of
the  great sacro-sciatic  ligament.   33. Hypogastric  artery.  34.  Hypogastric vein.
35.  Sacral plexus. 36. Sacro-lumbar mass of  muscular tissue, &c.
                           CHAPTER  IV.
                    OVULATION  AND MENSTRUATION.
   Another physiological phenomenon, namely, menstruation, is both ex-
 cited by and dependent upon the evolution of the Graafian vesicles or ovu-
 lation.  Ovulation and menstruation are, therefore,  intimately  connected
 and should  be studied consecutively.

                              ARTICLE  I.
    OF THE MODIFICATIONS  UNDERGONE BY  THE  OVARIAN  VESICLES.
   Until the age of puberty  the Graafian vesicles are of small  size;  but at
 this period, some fifteen to twenty of  them, Avhich  appear more  advanced
 than  the others, increase in size, and project from  the external surface of
 the ovary.   At the time Avhen the young girl becomes nubile, one of the
 latter vesicles seems to have  received a great increase of vitality;  it under-
 goes a remarkable hypertrophy, and forms a projection upon  the surface of
 the ovary ; this projection  becomes greater and greater until after some days
 it forms a tumor of the size  of a cherry, or  even of a small  nut, upon the
 ovarian surface.
   This considerable  augmentation of size is due to the  distention of the
 walls of the  vesicle by an increased secretion of the fluid Avhich it  contains.
 In proportion  as the development  proceeds, the Avails of the vesicle become
 thin; the vessels Avhich supply them being  compressed by the dilatation,
lose their volume and become obliterated and atrophied, especially upon the
point of culmination, Avhere the resistance is least.  When at  last it has arrived
at its full development, the ovarian capsule  appears to remain stationary,
until an over-excitement, produced either by the maturity of the ovule, or
by sexual intercourse, occasions its rupture. (Coste.)  Then, the walls of
the vesicle, although  more and more distended, begin  to  lose  their trans- 
94
FEMALE ORGANS OF GENERATION.
parency, on  account of the hemorrhage which ensues.   This is sometimes
limited to the production of  small extravasations upon the as yet entire
Avails of the vesicle, though most frequently a true effusion takes place within
the cavity.  The effused  blood and the superabundant secretion  increase
still  more the distention  of the Avails, Avhich  is  finally  carried so  far that
rupture becomes imminent, and it is possible to distinguish at the most pro-
jecting part  of the tumor, the point Avhere it is about to ensue.   This point
is  generally indicated  by a small  reddish spot,  of about a line in  extent,
produced by a strong injection, or even by a slight effusion of blood in the
Fia. 33.                                 Fig. 34.
 Fig. 33. Showing the ovary, and a Graafian vesicle at its highest degree of development, and just before its
rupture. '
 a. The hypertrophied vesicle (drawn from nature, and of its real size), b, c, c. Radiated cicatrices, left by
previously ruptured vesicles.
 Fig. 34. The ovary, with the ruptured vesicle and the large clot that fills its cavity.  (Drawn from nature.)
texture of the Avails of the vesicle. (Raciborsky.)  The thinned Avails finally
give Avay and tear gradually ; the membranes of the vesicle itself being the
first to yield, and after them the peritoneal layer.  As a consequence of this
rupture, the ovule is expelled, and carries along with it a part of the granular
contents of the A^esicle; it enters the Fallopian tube, the fimbriated extremity
of Avhich is prepared to receive it, and after traversing its  canal arrives at
a later period in the cavity of the uterus.                  ,
  The walls of the follicle collapse after the rupture, and its cavity becomes
filled Avith a small quantity of  blood, which is found fluid or coagulated
according to the time at Avhich the examination is made.
  The Avails of the torn vesicle contract gradually, and the clot, which some-
times at first is the size of a  small cherry, is  sloAvly absorbed ; the originally
spacious cavity diminishes, the margins of the rupture  approximate, so as
even  to  become united occasionally by cicatrization,  and order is finally
restored.
  The evolution just described, which  is terminated  by  the rupture of a
vehicle and  the spontaneous expulsion of an ovule, is not an isolated face;
on the contrary, it excites numerous sympathies in  the remainder of the gen-

  1 This figure, borrowed from M. Raciborsky, is the exact copy of a preparation which
he had the kindness to show me. But since that time (1843) I have never met with so
enormously developed a vesicle, and I am disposed to believe that  this  great size ia
rather pathological than normal. 
OVULATION  AND  MENSTRUATION.
95
crative apparatus and throughout the organism of the female. We shall first
study the generative organs and the modifications Avhich they undergo before,
during, and after this evolution.
  The ovary, which produces the hypertrophied vesicle, is notably enlarged.
It is  of  a deep red color, and its vascular  apparatus is remarkably con-
gested.
  The Fallopian tube itself shares in the congestion, being often of a violet-
red color, especially at its fimbriated extremity, Avhich has a sort of velvety
appearance.  It is also endoAved  at  this time with a special  erethism, in
virtue of which it applies its floating extremity upon the ovary, in such a
manner as to receive the ovule and conduct it into its cavity.
  The uterus undergoes such  important changes that, before the discovery
of spontaneous ovulation, it Avas erroneously supposed to play the principal
part in the  phenomena Avhich Ave  are  about to study.   I shall continue to
draAV from the beautiful works of M.  Coste, from which I have  already bor-
rowed so freely in the preparation of  this chapter, the principal features of
the ensuing description.
  Whilst the ovarian vesicle is undergoing the rapid  evolution Avhich we
have just described, the vascular apparatus of the womb becomes developed
and injected in an unusual manner; immediately beneath the delicate layer
of epithelium which covers  the surface of the  mucous membrane, it forms
in particular elegant reticulations, Avith irregular, lozenge-shaped intervals,
surrounding the orifice of each of the numerous glandular tubes of Avhich
this membrane is almost entirely composed.  This network  is so fine as to
give a violet hue of greater or less intensity to the  internal surface of the
womb, and  is formed of very delicate venous ramuscules.   The utricular
glands increase perceptibly in size, and the muscular structure of the uterus,
in consequence of the congestion which it undergoes, acquires greater exten-
sion, is of a more lively red color, and becomes  more spongy  and supple.
The entire volume of the organ is increased, the neck  is tumefied and  its
orifice narroAver ; the lips of the os tincae are warmer and their color deeper.
  The mucous membrane, in consequence of this development of its vessels,
and especially of the glandules of Avhich  it is composed, has its thickness
so much increased in proportion to the  size of the uterine  cavity,  as to be
thrown, in a great many subjects, into soft, projecting folds or  circumvolu-
tions, which are so pressed together as to leave no vacant space in the cavity
of the organ.   M. Coste has several Avombs in his possession, Avhose mucous
membranes  measure at certain points, from two to three-eighths of  an inch
in thickness ; still, to Avhatever degree the  hypertrophy may be carried, it
never presents  the floating villi Avhich Baer and Weber thought they had
observed; neither, except in  some pathological cases, does  it ever  exhibit
the pseudo-membranous exudation Avhich is acknowledged by almost all
physiologists.   (See Deciduous Membrane.)
  This great vascularity of the mucous  membrane, and the high vascular
congestion which the entire organ undergoes, is at first  accompanied with
the exudation of a few drops of blood, Avhich by admixture beloAV Avith the
vaginal mucus, Avhich is itself at this  period increased both in quantity and
fluidity, communicates to it at first a rosy, and then a light reddish  hue. 
96              FEMALE  ORGANS  OF  GENERATION.
After two or three days, a Aoav of blood, derived principally from the super-
ficial network of the mucous membrane, escapes through the neck and
mingles with  the vaginal secretions.   Henceforth, the effusion presents all
the characters of a true hemorrhage.
.  There can be no doubt that the chief source of this hemorrhage is the
superficial vascular netAVork of the mucous membrane; and in Avomen who
have died at this period the blood may be seen to transude through micro-
scopic fissures.
  The flow preserves the same characters during the two or three, be they
more or less, days of its duration ;  then, as the quantity of blood diminishes,
it resumes gradually the mucous and serous characters peculiar to the vagi-
nal secretion.
  It is impossible, in the present state of our knoAvledge of  the subject, to
                                        determine  precisely at  Avhat mo-
                 FlG-35-                  ment during  the  Aoav  of blood
                                        the rupture of the Graafian vesicle
                                        takes place.  The result of numer-
                                        ous autopsies admits of the sup-
                                        position that this moment is vari-
                                        able, and the curious experiments
                                        of M. Coste leave no doubt Avhat-
                                        ever  as  to the influence which
                                        veneral excitement  is capable of
                                        exerting upon it; this influence is
                                        so great, that it may determine
                                        the rupture of an  hypertrophied
                                        vesicle, Avhich, without sexual in-
                                        tercourse, Avould  have  remained
                                        intact for  several   days  longer.
                                        HoAvever, it may be  admitted, as
                                        a general  rule, that the rupture
                                        occurs during the last days of the
                                        Aoav:
                                          The series of phenomena  of
                                        which the  ovary is  the seat, is not
                                        terminated by the rupture of the
                                        vesicle, and it remains  for us to
state what becomes of its Avails after the expulsion of the ovule.
   Of the Corpora Lutea.—Immediately after the rupture of the Graafian
vesicle and  the  consequent expulsion of the ovule, an effusion of blood,
according to some,  and of  plastic lymph, according to others, takes place
into the emptied cavity; moreover, the walls, which were greatly distended,
retract strongly upon the effused matter, and form  with it a more or less
compact mass, which after a time assumes an orange-yelloAv color.  From
this latter circumstance, the tumor has  acquired the  name of the yellow
body, or corpus luteum.
   Although for a long  time considered  by nearly every author  as an  ir-
refragable proof of  a previous conception, it is at  present well knoAvn that
Uterus laid open, so as to exhibit the Hypertrophy of the
    Mucous Membrane at the Menstrual Period.
 A. Mucous membrane of the neck. B. Mucous mem-
brane of the body, much  swollen,  c. Thickness of the
section of the mucous membrane. r>. Tissue proper of
the uterus.  E, F. Diminution in the thickness of the mu-
cous membrane at the neck and at the orifices of the Fal-
lopian tubes. 
OVULATION  AND  MENSTRUATION.
97
 this body may exist in a virgin girl, provided she has previously men-
 struated.
   Very different opinions have been promulgated as to the mode of  forma-
 tion of the yelloAv body, as also in regard to the precise period at which it
 commences.  According to  Robert Lee, the mass  of this body  is formed
 exteriorly, around  the empty capsule  of  the vesicle, and consequently it
 has intimate connections Avith the ovarian stroma; but this opinion is inad-
 missible.
   From the  observations of Baer and Valentin, the  yelloAv body  results
 from the hypertrophy,  or a  kind of puffing up, of the membrane  of  the
 vesicle, which throws out a  species of  vascular processes that serve  to  fill
 up the Avhole cavity of the follicle, excepting at  the part occupied  by  the
 ovule.   In  the latter view, as Avell  as  in that entertained by Montgomery,
 the development of the corpus luteum will aid in rupturing the vesicle, by
 the distention it produces, and will soon  after determine  the  expulsion of
 the ovule, by pressing it gradually towards the thinnest part.
   Both  suppose that the corpus luteum is completely developed  Avhen the
 vesicular rupture and the discharge "of the ovule take  place, Avhich, how-
 ever, appears altogether inadmissible to me.  I  am convinced to the con-
 trary, from the specimens which  M. Raciborsky has had the kindness to
 show me.  In a female, who died during menstruation, I Avas enabled to
 prove the  recent rupture of a vesicle  that Avas very much hypertrophied;
 its cavity, hoAvever, did not  contain a  yelloAv body.  This does not, there-
 fore, precede the rupture of the vesicle.  In my opinion, M. Raciborsky has
 perfectly described the phenomena, consecutive to this rupture, in the interes-
 ting treatise published by him {Dela Ponte Periodique chez les Femmes et les
 Mammijcres, 1844).   It may prove useful to publish his views in this Avork.
   " If the ovaries be  examined eight, ten, or twelve days after the cessation
 of the menstrual discharge, a small, rounded tumefaction, surmounted by a
 red spot like an ecchymosis, and  presenting in  its  centre a slight  linear
 fissure, will be  found on the surface of one of these organs.   The margins
 of the fissure are agglutinated, even this early, in the majority of cases, but
 it is still easy to separate them by using lateral tractions.  If the ovary be
 then opened at the ecchymosed spot, the interior
 will exhibit a pouch, already smaller than the            fio.36.
 cavitv of the vesicle before the rupture, but
 entirely filled by a clot of blood, Avhich, Avhen
 placed  in  alcohol,  has  the  consistence  of a
 solid  body,  though  someAvhat spongy in its
 nature.  The  clot is usually about the size of a
 medium cherry (see Fig. 34), and may be raised
from  its cavity Avithout  difficulty.  The  pari-
etes of the  vesicle  exhibit,   at this period, a
yelloAvish hue, that disappears in spirits of Avine.
The surface of the membrane is at once  slightly
plaited and doAvny.   In the meanAvhile,  the
most soluble molecules of the  clot are absorbed,   ^^XZ^ST^i
and then a further retraction  of the tunic takes   certain stage <f its devuiopment.
 
 98              FEMALE  ORGANS OF GENERATION.

 place.  Being  continually forced to folloAv the diminution of the clot, and
 to become moulded upon it, it forms aneAv a certain number of folds, Avhich
 finally adhere  to  each other, and thus diminish the surface of the mem-
 brane.  AfterAvards, a new absorption of soluble  parts, a further retraction
 of the tunics, a fresh  diminution of the cavity,  &c, &c.  Whence, at the
 end of a month, the only remnant of the pouch,  that could once have con-
 tained a  small cherry, is but a  little spot, that Avould hardly inclose its
 stone."   (See Fig. 36.)
  The tunic of the  vesicle becomes hypertrophied Avhilst undergoing the
 forced plaiting, caused by the incessant retraction of the peripheral fibres,
 thus  constituting  a radiated mass,  which,  from the  imbibition  of the
 coloring principles of the blood, assumes a very characteristic orange-yellow
 color.
  This coloration  is not produced, as M. Montgomery and several others
 supposed, from the deposit of a substance of a new formation, either  exter-
 nally to,  or Avithin the  vesicle, or between the two tunics that constitute its
 walls, but is simply the result of imbibition.   Finally, the absorption of the
 clot being complete, the two opposed walls of  the pouch, in time, approach
 each  other, and thenceforth form merely a single slate-colored line.  The
 vesicular  cavities are reduced to  this condition in from four to six months.
  Both M. Coste and M. Raciborsky acknoAvledge the folding of the mem-
 brane of the vesicle, but the theory of the former in relation to it differs so
 much from that of the latter as to make it our duty to explain it briefly.
  Immediately after its  rupture, the ovarian  follicle  becomes filled with a
 gelatiniform  matter, Avhich often receives a  red color from  the blood which
 escapes from a feAV opened vessels; the matter  itself assumes at a  later
 period a  greater consistency.  By the spontaneous retraction of the Avails,
 as Ave have  already explained, they are promptly throAvn into folds, and
 the rugae which result from retraction are so  numerous,  so prominent, and
so compact, as to bear some resemblance to the circumvolution of the brain.
 (See Fig. 37.)  Contemporaneously with this folding,  the  Avail becomes
 hypertrophied and inflamed; it assumes a red color, and encroaches more
and more upon the cavity which it finally fills, just as though it had given
rise to granulations.   Ere long, however, the  plastic matter which at first
filled  the follicle, having been gradually absorbed, the juxtaposed  circum-
volutions contract intimate adhesions Avith each other, and the replete follicle
forms a large tumor upon the surface of the ovary.
  Long before the  folds or circumvolutions Avhich tend to fill up the cavity
of the ruptured follicle are so tumefied as to  come in contact, their  tissue
loses the  inflammatory redness  Avhich  it  at  first possessed.  But as M.
Coste does not recognize the formation of a clot  of blood  in the vesicular
cavity, he cannot  admit with M. Raciborsky that the  yellow hue of the
mass just described is due to the  imbibition of its coloring matter.  On the
 contrary,  he  considers  the color  to be  due simply to  the nature of the
 molecular granules which  enter  into the structure of  the internal  layer.
These granules, he -says, are  remarkable not  only from  their number, but
on account of their light yellow hue.  Therefore,  as after the folding of the
internal tuni -, they are both very numerous and  very compactly bestowed, 
OVULATION  AND  MENSTRUATION.
99
 the  yelloAv tinge, which is very light for each taken  separately, becomes
 deep for  the entire mass.
   The two opinions may therefore be recapitulated thus:  1. Effusion of a
 coagulable fluid, Avhich  is blood,  according to M. Raciborsky, and plastic
 lymph, according to M. Coste.  2. Folding,  and progressive hypertrophy
 of the Avail of the vesicle.  3.  Yellow coloration of the latter, either by the
 coloring matter of the  blood  (Raciborsky), or by the  condensation of the
 molecular granules (Coste).   These two theories, Avhich include nearly all
 the  others, yet differ upon an important  point.  According to MM.  Raci-
 borsky, Pouchet, Dalton,  &c, there  is at first an effusion of fluid blood,
 which soon forms a clot of greater or less density ; M. Coste, on the contrary,
 regards this  effusion of blood as pathological,  or, at most, as an exceptional
 occurrence.

   [Most physiologists noAv think that after its rupture, the cavity of the Graafian
 vesicle becomes filled with a plastic  secretion  sometimes tinged with blood; the
 formation  of a clot being an exceptional occurrence. While this secretion is  being
 formed, the muscular fibres of the stroma retract and compress the wall of the
 ovisac, which not being retractile, is thrown into folds, as has been said.   Some of
 the cells of the granular membrane which remain adherent to the internal surface
 of the ovary  undergo hypertrophy, and  fatty granules are produced which give
 a yellow color to the tumor.  The folds project more and more and finally become
 adherent.   Then, after having remained stationary for a certain  time, this corpus
 luteum  becomes atrophied and  giATes place  to a depressed cicatrix.  In short, M.
 Coste's theory Avould seem to be the true  one, whilst the phenomena described by
 Raciborsky, though real, are exceptional  and pathological.]

   Whatever be the fate of the ovule after its expulsion, Avhether it receives,
 or not, the vivifying influence of the  seminal fluid, the remains of the torn
 capsule always undergo the primary changes described  above.
   As the formation of corpora  lutea always follows the rupture of a Graafian
 vesicle, and as this rupture is most frequently spontaneous, it is evident that
 medical jurists have committed  an error in regarding their existence in the
 ovary as a certain indication of  an anterior fecundation ; but some modern
 physiologists have also  been  Avrong  in supposing that  the study of  the
 corpora  lutea could  have no medico-legal  importance  Avhatever;  for,
 although  the supervention of pregnancy modifies the  corpora lutea in no
 respect at the commencement of their formation, it exercises an incontestable
 influence  upon  their  ulterior  development.   M.  Coste, avIio has  followed
 their evolution step by step in the two cases, has deri\red from his attentive
 observation sufficient means of distinguishing  a  corpus luteum succeeding
 to a pregnancy, from  one pertaining to a female who has not conceived.
  Not less than a month, says he, is required in a pregnant woman for  the
 filling up of the  follicle, and  the  commencement of adhesion betAveen  the
 folds; and forty days,  nearly,  Avill  have elapsed, before the connections  are
 firmlv established.  At this time, their  assemblage forms a compact and
 rcsistino- tumor, of nearly an inch in  its  longest diameter, and  five-eighths
of an inch in its shortest.   Having thus arrived at its maximum, it remains
stationarv for some time, until toAvard the end of the third month its period
of diminution commences.  The  tumor  is gradually  absorbed, loses its 
100
FEMALE  ORGANS  OF  GENERATION.
volume, and seems to enter again into the organ upon the surface of which
it had been raised ;  at the same time it becomes more compact, denser, and
more shining.  In  the course of the  fourth month it is nearly one-third,
and  towards the end of the fifth, nearly one-half smaller.  From the
sixth to the ninth month it Avill  have  lost nearly tAvo-thirds of its volume;
still, hoAvever, it forms after labor a tubercle of not less than five-sixteenths
of an inch  in  diameter.  The  latter noAV diminishes with  considerable
rapidity, but  nearly a month  is  required for its reduction  to a small and
hard  nucleus of indefinite duration.  There is nothing absolute, however,
in the rate of retrogression of this phenomenon.  For, as in  some women
who  died between  the  sixth and eighth month of their  pregnancy, the
corpora lutea were  found as voluminous as in others at the fourth  month,
so evident traces of it may  sometimes be discovered several months after
labor.
  When the  corpus luteum is produced under other influences than  those
to Avhich impregnation gives rise, its development, adds M. Coste, is by no
means so great, and its rate of diminution  is more  rapid.   Whilst, for
example, from five  to six months are required for the completion of the
chief modifications  during  pregnancy, the capsules  are almost  entirely
effaced in from twenty-five to thirty days, in women who  have  not been

                                Fig.  37.
     Represents a corpus luteum derived from a female who died in the sixth month of pregnancy.

impregnated.  The phenomena presented at the commencement, in the last
case, are the same as in the former, but the vesicles  suddenly soften, and
are frequently entirely absorbed  before the circumvolutions of the internal
layer have acquired sufficient development to come in contact, or to con-
tract  adhesions.   M. Coste has  never  known the corpora  lutea of a non-
pregnant female, who had died suddenly, to resemble those observed in the
second or third  month of pregnancy; they have  neither the size nor the
density of the latter  (Fig. 37).  In a word, adds the learned  embryologist
a corpus luteum which is as large as the  ovary itself, which forms  a solid
and resisting tumor, exhibiting upon section the  capsule of the ruptured
vesicle filled with  the  strongly-adherent internal circumvolutions  must 
 
Pi.  h
u  i
if 4
Fig. 3
hfc.G
T Sinclair's lilh °hi 
OVULATION  AND  MENSTRUATION.
101
belong to a pregnant female.   If the circumvolutions are but feebly united,
having betAveen them a layer of plastic matter which serves as a medium
of adhesion, the  corpus luteum corresponds to the second month of preg-
nancy ; if, on the contrary, the circumvolutions are blended into a compact
mass,.preserving at the same time a size similar to the preceding, it may be
regarded as derived from  a Avoman who had died toward the end of the
third month of gestation.
   From this time the mass becomes more and more compact, remains station-
ary for a while, and then tends to decrease until the end of gestation.
   We have represented  in the  same plate, several corpora lutea resulting
from menstruation, together Avith others observed at a more or less advanced
period of pregnancy.1  By  comparing the physical differences presented in
the two cases, we may readily appreciate the truth of the observations just
stated.   For Figures  3, 4,  5, and 6, I  am  indebted to the kindness of my
' earned master, M. Rayer.

                   EXPLANATION OF PLATE II.

   Fig;, I. a a. Corpus luteum four weeks after menstruation.
   Fig. 2. Corpus luteum thirty clays after menstruation.
   Fig. 3. Represents the ovary of a young woman, who,  after passing the night with
 i^r lover, committed suicide by throwing herself from the third story ; death took
 dace twenty-four  hours after,  a.  Small rupture produced by  the bursting of  the
 'esicle.
   Fig. 4. Longitudinal section of the same ovary showing the interior of the vesicle.
   Fig. 5. Represents the ovary of a non-primiparous woman, who died in the fifth
 month of pregnancy, of  pneumonia, complicated with abortion.
   Fig. 6. Ovary of a woman twenty years of age, who died in the ninth month of ges-
tation.

   In reviewing  the facts whose history Ave  have just  traced, we see that
towards the age  of puberty, the ovary becomes the seat of an active conges-
tion, and, it might be said, of a neAV vitality; all the living poAvers of the
organ seem to be concentrated upon one of the Graafian vesicles, which sud-
denly assumes a  considerable  development, and  in so  doing, raises  the
. envelope of the ovary, and forms a tumor, Avhich is superadded to the organ.
The  Avails  of the vesicle  become weaker  and weaker as their distention
increases, until they finally give Avay;  in  consequence  of the  rupture, the
ovule is expelled and carries Avith it  a portion of the  granular fluid with
which  it Avas surrounded.   This expulsion  constitutes  the phenomenon
knoAvn  of latter  time  as spontaneous ovulation.  The void left in the vesicle
is soon  filled with blood and a gelatinous matter, Avhich is secreted  by the
Avails of the follicle; the latter becomes hypertrophied and thrown into folds
by the  retraction  of the external tunic, and soon constitutes  the  corpus
luteum.
   As accessory phenomena, it isjknoAvn that the uterus and its annexes par-
ticipate to a greater  or less  degree  in the ovarian activity, and Ave have
briefly described the peculiarities Avhich they present during the accomplish-
ment of the process ; Ave shall have occasion to return to it in future.  Our
attention should, however, be first directed to the great resemblance betAveen 
102             FEMALE  ORGANS  OF  GENERATION.
this succession  of physiological  acts,  and the series  of phenomena which
comparative physiology, and anatomy have shown to take place in mamma-
lia at the rutting season.   In them likewise, the approach of the male  ia
not necessary to the discharge of the ovule, and  the spontaneous ovulation
is accompanied with almost  identical  changes in the genital  organs, and
manifests its influence upon the entire organism by the same assemblage of
phenomena.  In  the human  female, as  in the  mammalia and birds, the
spontaneous ovulation,  accompanied Avith the same  cortege  of symptoms,
occurs at more or less  regular  intervals.  In the rabbit, it is the tume-
faction and almost varicose injection of  the vessels of the vulva.   To this
coloring and tumefaction is added, in the bitch, an odorous secretion, Avhich
allures the males, and puts them upon the track of the females.  Finally, in
monkeys, a more  or less abundant hemorrhage occurs, Avhich, in the case of
the macaquse and the cynocephalse, coincides Avith so monstrous a sAvelling
of the vulva, that, in certain cases, the surrounding parts are infiltrated as
though inflamed in consequence of the sting of bees.   We shall study here-
after the peculiarities of these returns in  the human species.
  The vesicular evolution,  accompanied Avith the array of phenomena just
described, is reproduced at intervals Avhich vary for  different  animals, but
in the human female recurs at much shorter periods.   Every month, hi fact,
in the normal condition, a neAv Graafian vesicle is found to increase in size,
to become excessively distended, and  finally bursting and discharging the
ovule, to become  the seat of the successive transformations presented by the
corpus luteum.   Every month, therefore, this curious  phenomenon of spon-
taneous ovulation is reneAved ; and the dark-colored cicatricules of various
form, Avhich are observed upon the surface of the ovary of nubile Avomen,
give rise to the  supposition exclusive of direct observation, that the opera-
tion of Avhich they are the consequence must have recurred a great number
of times.
  Of the phenomena which Ave have just described, the Aoav of blood had,
until  of late years, chiefly claimed attention.  This Aoav, as Avell as the vesi-
cular evolution of Avhich it  is the consequence, occurs for the first time
betAveen the ages  of twelve and  fifteen years, and is aftenvard periodically
reneAved every month until the time of life  at Avhich  the female  loses her
aptitude for fecundation, that is to say, until she attains  the  age of from
forty-five to fifty  years.   KnoAvn under the  names of the monthly sickness,
the monthlies, courses, &c, this periodical excretion constitutes menstruation;
a phenomenon  which, though doubtless  of importance, is nevertheless far
from being the capital fact amongst those Avhich Ave have studied, for it may
be absent, without the vesicular changes being  notably affected  thereby,
whilst, on the other hand, it never appears without having been  preceded
and accompanied by the development of  a Graafian vesicle.  It is therefore
a secondary phenomenon intimately connected Avith those Avhich are accom«
plished  in the  ovary.   The  details into which Ave are about  to  enter, in
reference to menstruation, will complete the history of the ovarian follicles, 
OVULATION  AND  MENSTRUATION.
103
                          ARTICLE  II.
                           OF MENSTRUATION.
   Menstruation is, as Ave have  said, a  periodical Aoav of bkod from the
 genital parts, having its source in the walls of the uterus.  Its fii>t appear-
 ance, Avhich  is ahvays determined by the ovarian evolution of Avhich it is
 one of the epiphenomena, reveals the aptitude of the female for fecundation,
 and  constitutes one of the earliest signs of puberty or nubility;  I say one of
 the  earliest signs, for it very rarely occurs suddenly, and Avithout having
 been preceded by precursory phenomena.
   These phenomena are  both local and general.   The first, which are
 purely physical, occur more especially in the generative organs.  Thus, the
 pubic  region becomes covered Avith hair; the pelvis, Avhich hitherto differed
 but slightly from that of the  male, increases in size in every direction, and
 gradually assumes  the shape Avhich we  have indicated as peculiar to the
 Avell-formed Avoman;  the breasts are rapidly developed, and the nipple is
 more  projecting, turgescent,  and sensitive; the skin  Avhich  surrounds the
 latter  is also of  a  darker  color than before.   The outlines of the  body at
 the same  time become rounded, in consequence of the greater abundance
 and  more harmonious distribution of the cellulo-fatty tissue.
   These physical  changes are rarely found unconnected Avith an alteration
 in the moral state of the young girl.  Her voice assumes a softer tone, her
 looks are more timid, and often embarrassed in the presence of persons with
 whom  but  a few months previously she had sported as a  child.   She
 experiences desires, Avhich are the vague expressions of the development of
 the senses, which she cannot yet understand.  A melancholy sadness, and a
 taste for solitary places congenial to reverie, replace the boisterous pleasures
 of childhood.
   The  congestion  which  precedes the  hemorrhage  is indicated  by new
 symptoms.  The young girl complains of lassitude, of a sensation of SAvell-
 ing and tension  in  the  loAver part of the abdomen, of lumbar and sacral
 pains,  of Avcight in the loins, of heat in the hypogastrium and peritoneum,
 of a  slight itching and tumefaction in the genital parts, and a painful swell-
 ing of the  breasts.   In many cases, the  excitement of the genital organs is
 so great as to produce a  violent general  reaction; and, according to i5oer-
 haave, the  first  appearance  of  the menses  is accompanied  Avith fever.
 Strange nervous disturbances not unfrequently occur, and I have sometimes
 observed attacks of genuine hysteria. These symptoms may last from one
 to ciiiht days, and are folloAved by  a more or less abundant Aoav of  mucus;
 in the course of a  feAV days, this becomes  mixed with a little blood, and
soon gives place to a Aoav of almost  pure  blood.  The hemorrhage continues
for several davs ; then, as the amount of blood mingled  Avith  the  vaginal
mucosites diminishes, the flow becomes less colored, and after resuming the
characters of the vaginal secretions, ceases entirely.
  Quite fretiuently, the first menstruation takes place Avithout having  been
preceded by  anv of these  discomforts.  Sometimes  the eruption of blood
occurs  whilst playing or  dancing, and sometimes during sleep..
  In most young girls the eruption returns after the lapse of a mouth, and 
104
FEMALE  ORGANS  OF  GENERATION.
 follows subsequently its regular periodical  course; frequently, however, it
 is not until after three or four periods, and  sometimes even later, that the
 courses become regular.   In other cases,  again, a long interval elapses
 between the  two first  menstruations: thus, M. Raciborsky, having noticed
 the time between the  two first  menstrual periods in eighty-seven females,
 found that in all but fifty-eight, more than a month elapsed betAveen them.
 In two women, the second menstruation  occurred six weeks after the first;
 in four, two  months; in five, three months; in four, four months; in  one,
 five  months; in one, eight months; in  three, a  year;  finally, in  one, two
 years.
   These irregularities in the return of the second period may, doubtless, be
 due to a morbid condition requiring treatment, but  they may also depend
 upon an atony of the genital organs, which does not alloAV the physiological
 development of the  Graafian vesicles to continue.   This temporary atony
 does not interfere Avith the general health of the female, nor prevent  the
 future performance of  the function ; it often disappears under the excite-
 ment produced by a change of life,  or  by the first  conjugal approaches.
 (Raciborsky.)
   In some  young girls, the functional  troubles and abdominal pains, which
 Ave have regarded as so many precursory  phenomena of the first appearance
 of the menses, may not be followed by the Aoav of blood, and,  after having
 lasted for several days, they diminish and cease entirely; they may recur
 thus every  month, for a certain time, with no other result than a momentary
 disturbance of the general health, and it is only, so to speak, after several
 fruitless attempts, that the courses become established in a complete  and
 regular manner.
   The symptoms which heralded the first menstrual Aoav do not usually
 recur at the subsequent periods, or, at least, they  continue to diminish Avith
 each monthly return.  In some females,  however, they always appear with
 their  original intensity, and I have often remarked, in reference  to these
 cases, that  the  acute pains and colics which prelude the  Aoav of blood,
 disappear,  or even  cease  entirely, immediately after  the  first conjugal
approaches, and especially after the first labor.   In a still greater number,
 the return  of the menstrual period is throughout life  indicated  by some
slight pains,  a little  uneasiness, or merely by a  more or  less  marked  dis-
turbance of  the general condition;  the  temper  is less  even, the Avoman
 becomes more excitable, more irascible, in a word, less amiable.
  The time at Avhich  the first appearance of the menses occurs varies exceed-
ingly from  the  influence of climate, habits of life, and  constitution.  The
following table, extracted from the Avork of Miiller, Avith notes  by Jourdan,
gives an idea of these variations in different countries. 
OVULATION AND MENSTRUATION.
105
						W	c					
					&<	m '^						
AOB				4i	a _ p		o P i 3	s 3		8 a		
				£< B	•^ o	aS	2 n	» 2	Ch 3	Ph 3	^g	f- 5
				5	o	2	o Pi	c	PJ		^	
5 years, . .				1							.x	
7 '				1								
8 «				2								
9 '				11						1		
10 '				29	5					7		
11 '				96	14	6	10		4	18		
12 '				129	26	10	19	3	10	34	4	
13 '				138	47	13	53	8	20	40	4	
14 '				212	50	9	85	21	29	55	13	1
15 <				204	76	16	97	32	38	77	14	15
16 '				140	79	8	76	24	41	81	20	27
17 '				133	58	4	57	11	20	72	13	35
18 '				95	38	2	26	18	20	35	13	13
19 «				43	21		23	10	12	26	6	6
20 '				33	9		4	8		24	8	2
21 '				8	5			1	4	14	3	1
22 '				8	1					2		
23 «				4				1				
24 <					5				2		1	
25 '										1	1	
Total, . .				1285	342	68	450	137	200	487	100	100
  According to this table, the greater number of first menstruations occur,
at Paris, betAveen  the ages of fourteen and  fifteen years; but it may be
remarked, that the most common variations fall betAveen the ages of eleven
or twelve, and seventeen or eighteen years.
  Warm climates, a residence in cities and the habits  Avhich are contracted
there, together Avith  robust  constitutions, seem to favor the precocious
development of puberty;  a Ioav temperature,  residence in the country, a
feeble and delicate constitution, appear, on the other hand, to retard the
appearance of the menses.
  Numerous exceptions to the averages above indicated are mentioned by
authors.   Thus, as examples of  tardy and precocious menstruation, Ave see
by the table that  five Avomen menstruated for the first time at the age of
twenty-three years, six at twenty-four, and  tAvo at tAventy-five.   In some
very rare instances, the first appearance has been delayed for a much longer
time; thus, M. Kleeman mentions the case of a Avoman avIio was married at
the age of twenty-seven years, and Avho did not  menstruate until tAvo months
after her eighth confinement; she then continued regular until the age of
fifty-four years.  Pecklin  speaks of a strong  and healthy married woman,
who had  never  menstruated, although she Avas  forty years of age;  her
courses made their appearance upon one of the first nights succeeding her
second marriage, and  recurred regularly for tAvo years, at the expiration of
which time she became pregnant.
  If Ave  compare  these cases of tardy menstruation Avith the numerous
instances of Avomen Avho become  mothers Avithout ever having menstruated,
and of nurses in whom the suppression of the menses did not prevent con« 
L06
FEMALE  ORGANS  OF  GENERATION.
 ception, Ave shall find a full confirmation of Avhat was stated in the preceding
 chapter, in relation to the secondary importance of the menstrual discharge.
 Regarded as a phenomenon  attendant upon the changes  going on in  the
 ovary, it may be absent even  though the Graafian vesicle should undergo
 all its phases of development; nor  can its absence be now considered as
 indicative of the impossibility of fecundation.
   We cannot accept all the observations of very precocious menstruation ;
 but, laying aside  the numerous  cases in Avhich the nature of the discharge
 has not been so well determined as to allow of their reception Avithout ques-
 tioning, there are  some Avhose  genuineness  is  undoubted, inasmuch  as  the
 appearance of the discharge Avas attended Avith all the attributes of puberty.
 Thus, Dr. Susewind  kneAv of a child of seventeen months, Avhich had men-
 struated since she. was a year old ; the hemorrhage returned regularly every
 month, and the breasts and mons veneris were those of a girl of fourteen or
 fifteen years of  age.  The child observed by Lenhossek menstruated Avhen
 nine months old, and at tAvo years she  presented all the external signs of
 puberty.   The girl mentioned by D'Outrepont, Avho had  four  teeth Avhen
 tAvo weeks old, was  regular from  the age of nine months; she had at that
 time long black hair and prominent breasts.  A woman observed by Carus,
 menstruated when two years old, became pregnant at eight, and died at an
 advanced age.
   In  a memoir by M. Dezeimeris, many other similar  facts, derived from
 Schoefer, Louis  Robert, Le Beau, Descuret, Comarmond, Clarke, Lobstein,
 &c, &c, are recorded.
   These premature  menstruations are certainly due to the  same  causes
which determine their appearance in most women  about the age of fifteen
years.  Being always accompanied by the  development of the  breasts  and
 the other marks of puberty, they are the evidence, that under the influence
of an anomalous vitality of the ovaries, the Graafian vesicles  haA^e  under-
gone a very precocious development.
   When once Avell  established, the menses assume their regular periodicity,
Avhich is generally preserved up to the time of their cessation, Avithout other
interruption than that Avhich is occasioned by nursing or  pregnancy.  They
return about every month, as their name indicates; yet the interval between
them is far  from  being the same for  every female.  The average of  the
catamenial period is stated by Roser and Wunderlich at tAventy-eight days ;
in a large number,  according to Brierre de  Boismont, it is thirty days; and
in some  instances  the intermenstrual  period  is longer than  thirty days,
extending to five or six Aveeks, and sometimes even to tAvo months.  In some
women the returns  occur  upon the same day of each  month ; in a much
greater number, the end of the solar month  is anticipated by tAvo, three,
four, or five days.   Sometimes the period is much shorter, the returns occur-
ring at an interval of tAventy-four, twenty-two, tAventy, and even fifteen days.
  These frequent variations in  the duration and  return of the  catamenial
period are  a refutation in  advance of the opinion of those authors Avho
think that all women menstruate generally at the same periods, and that
there are times in each month when no one is  unwell; it  is evident that  the
retardations or the  anticipations of Avhich Ave  have spoken, must have  the 
OVULATION  AND  MENSTRUATION.
107
effect of bringing  the  return of some female upon  every day of the year.
The flow also commences almost indifferently, during the day or right.
  The  periodicity of the  catamenia generally continues until the age of
from forty to fifty years, at Avhich time they usually  cease.   We shall here-
after treat of the peculiarities Avhich often attend their cessation.
  The  duration of the flow varies between one and  eight days; according
to Brierre, it most  commonly lasts for eight days;  and next in order of
frequency, we have three, four, two,  five, one, six, ten,  and seven  days.
Many observers  ha\x  noted three or four  days, as expressing the most
usual duration.   In some very exceptional cases, it lasts for a fiVw hours
only; in others quite as rare, apart from  pathological conditions, it is pro-
longed through tAvelve or  fifteen days.
  The  quantity of blood lost is variable for the same  Avoman, and especially
so when observed in different individuals;  Ave may here add, that it is very
difficult  in  any  case to estimate it exactly.   If the two cotylcs of Hippo-
crates  be eighteen ounces (550 grammes), as  translated by Galen, his esti-
mate (provided  Galen's rendering is  correct) is evidently exaggerated, at
least for our  time and climate.  If Ave  appreciate the amount of blood
lost  by the  quantity of stained linen, I think the  estimate  of Haen, Avho
set it doAvn as averaging from three to five ounces, will be  found  to  come-
nearest the truth.
  The  quantity  of the  discharge appears to be greatly influenced by the
diet, habits of life, and climate; it is greater Avith rich and indolent females
who  use  a succulent diet, than with  those Avho are  placed  in an  opposite
condition.   According to  most authors, very Avarm climates exert a marked
influence upon  it, and, for  my  OAvn  part, I  am  acquainted  Avith  several
ladies Avho menstruate much more abundantly in summer than in Avinter.
  It is said  that Avomen from the country, avIio become domestics in Paris,
soon find their  courses to  diminish,  and sometimes e\ren  cease  entirely.
Such may be the  case Avith many of them, but it is due chiefly to the in-
fluence upon their constitutions of the Avant of fresh air, exposure to the
sun,  and of the  exercise  to Avhich  they had been accustomed from child-
hood, rather than to any change in their  diet; for, in general, the nourish-
ment Avhich  they receive  from their  employers is much better than  that
with which they Avere obliged to content themselves  in their oavii families.
  The  amount of the discharge is not the same throughout the duration of
the menstrual period ; ordinarily, it Aoavs moderately on the first and second
days, increases  on  the third  and  fourth, and then gradually declines.
Neither is the discharge always continuous;  it sometimes diminishes and
even stops  entirely  for several  hours, sometimes  for one or  tAvo days, and
afterAvards reappears either spontaneously or under the influence of a Avalk
or a  ride.  Moral emotions,  sometimes the process of digestion, and, above
all, the action of cold, may determine its momentary or final diminution
or suppression.
  The  seat of the hemorrhage and the nature and qualities of the menstrua]
blood,  have been  the  subject of very different opinions.   AVhat Ave  have
already said, Avhilst  describing the changes  in  the  uterine mucous mem-
brane,  during the ovarian evolution, leaves no doubt as to the source of the 
108             FEMALE  ORGANS  OF  GENERATION.
menstrual fluid.  It exudes, manifestly, through  microscopic fissures on the
internal surface of the mucous membrane of the uterus.   This fact, which
is placed beyond a doubt by numerous autopsies of women who died during
menstruation, had  been already proved by the  accumulation  of blood in
the cavity of the Avomb, where the neck was imperforate,  and by  the touch,
and the speculum, whereby it  has been both felt, and seen to Aoav from the
orifice of the uterus.
  Certain facts have  been adduced in order to prove that, in some  caseu,
the menstrual  blood proceeds frOm the vagina.   I think that the greater
number  of these observations have been either  badly made, or wrongly
interpreted.   I do  not deny the  possibility  of exhalations of blood  from
the Avails of the vagina; but if they present  the periodicity of the menses,
they can be regarded in no other light than as a misplacement of the latter.
The fact related  in the note beloAv appears to me to possess  great interest
in reference to this subject.1

  1  I have recently (November, 1849) seen, in connection with my excellent confrere,
Dr.  Thirial, a young girl,  twenty-one years of  age, who had menstruated  only twice
and for three days at a time; and in whose case the hemorrhage must of necessity
have had its origin in the  mucous  membrane of the vagina.
  This young girl, who had  been for a long time violently in love with  an officer,
finally yielded herself completely  to his wishes.  After several  attempts, renewed
with much ardor, but which each time proved fruitless, the young man  finally dis-
covered, and acquainted her with the fact, that  she was not formed like other women,
and advised her to consult a physician.   She applied first to M. Thirial, who solicited
my opinion.   A very careful examination enabled me  to ascertain as follows:
  The countenance, stature, and development of the limbs and  breasts, differed in no
respect from what is usual in young girls at her age.   Her general health  had always
been good.  In the month of  May last, her courses  appeared for the  first time, and
continued three days; she had, however, for several years before, experienced symp-
toms of uterine congestion.  In  the month  of July, they showed themselves  again
for  the last time.  The attempts of her lover were  twice followed by a considerable
flow of blood, which lasted two days, but she attributed it much rather to the amorous
violence to which she had  been subjected than to a periodic return of the menses.
  The mons veneris is completely destitute of the hair with which it  is usually
covered.   Upon  the lateral and  inferior regions,  immediately  above the external
orifice of the  inguinal canal, a  tumor is observed on  each  side which elevates the
integuments.  The  tumor  has the size, form, and consistence of an ovary  or testicle ;
it is but  slightly painful; under  a very moderate  pressure it retreats through the
inguinal canal, and disappears in the abd«omen,  but as soon as the  pressure is removed
from the internal orifice  of the canal, it reappears,  sometimes spontaneously,  some-
times on the slightest movements, or the  least effort of coughing or respiration.  On
no occasion was I able to perceive the signs which ordinarily accompany the  reduc-
tion of an intestinal or epiploic hernia.
  The vulvar opening was bounded by the greater and the lesser labia, but both were
much  less developed  than usual.   The  finger, which could  be  introduced only with
difficulty into the vulvar orifice, was arrested at a depih of three-quarters  of an inch
so that it was only by forcing up the  extremity of the vagina, that the first phalanx
could be made to enter that canal.
  Upon introducing the  extremity of  a speculum, it was impossible to discover anj
opening, or any point which would afford passage to the end of a stylet.  I was able
lo ascertain, at the same  time, that the membrane  pressed  upon  by the extremity of
the  speculum, possessed  all the ruga?,  and other characters of  the vaginal mucous
membrane. 
OVULATION AND  MENSTRUATION.
ioy
  As we have  already said, the menstrual blood, which is at first small in
quantity, becomes mixed with the mucosities which are secreted abundantly
by the vagina for a day or tAvo preceding the appearance of the catamenia.
The amount of blood soon increases, and the  flow  becomes almost exclu-
sively sanguineous.
  It is very difficult to say whether the blood is furnished by the arteries
or veins, or by both together.  In all probability, the blood exudes through
the Avails of  the very delicate ramuscules  which form the vascular network
of the innermost layer of the uterine mucous membrane.  The AA7alls of the
capillaries are ruptured, and through this solution of continuity the blood
escapes.   It  is not, therefore, a true exhalation.
  Now,  when  gestation has progressed to  some  extent,  these  ramuscules
become so greatly developed that  many of  them acquire  the calibre of a
quill.  At this time their true nature may be  ascertained, and the fact
settled, that they belong to the venous  system;  so that the  menstrual
hemorrhage  which they  supply must evidently  have  its source, in great
part at least, in the reservoir of dark blood.
  The physical  characters of the  menstrual blood vary according to the
time at Avhich it is examined,  since  it is mixed at the beginning, at the
middle, and at the end of the Aoav, Avith different amounts of vaginal mucus.
   The portion Avhich escapes during the second  period, not only resembles
completely in external  characters  that which  is obtained directly from a
Arein or an artery, but is  shoAvn  to  be identical by chemical  analysis.  Its
slight coagulability has been regarded as  an evidence of a want of  fibrine;
but, though  it coagulates rarely, as a general fact, yet  there  are occasions
in which clots  exist  in the vagina, and in the cavity  of the uterus itself.1
The presence of fibrine has  been chemically demonstrated, so that though
the  coagulation of the menstrual  blood be of  rare occurrence,  the  fact is
certainly due to its being uniformly mixed Avith  a considerable amount of
vaginal  mucus.
  On examination by the  rectum, I found: 1.  That  the rectal pouch, or dilatation,
was much larger than in the normal condition; 2. That above the  extremity of the
vagina, when pressed upward by my thumb, the index  introduced at '.«he same time
by the anus and carried as high as possible, could discover neither  fibrous cord nor
tumor ; nothing, in fact, which  could lead to a belief of the existence  of the upper
part of the vagina and of a uterus; 3.  Having introduced a sound into  the bladder,
the finger in  the rectum perceived with the. greatest  ease that nothing intervened
between its palmar surface and the vesical sound, except the normal thickness of the
two walls of the rectum and bladder.   The sensation was identical with that  expe-
rienced when  the  index  is introduced  into the vagina in order to  direct a sound in
the urethra.
  From this examination I thought myself justified in concluding: 1, that the tumors
found in the inguinal regions were the two ovaries ; 2, that the lowest extremity only
of the vagina  was present;  3, that the upper four^fifths of that canal were completely
wanting; 4, that, most  probably, there was no uterus; 5, that the  hypogastric and
lumbar pains which were experienced quite regularly, and almost monthly, were the
expression of periodical ovarian operations ; 6, that the blood of the menses which
had appeared  twice in this young woman, had its origin in the mucous membrane of
the vagina.
  1 It is, however, right to observe, that the presence  of clots in the menstrual dis-
charge is frequently due to an alteration of the structure of the uterus, or, at th<
least, to a functional derangement. 
110             FEMALE  ORGANS OF GENERATION.
  The eruption of the menses is generally attended with a peculiar odor
proceeding at that time from the  secretions of the vulva; it increases in
intensity during  the flow, and has been compared by some persons to the
smell of the marigold.  Can it be that the strange fears Avith Avhich men-
struating Avomen are regarded in some countries, are  attributable to  this
odor, which in uncleanly individuals is  very  strong?  Although this is
probable,  I  should think it  futile  to discuss  the incredible stories upon
Avhich are based  the popular notions of the noxious properties of the men-
strual emanations.
  Certain females discharge by  the vulva, at the menstrual period, a kind
of membranous bag, which Avould seem by its form  to  have been moulded
upon the uterine cavity, and Avhich bears a strong resemblance to the mem-
branous pouch (deciduous membrane)  which is  expelled with the ovum in
some cases of abortion.   The nature of the  pouch  is,  in fact, the  same in
both  cases, being  formed of cellular tissue, Avhich is both  vascular  and
glandular; its internal surface is ahvays smooth, provided Avith ejiithelium,
and  often abundantly perforated with glandular  orifices.   The external
surface, by Avhich it adhered to the organ from which it Avas separated, is
shaggy and  torn.   It is evidently  an exfoliated  portion  of the  mucous
membrane.
  This exfoliation  usually occurs in such  Avomen only as are afflicted Avith
difficult or very profuse menstruation,  accompanied Avith violent pain (mem-
branous dysmenorrhcea), or in such as experience a delay in  the  appearance
of their courses.  According to M. Coste, this phenomenon is the result of an
excessive congestion, a sort of apoplexy of the mucous membrane;  for,  says
he,  coagula  are  almost ahvays  found infiltrated in the substance of the
expelled membrane.  I Avould add as probable, that, in some cases at least,
this  exaggerated congestion may have been the consequence of  an  abortive
conception, or perhaps of solitary venereal excitements.
  Those physiologists  Avere mistaken who supposed that at every menstrual
period a free secretion took place upon the internal surface of the uterus,
and  gave rise to a false  membrane.  Nothing of the kind  has ever  been
proved by anatomical investigation ; for the  internal surface of the uterus,
at Avhatever  moment examined during the  catamenial period, ahvays retains
the characters peculiar to  the mucous  membrane, remaining smooth  and
covered Avith  epithelium.  Sometimes, hoAvever, the latter exfoliates, and
bears away with- it a portion of the substance of the mucous  membrane in
which case, the torn  glandular tubes rendered  free  and  fioatino- by the
separation, form, as it Avere, a forest of white filaments, and give accidentally
to the internal  surface of the uterus the villous and shaggy appearance
which some  authors have erroneously considered as normal.  This circum-
stance is, hoAvever, altogether exceptional, and results from the membranous
exfoliation of which Ave have just spoken.
   Cause of Menstruation. — FeAV  questions have given rise to more lively
discussions than the cause of menstruation; I  think it useless, however to
mention  here the  numerous  and more or less Avhimsical hypotheses which
have successively appeared in reference to it.  The fact is, that after having
read all that has been written on this  subject, the  mind  rests  entirely 
OVULATION  AND  MENSTRUATION.
Ill
satisfied in its ability to refer this  singular phenomenon to one unchange-
able and easily verified fact, namely, the successive evolution of the  Graafian
vesicles.  We  OAve this satisfactory explanation to the admirable labors of
Negrier,  Coste,  Pouchet, Raciborsky, Robert Lee, and Bischoff; so that
the credit of so beautiful a discovery belongs almost exclusively to France.
  That the cause of the menstrual discharge is the evolution of a  Graafian
vesicle, would  be an indisputable proposition, provided Ave are able to sIioav:
1, that the examination of Avomen Avho died during or shortly after the men-
strual period, has uniformly revealed the above-named changes in the ovary;
2, that the absence of ovaries involved of necessity the absence of menstrua-
tion ; 3, and lastly, that there is a complete analogy between the anatomical
and physiological  phenomena of  the  heat of animals, and those  Avhich
accompany menstruation in the human female.
  1. Since attention has been directed to this subject, no one has succeeded
in instancing the case  of a single Avoman, Avho died at the menstrual period,
Avhose ovary did not present a vesicle in a greater or less degree of develop-
ment, or else one which had been already ruptured.   The facts related by
Coste, Negrier, Pouchet, Raciborsky, and others, are now so numerous, that
it would be impossible to reproduce them in a work  like the present.   I
might myself add, if it were necessary, a considerable number of cases to
the others.  This universal coincidence affords from the outset a very strong
probability of the relation of causality Avhich Ave Avish to establish; but it
would become an absolute certainty, Avere  it possible  to  prove  that the
absence of the ovaries involved of necessity the absence of the menses.
  2. In the case of animals, on Avhich the experiment  can be repeated at
pleasure, not a doubt is permitted, that the extirpation of the ovaries causes
the disappearance, forever, of all symptoms of heat.  Analogy alone Avould
lead us, in the absence of positive facts, to suppose that  menstruation, also,
Avould cease after castration.   But  although Avell-observed  instances of the
performance of this operation on women are happily very rare, there is yet
one w»liich derives  a great value in the present discussion from the name of
the author. The folloAving is an abridgment of it. A woman, says Percival
Pott, had tAvo small tumors, one in  each groin, Avhich Avere so painful as to
render Avorking impossible.   It Avas decided to extirpate them.  After hav-
ing divided the skin and the subcutaneous tissues, a membranous sac Avas
exposed, Avhich contained a body resembling an ovary ; a ligature Avas throAvn
around it, and it Avas removed.  The same operation Avas performed on the
opposite side.   The woman recovered;  but the menstruation, which before had
occurred witli  the greatest regularity, never afterwards appeared; the breasts,
which had been voluminous, subsided ; she also became thinner, and assumed
a more masculine appearance.
  From the statement of  M. Roberts it Avould appear that  in Central Asia.
vest i-res are still to be  rnet Avith of the cruelty of the ancient kings of Lydia,
who castrated Avomen,  either that they might put them in charge of their
seraglios, or in order to gratify their unbridled passions.  After arriving at
Serai, he obtained a nocturnal rendezvous Avith three  persons known as
Pad/eras.   The necks of these individuals Avere not developed, nor  had they
any nipple ; the orifice of the vagina Avhich Avas entirely obliterated, presented 
112
FEMALE  ORGANS  OF  GENERATION.
no trace of a cicatrix; their hips were narrow, the pubis entirely destitute
of hair, the nates were fiattened, &c.; they had no hemorrhoidal flux., no
epistaxis nor menstrual  discharge, neither had they  any sexual  desires.
They were very muscular, and there was something masculine both in their
external appearance and in the character of the voice.
  M. Roberts was unable to ascertain precisely the nature of the operation
to which they had been subjected in their childhood, for they had no  remem-
brance of  it; but if we may judge by the results, Avhich are altogether simi-
lar to those produced by  castration in animals, it becomes more than  prob-
able that the same  alterations are due to the same cause.
  3. Admitting, finally, the incontestable  analogy betAveen the symptoms
of heat and menstruation, it will be sufficient to prove, in order to deduce
therefrom  a favorable argument, that the former is ahvays connected in ani-
mals Avith the ovarian evolution.  Noav certain experiments do not allow of
hesitation.  By these it  is in fact proved  (Coste), that the females never
enter into heat except Avhen the  preparation for the  spontaneous ovulation
is going on in the ovaries, that the venereal erethism continues throughout
the entire duration  of the process of evolution, and that  it ceases Avhen the
rupture of the capsule has taken  place.  Finally, it is universally knoAvn
that castration prevents the females from entering into heat, whilst those which
have been deprived of the Avomb, but not of the ovaries, lose nothing of the
ardor with which they receive the male.
  Menstruation is, therefore, intimately connected with the evolution of the
ovarian vesicles, and cannot occur without it;  and every time that it appears,
we may feel entirely satisfied as to the existence of the vesicular develop-
ment.  But,  as an additional phenomenon, the uterine hemorrhage may be
wanting Avithout hindering, in any degree, the regular march  of  the process
going on  in the ovary.   In a Avord,  the spontaneous ovulation which ordi-
narily gives rise to  an exhalation of blood  from the internal  surface of the
womb, may have its influence restricted to  the ovary alone; and to assume
the non-appearance of the menses as a ground for denying aptitude  for con-
ception, Avould be incurring the  risk of frequent deceptions.   Thus it hap-
pened  that science possesses numerous examples of young girls who became
pregnant  before they had ever menstruated, as also  of Avomen Avho con-
ceived, notAvithstanding a suppression Avhich had lasted for several  months.
   On  the other hand, the regularity of the  menstrual  function does not
necessarily imply the entire fulfilment of the vesicular evolution.  In cer-
tain cases, the latter process has been seen to remain  incomplete, and the
vesicle after having attained a certain degree of hypertrophy, to be suddenly
arrested in its development, to remain stationary for some time, and then
abort without rupture.   I  have  chanced  to meet, says  M. Coste,  cases  in
which the menstrual Aoav had passed over  entirely, Avithout the ovarian fol-
licle, whose evolution had commenced and even progressed to its final period,
having ruptured, or accomplished the result toAvard Avhich it  tended.
   The cause of menstruation being ascertained, hoAV shall Ave account for
its monthly periodicity ?   In other words,  Avhy is  it that ovulation in the
human species  recurs  about every month?  To this question science  is
unable to  reply, for it is probably one of the  impenetrable mysteries of nature. 
OVULATION  AND  MENSTRUATION.             113
But Avhy should our ignorance upon the subject be a cause of wonder? Do
we  know  Avhy certain trees  produce new fiWers every month ? Avhy this
animal is  prepared for fecundation every two or three months, whilst that
one is so but once a year ?   The processes which Ave have studied  are inti-
mately connected Avith fecundation, and are, so to speak, its preludes. Why,
Avhen the Avhole book is unintelligible to us, should Ave expect to compre-
hend the preface ?
  Cessation of the Menses.—As we have before said, the menses continue in
the majority of women until  about  the age  of 45 years.  According to a
table of Brierre de Boismont, 40 years is the age at Avhich the greater num-
ber of women cease to be regular.  In 60 Avomen observed by M. Petrequin,
it Avas betAveen 35 and  40 years in $, betAveen 40  and 45 in i, betAveen 45
and 50 in £, and between 50 and 55 in i.   In 110 Avomen mentioned by M.
Raciborsky, the average age of cessation Avas 46 years.  The  latter author
cites from Dr. Lebrun of Varsovia, and Faye of Skeen, results Avhich go to
prove that in Poland the average term is 47 years, and in the neighborhood
of Christiana 48 ; all Avhich tends  to shoAV that in cold climates menstrua-
tion terminates later in life.   It may be admitted, therefore, that  the aver-
age duration of the menstrual function is from 25 to 30 years.
  But like their commencement,  the period at Avhich the menses cease is
subject  to great variation.   Desmoreaux mentions a lady Avith Avhom they
stopped at 23 years of  age; nor is it rare to find them suppressed  between
35 and 40.  On the other hand, they are often prolonged much beyond the
ordinary period, and Avith  them, the Avomen retain the poAver of conception
up to 60, 6o, and even,  as some authors relate, to 70  years.  I leave to the
lovers of  the  marvellous those instances  in which menstruation continued
until 80, 90, and even 106  years.   It is infinitely probable that, in the cases
of this nature, the  pretended menstrual returns Avere really due, as Haller
remarks, to uterine disease.  I Avould add, that Ave should place in the same
category those examples of Avomen avIio, after having  ceased to menstruate
about the age of 45 or 50 years, have had their courses to reappear several
years after, and continue with regularity.
  According to most authors, those women avIio menstruate very early also
cease to  do so sooner than others.   This remark appears, both to  M. Raci-
borsky and myself, to be inexact,  Avhen not  applied  to individuals  living
under different  climates.   With the former author, Ave think that  preco-
cious menstruation is due to an excess of vital power  in the individual, and ■
that, exceptional circumstances excluded, the influence of this vital activity
is felt later in life, and  prolongs the  aptitude for procreation in the Avoman.
So that, in general, it ceases as much later as it begins at "an earlier age.
  The cessation of the menses, and of the  vesicular evolution of which they
are an  epiphenomenon, produces  in the  generative  apparatus and  entire
organism of the Avoman, effects the  opposite of those Avhich their first appear-
ance had  determined.
  The ovaries become atrophied, and diminish in size in every direction,
and their external envelope becomes folded and Avrinkled, so as to present
an appearance Avhich, says M. Raciborsky, Ave can compare to  nothing
better than the surface of a peach-stone.
       8 
114             FEMALE  ORGANS  OF GENERATION.
  The Graafian vesicles appear as  pouches of a  grayish  or opaque  white
color, Avith  Avrinkled Avails;  the fluid Avhich they  contained  is absorbed;
sometimes their cavities are effaced, their thickened Avails  are in contact,
and  look like a sort of tubercle, in  the centre of Avhich barely a trace of
the former  cavity  is visible.  Sometimes no part of the vesicles can be
discovered,  and the ovary, Avhich  has become transformed  into a  fibro-
cellular  substance, is so flattened as to be hardly distinguishable at the
extremity of its ligament.  We have already spoken  of the deep  folds and
wrinkles of  its external membrane.
  Finally, the womb and  the breasts, whose vitality became suddenly so
active towards the age of puberty, seem struck Avith  the same blow which
destroyed the ovarian orgasm;  they  waste gradually away, and become, so
to speak, foreign to the general life of the body.
  This cessation of the ovarian  functions rarely takes place suddenly, but
is almost always announced several years in  advance  by  more or less
marked irregularities  or  intermissions.   Frequently, the  returns of the
menses suffer postponements, Avhich may be prolonged for several Aveeks or
months, and then, after reneAval, be deferred  for a still  longer period.
Sometimes the epochs are marked by a very small discharge, and last for a
very short time; again, on the contrary, the quantity of blood lost  may be
so considerable as  to give  rise  to apprehension.   With certain women the
Aoav  is  so  excessively prolonged  that  the menstrual  periods  are only
indicated  by its increase;  a mucous  flux of a yelloAvish-Avhite color, Avhich
is quite abundant,  and either continuous or periodic, replaces the  flow of
blood in the interval of the epochs, and sometimes remains  for a  long time
after they have ceased.  Finally, a general and indefinite feeling of uneasi-
ness, lumbar and pel vie pains, colics, itching at the  genital parts, flashes of
heat  in the face, and sudden and spontaneous alterations of chilliness Avith
profuse perspirations, are added to the local phenomena above indicated.
  In the majority of cases,  all these troubles are quite slight and disappeai
promptly; but, in some instances, diseases before latent then declare them-
selves.   It is this fact Avhich, though much rarer than is commonly supposed,
has  obtained  for this time of  life  the name of the critical period.  Its
dangers have been  Avonderfully exaggerated, and modern  researches prove,
in opposition to the opinion of  physicians Avho have preceded us, that the
organic  affections of the breasts, of the  uterus, and  of the ovaries,  begin
much more frequently before than after the cessation of the menses.  Finally,
it is  shoAvn by statistics, that the mortality in Avomen between the ages of
40 and 50 years is  not greater than at any other period of life. 
OF THE BREASTS.                         115
                            CHAPTER  V.

                             OF  THE  BREASTS.

  [The breasts, two in number, are large glands, annexes, so to speak, of the organs
uf generation.  They are symmetrically placed on the upper and anterior part of the
thorax on each side of the sternum, generally occupying the space included between
the third and fifth ribs.  Rudimentary in man and in the young  girl, they become
developed in the  latter at the period of  puberty.  They present  great individual
difference in size, but in the women of certain races they are generally very large,
some African nations, for example,  having them extremely long.
  The  left breast  is often larger than the right one.   Curious anomalies, also, some-
times come under observation.  Thus, women are reported having four breasts, and
I have myself met with  an instance of this  kind in a woman Avho  died  at the
Maternity Hospital.   Two breasts of the usual size occupied their normal position,
whilst  two others, as fully developed, were situated on the upper and lateral parts
of the  abdomen on the same vertical line Avith the thoracic ones.   At the autopsy,
I found abundance of glandular tissue in all four of the breasts, which also con-
tained  milk.
  A supplementary nipple at a short distance  from  the principal one,  is  a more
frequent anomaly, of which I have already seen several  examples. A wax model
from a cast of one of these is now in the collection of the hospital of the " Clinique."
In the  instances which have come under my observation,  the supplementary nipple
was well formed,  but smaller than the normal one, and  milk  flowed from it when
the gland was pressed.  One of  the women  assured  me that the peculiarity was
hereditary in her family.
  The  natural form of the breast is hemispherical,  or rather represents a flattened
cone with the  base upon the chest.  The skin covering it presents in  its centre a
projection known as the nipple.  Around the nipple is a colored circle, from an inch
and a quarter to rather more than an inch and a half in diameter, called the areola,
and is  easily distinguished by its contrasted  hue.  Some further  remarks  will be
necessary to the proper study of all these parts.
  The  skin  covering the breasts  is fine  and soft, and is provided with piliferous
follicles to which  are connected large sebaceous glands.  The hairs are extremely
fine and readily seen otdy when magnified.  Beneath the skin, and betAveen it and
the gland proper, is a layer of cellulo-adipose tissue,  Avhich increases in  thickness
in approaching the circumference of the organ.   To this fatty layer the  breasts owe
their regularly rounded form, their softness, and very often the greater part of their
Bize.
  The  areola is  rose-colored in young women, and brown  in  those who  haAre
borne  children.   The skin covering it is rugous, abundantly furnished with seba-
ceous  glands, and exhibits here and there  tuberculous elevations  of variable size.
These  projections, numbering  from tAvelve to twenty, have a somewhat circular
arrangement, and are composed of collections of highly developed  sebaceous glands
which  secrete  a yelloAvish-A\diite fluid.  The character  of the secretion was doubtless
the cause of their having been so long regarded as rudimentary nipples  giving issue
to drops of milk.   This erroneous vieAV can no longer be  maintained since they are
proved to be sebaceous glands.
  The  areola does not rest upon a fatty cushion like the remainder of the  skin of
the breast, but is in direct relation with  the gland; its  lower  surface,  however, ia
provided with a layer of smooth muscular fibres disposed  around the nipple  in close
concentric circles, which become  more  widely separated toward  the  edge of the 
116
FEMALE  ORGANS OF  GENERATION.
areola where they finally disappear.  The skin-muscle thus formed compresses the
nipple when it contracts.   Under its action also, the skin of the areola contracts
and Avrinkles if the nipple be excited by tickling.
  The nipple, situated in the centre of the areola, presents a slightly conical pro-
jection, from three to five eighths of an inch in height  and from five-sixteenths to
three-eighths of an inch in diameter at the base.   These dimensions, hoAvever, as
well as  the shape of the nipple, vary greatly.  In some women it is Arery slightly
developed and barely projects at all; in others, it is actually below the surface of
the areola, presenting a sort of umbilical depression.  On  the  other hand it may
be very large or  even  club-shaped.  The  skin  coA^ering  it presents  numerous
papillae, separated by creases  in  the bottom of which are the orifices of great
numbers of sebaceous  glands.  Beneath the  skin are connective tissue, elastic
tissue, and bundles of muscular fibres.
  This structure explains sufficiently why touching the nipple should, by  exciting
contraction of the fibres which it contains, render  it for the moment harder and
more  projecting.  Still, it  must not be confounded with the truly erectile organs,
inasmuch as its arteries are small  and  not  contorted and  the  veins also  of small
  The nipple is traversed from base to summit by lactiferous ducts fifteen or twenty
in number, which open by as many minute  orifices near the free extremity of the
organ at the bottom of the folds between the papillae.
  The mammary gland proper, is situated beneath the parts just described, in a fold
                              of the fascia superficialis.   It presents a hard,
             Fig. 38.             flattened mass Avhich is thicker at the centre  than
                              at the circumference.  The glandular structure is
                              disposed in fifteen or twenty lobes, separated by a
                              fibrous envelope surrounded by fatty tissue.
                                Each lobe is formed by the aggregation of a cer-
                              tain  number of  lobules, themselves composed of
                              glandular culs-de-sac or acini dilated into terminal
                              vesicles.  From each vesicle departs a minute duct
                              which joins those of neighboring acini.   The ducts
                              from  the lobules  unite  in  their  turn to form in
                              each  lobe a principal canal AA'hich has received the
                              name of lactiferous duct.
                                As each lobe has its principal or lactiferous duct,
                              the whole number of these vessels is the same, e. g.
                              fifteen or twenty, as that of the lobes.
                                The lactiferous  ducts all proceed toward the
                              nipple, but in passing under  the  areola they  ex
                              hibit dilatations which haA'e received the name of
                              sinuses.  Then entering the nipple,  they diminish
                              in size and  terminate by separate and very minute
                              openings.
  It is  most probable that the lactiferous ducts  are independent of each other
throughout their  extent.   Prof. Dubois, indeed,  expressed  the opinion that they
often  anastomose;  but M. Sappey, who has investigated the subject more recently,
failed to discover any connection between them.
  The fact that the walls of these ducts are provided with muscular fibres is suffi-
cient  to explain the spirting out of the milk when they contract.
  The arteries of the breast come from the external and internal mammary and  the
intercostal arteries.
  The A'eins  follow the  same course with the arteries, and empty, some into  the
internal mammary, and others into the axillary vein.
  Lobules of a mammary gland.
A. Acini.
B. Canaliculi.
C. Duct formed by several canaliculi. 
OF  THE  BREASTS.
117
  The lymphatic vessels, which are very abundant, pass into the axillary ganglia.

  The  nerves come from  the intercostal and thoracic branches of  the brachial

plexus  ]
                                        Fig. 39.
                      A Lobe of the mammary gland.

A. Lob-vlee.  B. Canaliculi proceeding from the lobules.  C. One of the lactiferous daca.
           D. Areola.  E. Nipple.  F. Sebaceous tubercles of the areola. 
PART  II.
                       OF  PREGNANCY.

   GENERATION is effected in the human species through the medium of
    two  sexes distinguished  by the possession of different organs.  The
sexual characters being therefore peculiar to distinct individuals, the male
and  the  female,  these evidently must  first  approach  each other before
generation can take place.  This first act constitutes  copulation.   The con-
sequence of the approach is an application of the fecundating  principle of
the male to the germ furnished by the female, in other words, conception or
fecundation.  The ovum having been fecundated, remains, and  is developed
in the organs of the mother during the whole term of gestation.  Lastly, at
the expiration of a nearly uniform period, the new being is  expelled, to
maintain thenceforth a separate  existence;  this  final act is termed  the
accouchement or labor.
  Pregnancy is, therefore, the condition of a woman Avho has conceived, and
bears Avithin her womb the  product of conception.
  This state commences at the instant of fecundation, and terminates Avith
the expulsion of the  body which results from that function.   It continues
for two hundred and seventy days, or nine solar months.  This term, hoAV-
ever, is not  invariable,  as  it  is  by no  means rare  for the rregnancy to
terminate sooner, and in some very feAV instances Ave find it of longer duration,
though some persons have denied this latter fact, and everybody recalls the
sharp discussions carried on in France about the middle of the last century,
and still  more recently in England, on the question of retarded births.
  We. have already stated that the fecundated ovule traverses the tube, so
as to reach the uterus, where it is developed and continues to  grow durino-
the whole term of gestation. When the succession takes place  in this
manner, the pregnancy is said to be a good, normal, or uterine one;  but, on
the contrary, if the ovule  be  arrested at some point of its passage, and is
developed elseAvhere  than in the Avomb, the pregnancy is denominated bad,
extraordinary, or  extra-uterine.  The first, or uterine pregnancy, has been
dr. ^ded into,—the simple, Avhere only a single foetus exists; the compound, or
double, triple, &c, Avhere there are tAvo  or three  children; and the com-
plicated pregnancy, or that in Avhich the positive existence of a foetus is
coincident Avith that of a pathological tumor of the abdomen.   Again, the
term false pregnancy has been  improperly applied to certain diseases simulat-
ing pregnancy, where this  state does not really exist.
   We  shall first treat of simple pregnancy, leaving the  subject of tAviu
pregnancies for a special chapter.   Extra-uterine pregnancy will be  studied
with the other diseases of the  pregnant female.
                                                             118 
OF  CONCEPTION.
119
  The pregnant condition presents tAvo classes of phenomena,, one of which
pertains to the Avoman, and the other to the product of conception: they
are to be studied separately.
  We have already described the genital organs of the female, and it is not
our province to notice those of the male.   AVe shall be equally silent upon
all  that relates to sexual intercourse,  though it is  our purpose to treat
briefly of  conception, and in detail of gestation.
                          CHAPTER  I.
                           OF  CONCEPTION.
  Conception takes place during sexual congress; but to understand how
it occurs, requires that Ave should  knoAV first Avhat materials are  furnished
by each individual, Iioav  and where these  are brought into contact, and
lastly, what is not yet, and  probably never Avill  be explained, Iioav from
this contact a  neAV individual is  produced.
  1.  The spermatic fluid, a glutinous, consistent, and Avhitish liquid secreted
by the testicle, is the fecundating principle  furnished by the male.   It is
heavier than Avater, and, Avhen shaken with it, forms an emulsion.  Its odor
is peculiar, and has been justly compared to that emitted by bone filings,
or the floAver of the chestnut-tree; AVagner states that the odor is due rather
to the secretions Avith Avhich it is mixed than to the sperm  itself, the latter,
Avhen pure, not appearing to possess any particular smell.  By chemical
analysis it is  shoAvn to contain albumen, salts of phosphoric and chloro-
hydric acids, and a peculiar animal substance called spermatine.
  When examined under  the microscope, Avith a magnifying power of three
or four hundred diameters, the spermatic fluid exhibits: 1. A great number
of little bodies, lying quite close to each other, and Avhich are still moving
Avith more or less activity  if the  fluid has been taken from a recently-killed
animal; these  minute bodies have, been designated as the spermatic animal-
cules, or the spermatozoa.   2. Epithelial cells  and minute granules of a fatty
nature.  3.  These tAvo principal elements of the sperm SAvim in a  small
quantity of clear,  transparent,  and  perfectly homogeneous  liquid,—the
spermatic liquid.   At the time of the ejaculation, this liquid is mixed Avith
a variable quantity of the fluids  secreted by  the prostate gland and the
glands of CoAvper, Avhich latter evidently serve merely to lubricate the parts,
to render the sperm more fluid,  and, consequently, its expulsion more easy.
  The spermatic animalcules attract particular attention by their  varied
form, their vital properties, and  their development.  They are met Avith  in
all animals  capable of reproduction.
  In man they are very  small, scarcely surpassing the eightieth  or the
hundredth of  a  line in diameter.   The body is small,  oval, somewhat
flattened like  an almond,  and transparent, having a diameter equal to the
three or four hundredth part of  a millimetre ("001 of an inch).   The tail is
filiform, thicker at  its origin than  at any other part, and is large enough to
present clearly its double  outline; towards the extremity it becomes so fine 
120
PREGNANCY.
that it cannot be traced, even by means of the highest magnifying poAver
whence it  may be possible  that its  delicate extremity is still furthei
elongated, and that the spermatozoa may be much longer than they appear.
  It is impossible, says AVagner (from  whose able works  I extract  this
paragraph), to decide whether the spermatic animalcules have an animal
organization, that  is, whether they are true animals Avith an independent
life, or not; and all that is  either knoAvn, or plausibly supposed on  this
point, may be reduced to a few obscure indications, that  are wholly insuffi-
cient to establish any  positive opinion.
  The movements  Avhich they exhibit  prove nothing, because it is exceed-
ingly  difficult to ascertain whether they  are voluntary or not.  Again, the
duration of the movements also varies in the different classes of animals;
in the mammalia, they have been observed for twenty-four hours after death.
  The spermatozoa do not appear in the  human species before puberty; at
this period, the testicles  receive a large supply of blood, and increase in
Bize; the parietes of the semeniferous tubes become thickened, their capacity
increases, and they are filled with granules; then cells containing globules
begin to form, and finally the spermatozoa appear in these cells.   They are
ahvays found in the testicles of men of sixty to seventy years of age, though
they are then frequently absent  from the vas deferens;  the vesiculse semi-
nales, hoAvever, generally contain them even at this time of life.
  The germ furnished by the female is  evidently existent in the ovary at
the marriageable  period, and this germ is the ovule.   (See p.  90 for its
description.)
  2. It is unnecessary in  our day to prove that an absolute contact of the
semen of the male  Avith the ovule of the  female  is indispensable to fecun-
dation, for  innumerable experiments upon living  animals,  and   numerous
facts observed in the  human species, have long since demonstrated  that,
whenever any obstacle prevents the approach of these two elements, a con-
ception cannot take place.  But at what  point does this contact occur?
Already had the pre-existence of the ovule in the ovary, the  occasional
occurrence of ovarian and abdominal pregnancies, and the experiments
of Nuck and Haighton, Avhich  had rendered  fecundation  impossible  by
ligating the Fallopian tubes, tended towards the conclusion that it occurred
in the ovary; still  this  fact Avas not actually demonstrated, and it needed
the definitive proof of finding  the spermatozoa on the ovary itself.   At
present, there cannot  be a further doubt on this  point, for Bischoff has
been  fortunate enough  to  see them  there.  "I had often  seen," says he,
"living and moving  spermatozoa in  the vagina, the Avomb, and  the Fal-
lopian tubes of bitches; but, on the  22d of June, 1838, I  had  the  good
fortune to perceive one on the ovary itself of a young bitch  in heat for the
first time;  she Avas covered on the 21st, at seven o'clock in the evening,
and again the folloAving day, at two o'clock p. m., and at  the expiration of
half an hour, that  is, tAventy hours after  the first copulation, I killed  her,
and found  some living spermatozoa, endowed Avith very active movements,
not only in the vagina, the entire Avomb  and tubes, but even betAveen the
fringes of the latter in the peritoneal pouch that surrounds  the ovary, and
on the surface of this  organ itself."   Since that period, AVagner and Barry
have  raat'e the same observations. 
OF  CONCEPTION.
121
  Noav such results evidently prove that fecundation sometimes takes place
in the ovary; but are Ave hence  to conclude, that  it is possible in that
organ alone?  If spontaneous ovulation be now an incontestable fact, may
it not be supposed that the ovule, after having left the ovary, can encounter
the spermatic fluid and  become fecundated, Avhether it be in the Fallopian
tube, or even  in the uterine cavity ?

  [M. Coste's  observations  seem, however, to prove that fecundation is  almost
ahvays effected either upon the ovary or in the part of the tube  nearest the fim-
briated extremity; inasmuch as he  maintains that  the ovule spoils very quickly
when it enters  the tube Avithout previous fecundation.]
  But the question arises, how does the fluid ejaculated  by the male get as
far as the ovary?  We answer that, in  the great  majority of cases, it is
evident that the sperm having first reached the uterus, upon the neck of
which it was thrown by the membrum virile, travels through the tube until
it arrives there.  This course is certainly due,  1st, to the movements proper
of the Avomb  and the tubes; for  in the latter, a rapid  contraction is ob-
served, folloAving the direction from the vagina toAvards the ovary, Avhich,
of course, is calculated to assist the progression of the sperm ; and 2d, to
the movements proper of the  spermatozoa, Avhich thus of themselves facil-
itate their OAvn advancement.
  3.  This first point being once established, the question naturally arises,
Avhat Avas the  influence exercised by the sperm upon the ovule of the female
during the  contact ?  Noav, numerous  experiments clearly prove that the
sperm OAves its fecundating  properties to the presence of the spermatic
animalcules, and that, Avhenever  it is deprived of these, it  immediately
becomes unsuited to  its  proper  function.  But, unfortunately, it  is  far
more difficult to ascertain  the part acted by the spermatozoa, though there
have been three hypotheses started in regard to that subject deserving our
consideration.
  Again, according to  certain authors,  the fecundating poAver does not
belong to the spermatozoa, but to the seminal  liquid interposed betAveen
them.  In this hypothesis, the animalcules  are  the transporters of  this
fluid, and the object of their movements is to conduct it to the ovule.
  In the opinion of Bory-Saint-A^incent, Valentin, and Bischoff, the sper-
matozoa are  solely destined to maintain the  chemical  composition  of the
sperm by their active  motions.  They  suppose that the spermatic fluid is
a substance  endowed Avith a chemical sensibility of such a character that,
like the blood, it can only preserve the fecundating poAver while it remains
in motion ;  Avhence these active elements are inclosed in it  whose presence
is indispensable — elements, the movements of Avhich are never more active
than  just at the moment Avhen the semen leaves the place of its secretion,
and Avhich appear to exercise  the  most favorable influence  for  the  main-
tenance of its composition.
  [The oldest view is, that during fecundation the spermatozoids penetrate directly
into the ovum.   Barry even asserted  that  there existed in the ova  of rabbits an
opening for this purpose, and he had once the good fortune to see a spermatozooB
enter by means of the fissure. 
122
PREGNANCY.
  For a long time this view was thoroughly contested, but has now c* me into
favor again.  In 1854, Meissner saw in the ova of a rabbit suermatozoa within the
transparent zone and in immediate contact with the yolk.  The observation was
verified by AVagner, Heale, and several others; and M. Coste, whilst examining the
ova of salmon  and trout,  discovered in the vitelline membrane a  well-defined
microscopic opening provided with  an internal  valve.  In other ova, M. Robin
saw spermatozoa inside of the vitelline membrane .without being able to discover
the opening through which they had passed.
  Similar observations have become so numerous,  that the  passage of  more or less
spermatozoa into the ovum itself is regarded as an  established  fact.   Once Avithin
the ovum, they undergo a retrograde metamorphosis, and are resolved into granula-
tions which mingle with the elements of the vitellus or yolk.]

  This is a summary of  the most  recent opinions.   Whichever one  may
be adopted, the mind remains  unsatisfied; for  it must  be acknoAvledged
there is still a mystery that all the most ingenious hypotheses have failed
to solve,  and which will probably escape all our researches.
  When fecundation takes place, the Fallopian tubes, which  participate
in the stage of turgescence of all the other genital organs, retain their free
extremities in  contact with the ovary, and the ovule, having escaped from
the vesicle, immediately engages in their canal; being pressed omvards by
the peristaltic contractions of the  tube, it advances step  by step through
this duct, and finally arrives in the uterine cavity, Avhere  its  development
unceasingly progresses until the regular term of pregnancy.   (See the
chapter on Ovology.)
  Nearly the same phenomena take place, when the contact of  the fecun-   '
dating fluid with the ovule is deferred until after the latter has passed into
the tube.
  It is extremely difficult, not  to  say impossible,  to  ascertain  the exact
period at which the fecundated ovule reaches the cavity of the womb.  In
animals,  Ave may note without difficulty the time of fecundation; but  this,
of course, is generally impossible in  the human species, and this obstacle
renders nearly all our observations uncertain and incomplete. Further, very
numerous researches have clearly proved that the ovule in mammalia  does
not always  arrive at the same moment in the womb, and it is exceedingly
probable that the same variations exist in the human female.
  In the present records of our science, there is no one conclusive fact that
proves the ovule to have ever been seen in the Avomb of a woman  prior to
the tenth or twelfth day after her conception.
  Bacr examined a Avoman,  Avho  committed  suicide eight  days  after  con-
ception ;  the deciduous membrane had commenced forming, but he could
not detect any trace of the ovule in the uterus.   (British and Foreign New
Review, January, 1836, p. 328).  The same occurred  in the cases cited by
Weber (Disquisitio anatomica uteri et ovariorum puellce, sejrtimo a  conceptione
die defunctce instituta).  Dr. Pockels speaks, it is true, of an ovum of eight
days, found in the uterus, and in which the foetus could easily be distinguished;
but the description furnished by him evidently applies to an older product.
(Allen Thompson, in the  Edinburgh Med. and Surg. Journal,  vol. lii.  p.
122.)  Ovules of eleven days were the youngest observed by M.  Velpeau. 
OF  CONCEPTION.
123
   After the exit of the ovule, the Graafian vesicle soon retracts upon itself,
and thus contributes to the  formation of the corpus luteum before spoken
of (p. 96).
   AVe shall hereafter describe the modifications which the ovule undergoes
during its passage through the tube, and after its arrival in the uterus.
   Conception  is an act that takes  place unconsciously,  and  altogether
involuntarily ; although some females, more especially those who have had
children,  imagine that  they can  distinguish  a  prolific connection from
others.  They say a much more voluptuous sensation is then  experienced,
a  spasm much better marked ;  and I have met with too many females who
acknoAvledged having  made  this observation, not to believe there  is some
truth in the assertion.
   The same ignorance that  prevails  as to the causes of fecundation, like-
Avise exists with regard to those opposing its accomplishment.  For, though
vices of conformation or faulty  position of the uterus, as also  obliterations
of the neck or tubes,  may explain  the  sterility of some individuals, it is
Avholly impossible to understand why some  women are  barren, although Avell
formed — why, in a considerable number of cases, married females have not
had children  during their first marriage, Avhereas they subsequently became
pregnant, Avhen even it has been observed  that the first husband had chil-
dren by a former bed.
   The period at Avhich fecundation is  most  likely to take place, appears to
be  that immediately following  the Aoav of the menses; thus M. Raciborsky
has  ascertained  that the conception took place a little before or after their
appearance, in fifteen females, Avho  could designate precisely the time of the
sexual approach.  It is indeed  evident, that everything seems admirably
prepared  at this period for the  reproduction of the species; but I  am  far
from concluding, as M. Raciborsky has done, that the aptitude for fecunda-
tion in the human race is limited to  a feAV days, either preceding or folloAving
the  menstrual terms.  Experience  has  convinced  me  that sexual inter-
course may be fruitful, even Avhen it takes place in  the middle of  the
interval between the two  menstrual  epochs.  In this case it  is probable
that  the  excitation produced   by  coition  may  be  communicated to  the
ovarian vesicles, and cause modifications in them altogether similar  to those
experienced in the menstrual evolution; the fact itself appears to me to be
settled beyond a doubt.1

  1 M.  Coste, Avho also admits the  possibility of conception without  regard to the"
period at which copulation takes place, is prepared, he says, to demonstrate by undeni-
able  proofs, that the ovum detached from the ovary during, or  towards the  close of
menstruation, loses all capacity for  fecundation within a very few days after being set
free.  Conception is, therefore, only possible at  other times than near or during the
menstrual epochs, when other circumstances happen to produce in the ovary an opera-
tion similar to  that which takes  place at the  period of heat.  Now is this possible?
Comparative physiology replies in  the  affirmative, by demonstrating it  to  be so aa
regards certain  animals, thus rendering it at least very probable  for the human species
also.
  In animals living in the savage state,  says the learned professor of the College of
France,  the ovaries accomplish  their functions  only at  rare  intervals ; but when
domesticated, the maturation of  the eggs may become so frequent in certain species, 
121
PREGNANCY.
   I  shall  not undertake  to refute the  opinion of those who  believe that
 either sex can be created at will;  yet I think it not  improbaole  that the
 physical constitution of the husband or of the Avife may have some influence
 in determining the sex of the child.   The admirable  observations of M.
 Girou seem to me to  have proved  that Avith the inferior animals, at least,
 the stronger the  male  is in comparison  Avith the female, the greater is the
 chance of  producing a male, and vice versa.   The  observations I have been
 able to make on the human family since reading the statistical  results of M.
 Girou, have generally confirmed their conclusions.
   Here terminates what I had proposed to say in reference to  fecundation.
 It will be seen that I have limited it to a very brief exposition of the  most
 generally received views  of this point of physiology.   The size, and  espe-
 cially the  object of  the work, seem necessarily  to  exclude   more  ample
 details.

 that the ovulation occurs almost daily.   Thus the wild pigeon, which deposits her eggs
 but  once or twice a year,  sets seven or  eight  times, when she takes up her abode in
 our  dove-cotes.  Under the influence  of an appropriate nourishment, our domestic
 fowls lay almost every day for eight months in the year.  The rabbit of the fields brings
 forth but once or twice yearly,  whilst living at large; but in the domestic condition,
 Bhe will reproduce  as often as seven times, if  care be taken to Avean the young at the
 proper moment.
   There are therefore conditions of shelter, of temperature, and of alimentation, which,
 by acting on the organism of animals, may cause their ovaries to exercise their  func-
 tions more  frequently  in  a given space of time.  To this it may be added,  that in
 mammalia, the cohabitation of the males is one of the most active accelerating causes
 of the  dehiscence of the vesicles.  Thus, for  example, a female rabbit when placed
 alone in a cage where she is completely protected from the attempts of the male, enters
 ordinarily  into heat about  every two  months, and when  the time of this periodic
 excitement is past, she refuses obstinately to submit to coition; but if, instead  of sepa-
 rating  her  from the male, whom she  then  repels with violence, he  be  allowed to
 remain with  her for a few days only, it  may be regarded as certain that she  will not
 resist long,  because the solicitations to Avhich she will  be incessantly subjected will
 provoke the return of  a condition which, in the absence of this excitement, would
 have been much longer  in appearing.
   There are, therefore,  natural and entirely spontaneous periods for the maturation
 and discharge of ova, and  there are also  others which may be styled artificial,  because
 it is possible to produce them through the means of external agents.
   Now, is it possible to suppose that the human female, Avho commands all these con-
 ditions at her will, is,  by an inexplicable exception, inclosed within  the  impassable
 boundaries  of her menstrual periods ?   And if, in spite of her first vigorous resistance
• to the attempts of the male, the rabbit finally yields to the influence of his companion-
 ship, why in woman, who of all the females of the mammalia is endued with the most
 constant readiness for coition, should not the sexual allurements have the same result?
   This accidental evolution of a vesicle is not followed by the menstrual  flow  Avhich
 ordinarily accompanies it; all which is very  comprehensible, for Ave must not  forget
 that the  same cause which provokes  the discharge of  the  ovule, is also that which
 fecundates  it, and  that in doing so, it arrests the tendency to hemorrhage before  it
 has time t;> appear.  (Coste, Hisioire generate et particuliere  du developpement  des corps
 organises.)   The same  thing, in fact, happens when  fecundation occurs a few days 01
 hours only before the appearance of the menses. 
             ORGANIC  CHANGES  DURING  PREGNANCY.         125


                         CHAPTER  II.

   CHANGES IN THE MATERNAL ORGANISM DURING PREGNANCY.

   A deep impression is produced upon the maternal organism by the preg-
 nant condition, giving rise to important anatomical and functional alterations.

                           ARTICLE  I.
                ANATOMICAL CHANGES  IN  THE UTERUS.

   The uterus undergoes  remarkable changes, and Ave  shall commence  our
 description Avith them.
   These modifications may either be  in  the volume, form, situation, direc-
 tion, and  relations  of  the Avomb; hence, on  account of their great impor-
 tance, we shall successively study them in the body and in  the neck; then
 we will point out the changes which the structure of the organ undergoes.

   § 1. Changes in the Body  of the Uterus.
   a.  Volume.— We have already learned that under the influence of the
 hemorrhagic congestion Avhich the uterus undergoes at each menstrual period,
 the bulk of the organ is  increased.  If conception takes place within a few
 days preceding or folloAving the flow of the blood, the  excitement produced
 by the fruitful coition maintains, and soon increases the hypertrophy of its
 Avails.   Thus, we shall find further on (see Decidua), that the mucous mem-
 brane  especially becomes  almost doubled in  thickness, so that when  the
 fecundated ovule arrives  in the cavity of the Avomb, it finds it entirely filled
 with the membrane, Avhich is swollen to such an extent as to be throAvn into
 folds from want of  room  to develop itself. (See page 95.)
   The same thing precisely occurs in those exceptional cases in which fecun-
 dation takes  place some time from the menstrual period.  Here the hyper-
 trophy also begins under the influence of the evolution of a Graafian vesicle;
 only the evolution,  instead  of being spontaneous, is the result of a more or
 less prolonged venereal excitement.
   As soon as the ovule arrives in the AAromb, the  latter begins to develop,
 and its volume continues to increase until the  end of pregnancy; but this
 progression is not uniform, for, according to the observations of Desormeaux,
 it  is much slower in the  early months, and  more rapid  in the latter.   An
accurate idea of this increase may be formed from the following table, which
represents the usual dimensions  of  the uterus at the principal  periods of
 pregnancy.
	Vertical Diameter.	Transverse.	Antero- Posterior.
Third month, . . Fourth " ... Sixth " ... Ninth «' ...	2| inches. 3| 12Jtol4J "	2| inches. H '• 6J " 01 ((	2^ incaes. 3* " 6* » 8| to 9} « J
 
126
PREGNANCY.
   The development of the uterine walls is  not  purely mechanical, as has
 been supposed, nor is their distention  the  result  of the development of the
 ovum, which, by pressing  upon the different points of the internal surface,
 would tend to separate them more and more.
   If Ave consider the  small  volume of the ovule in the first Aveeks of preg«
 nancy, as compared Avith the thickness of the Avails of the uterus at the same
 period, Ave shall not fail to  be convinced  that the expansive force of the
 ovum Avould be unable to overcome  their  resistance.   The  development of
 the  ovum  and that of the uterus are  simultaneous, but  effected  by forces
 which are inherent in each ;  in a word, the  groAvth of the  ovum acts as a
 physiological cause, but not as a mechanical agent in the  development of
 the Avails of  the uterus.
   B. Shape.—The  shape of the uterus changes simultaneously  with  the
 alteration  in its volume.  Being flattened,  at first,  on its tAvo  faces,  the
 womb groAVS rounder and soon becomes pyriform, then  spheroidal, and
 toAArards the end of pregnancy it has the form of an ovoid, which is slightly
 flattened from before backwards.  The anterior face, hoAvever, is much the
 more convex, and  the posterior one  is depressed, so as to  accommodate
 itself to the prominence of the lumbar vertebrae.
   At the end of pregnancy, the superior extremity of the  uterine ovoid is
 quite regularly rounded; that side of the fundus, hoAvever, Avhich is occupied
 by one of the extremities of the foetal ovoid, being often more elevated than
 the other, Avhich is filled with fluid only.   Noav, as in the most usual pres-
 entations, the trunk of the foetus is generally inclined towards the right,
 the right side of the fundus  of  the uterus  is commonly the  most  elevated.
 (Hergott.)   Sometimes both sides are  alike in this respect, and there is a
 depression  upon the middle and upper  part of the organ.
   Such is the shape of the uterus in the majority  of cases ; but the situation
 and number of the foetuses, and the  structure and primitive form of the
 organ, may produce important'changes in the shape which it assumes during
 gestation;  and which will claim our attention hereafter.
   c Situation.—It is evident that the  uterus cannot thus change in shape
 and  size, Avithout undergoing a  simultaneous alteration in its position ; for
 example, during the first three months of  gestation,  the  Avomb  remains
 sunken in the excavation, but as the volume  increases in all directions, the
 fundus of the organ rises tOAvards the superior strait, Avhilst  its inferior part
 and neck subside still more tOAvards the floor  of the pelvis.   This depression
 of the organ is produced by its yielding to  the laws of gravitation from its
 OAvn increased weight,  as also by the augmented  pressure of the  intestinal
 mass upon  the larger surface, created by the change in the fundus.  Hence,
 both its increase of volume and its  weight, augmented by  the pressure of
 the intestinal mass, Avhich now has an extensive point d'appui on the fundus,
 contribute to produce the first change in position.
  At the same time, the uterus remains in the sacral cavity from the greater
space found there, and, the fundus being turned a little backAvards, causes
the neck to advance slightly.  Besides, the presence of the  rectum on  the
left most generally obliges the organ to deviate tOAvards the  right, and  the
 neck, in a corresponding manner, to the left; consequently, during the first 
ORGANIC  CHANGES  DURING  PREGNANCY.        127
three months, the cervix  is directed downwards, forwards, and a little to
the left.
  About the third month and a half, or the  fourth month, the uterus, no
longer finding  sufficient room in the excavation for its continued  develop-
ment, rises above the superior strait, then to the level of the umbilicus, and
reaches the epigastric region tOAvards the end of pregnancy.
  In tracing out the gradual elevation of the fundus uteri, it will be found,
at the fourth month, to rise two or three fingers' breadth above the  pubis;
at five months, it is within one finger's breadth of the umbilicus;  and from
the fifth to the sixth month, it approaches and passes the umbilical depres-
sion, so that at six months it is. half an inch above  this ring; three fingers'
breadth at seven months; and four to five at eight months ; it still continues
ascending  in the commencement of the ninth, but in  the last  fortnight of
gestation, the womb seems  to sink  doAvn, being, in fact, on  a lower level
than before.   This last is a remarkable occurrence, though it has been said
in explanation that the uterus, as if overburdened Avith the Aveight of the
foetus during the latter period, collapses to some extent, and enlarges in the
transverse and the antero-posterior diameters.   This may be true as regards
some females avIio have previously had children, for not unfrequently they
say to us at this time, " It has  all gone to the sides;"  but I believe  a more
general explanation of the fact may be given; for, in the great majority of
cases,  if females be " touched " near the end of pregnancy, a voluminous
tumor, covered  by the inferior  and  more especially by the anterior part of
the uterine body, will be readily felt occupying the excavation.   This is the
head of the foetus, Avhich has descended in consequence of its own Aveight,
carrying the wall of the uterus before it, and become engaged in the excava-
tion, sometimes even as low down as the floor of the pelvis.
   Noav, does not this  circumstance, Avhich may be remarked Avhenever the
head presents regularly, and Avhen there is no malformation of the  pelvis,
furnish us a sufficient reason for the depression of the entire uterus ?   How,
in  fact, could the superior do other than folloAV the inferior part of the organ ?
   D.  Direction. — In passing  up into the abdominal  cavity, the uterus is
obliged to follow the direction of the axis of the superior strait, and being
thrown off by the lumbar column, and finding  much less resistance from the
anterior abdominal Avail, it necessarily inclines fonvard; but,  owing to the
lumbar projection, it cannot possibly remain on the median line, and hence
it leans towards one side of the abdomen, the right one, remarkable as it
may seem, at least eight times in ten.
   Most authors, since  the days of Levret, have endeavored to explain this
great frequency of the right lateral obliquity.   Levret himself taught, that
the uterus ahvays inclines towards  the side Avhere  the placenta is inserted;
for this point, he said, being the thickest and most  vascular part of the
whole organ, is  also the heaviest, and this increased weight  augmented by
that of the placenta,  must necessarily  draAV the  organ to that  side;  but
experience has  sIioavii  that the  placenta, is far from being ahvays inserted
on the one side towards which the uterus is inclined.   Again,  according to
Desormeaux, the presence of the iliac portion  of the colon, which is usually
filled Avith fecal   matter, prevents the womb from  leaning to the  left, when 
128
PREGNANCY.
it commences  ascending out of the  excavation, and thrusts  into  the right
iliac fossa, whilst the mass of the small intestines is pushed to the left side
by the ascent of the womb (Avhere the  direction of the mesentery would
naturally draAV them), and this assists both to maintain and to increase the
inclination of the uterus to the right.   But, as M. Paul Dubois has justly
remarked, any influence which the  colon, placed on  the left, may have, is
fully compensated  by the presence  of the ccecum on the right; and, from
the observation of M. Velpeau, the  mesentery is directed from left to right,
and  not from right to left as Desormeaux has it, doubtless by mistake.
  The habit of using the right arm,  and of lying upon the right side, has
also  been  brought forward in explanation of this right lateral obliquity, but
subsequent observation has not  sustained the assertion;  thus, for instance,
in seventy-six females, all of Avhom  had the uterus inclined to the right,
thirty-eight rested on the right side, twenty on the left, fourteen alternately
on both sides, and  four on  the back.   And Ave may further remark that,
down to the present time, it has not been observed that the uterus is placed
upon the  left  side of the  abdomen more frequently in those  women  who
habitually use  the left arm  than in  others.
  Madame Boivin  has given an entirely different  explanation of this fact;
she asserts that the round ligament of the right side is shorter, stronger, and
contains more  muscular fibres than that of the left, and she attributes the
right inclination of the organ to the more powerful action of this ligament.
  Professor Cruveilhier thinks that  the shortness of the round ligament on
the right,  is the effect  and  not the  cause of the  uterine obliquity; "for I
have frequently had occasion," he remarks, " to observe that the shortening
which  occurred on  the left,  in left lateral obliquity, Avas constantly accom-
panied by a remarkable increase of volume."  I must confess that I do not
comprehend upon what M.  Cruveilhier founds this opinion.

  [In order to test Madame Boivin's explanation, M. Pajot, in connection with Dr.
Rambaud,  former prosector to the hospitals, undertook new measurements of the
length of the two round ligaments.
  From their  investigations it would appear, that even in women who haAre been
delivered, the  left  round ligament is not  so often the longer as has been supposed,
and  more  especially is this greater length far less common than the right lateral
inclination of the womb during pregnancy.
  All the explanations of the  fact being then so unsatisfactory, M. Pajot comes to
the conclusion  that the inclination of  the pregnant uterus is due to the  mode of
evolution of the organ itself.
  Beside this  lateral inclination, the entire womb undergoes a rotation upon its
axis, which carries its anterior  surface a little  to the right, whilst the posterioi
surface looks backward and to the left.
  From this it results,  that, if during an autopsy the  abdominal parietes be
removed without disturbing the womb,  the annexes of the uterus and the ovary of
the left side are found in front, whilst  the  same parts belonging to the right sida
are concealed behind near the right sacro-iliac symphysis.]

   e. Relations.—At term, the uterus is in relation — 1. In front, Avith the
vagina, the  posterior  face of the  neck  and body of the  bladder  and
superiorly, with  the anterior abdominal wall.   This last  is  not always 
            ORGANIC  CHANGES  DURING  PREGNANCY.         129

immediate, for occasionally a portion of the intestinal mass  slips between
the uterus  and the ventral  parietes, as occurred in the Avoman upon Avhom
M. Dubois practised the Csesarean operation in 1839; and, as the professor
has remarked, the operator should be very prudent in making his incisions,
from  the  possibility of encountering this anomaly.   2.  Behind, Avith the
rectum, sacro-vertebral angle, and vertebral  column below,  and Avith the
mesentery and intestinal mass above.  3. On the right, with the correspond-
ing side of the pelvis, the  iliac vessels, psoas  muscles, coecum, and  right
abdominal Avail.   4. On  the  left, with that part of the pelvis, the iliac
vessels  and aorta, the sigmoid  flexure, the  psoas muscles, and  the Avhole
body  of intestines which separate it from the abdominal Avail.
  F.  Thickness of the Parietes.—The earlier authors on this subject enter-
tained very different views  concerning it:  some, judging the thickness of
the body by that of the neck  during  labor, concluded that the uterus could
not be  distended Avithout a great diminution  in the depth of  its  Avails;
others, having had better opportunities of examining the Avombs  of females
Avho  died  soon  after  the accouchement, observed  the  very considerable
thickness   exhibited by  the uterine  parietes at that time,  and therefore
adopted the opinion that the latter become much thicker during  gestation.
   Both sides Avere in error,  for numerous  autopsies, made since that period,
of Avomen  Avho  died  during  gestation, have established the truth of the
folloAving propositions, namely:
   1.  In the three first months, the uterine Avails augment a little in thick-
ness,  doubtless in  consequence of the  development  of their vascular and
muscular apparatus.   2.  Towards the fifth month, they are about the same
as in  the  normal state.   3. At term, the parietes are thicker than in the
natural condition, at the point corresponding to the insertion of the placenta,
thinner at the neck, and they present but very little difference throughout
the remainder of their extent.
   We may here  notice some  further exceptions: thus, M. Moreau, having
measured the thickness of the Avails in a Avoman  deceased at term, found it
one-sixth  of an inch at the fundus, one-fourth of an inch at the insertion of
the placenta,  and one-third of an inch at the neck.   This singular anomaly
may be explained, says M. Moreau, 1st, as regards the thinness of the fundus,
by the enormous distention the  uterus had undergone (being a twin preg-
nancy).  And 2d, the greater thickness of the  neck  resulted from the con-
siderable retraction this part had sustained from the  escape of the amniotic
liquid before death.
   In  one  instance, Saviard found it one-third  of an inch at the placental
attachment, and  only a line in other parts.
   My friend, Dr.  Ripault, in  performing  the Csesarean operation, found
the uterine wall  only one.or two lines thick.

  [At an autopsy made near the end of pregnancy, I found the walls of the uterus
remarkably thin, from TV to ^ of an inch, throughout the greater part of their
extent;  M. Nelaton, Avho Avas present, confirming the observation.  This thinning
is, therefore, not very unusual, and I am  even inclined to think is the most frequent
condition.
  In many pregnant women, the parts of the child may be felt very easily; in some
       9 
130                          PREGNANCY.
cases the hand appearing to be separated from them by a layer of but a few lines
in thickness.  NotAvithstanding all this, it is nevertheless true that the entire bulk
of the uterine walls undergoes considerable increase during gestation in consequence
of the great extension in surface.
  To prove this, it is only necessary to weigh the uterus of a woman  dead at the
end of her  pregnancy, when it will be found that the weight of the organ, after
separation from the neighboring parts and  removal of its contents, will A'ary from
three to almost four pounds.  In the case of M. Moreau, above cited, it was nearly
four pounds.
  The uterus, therefore, increases at least tAventy times in Aveight during preg'
nancy, a fact surely sufficient to prove the occurrence of hypertrophy under these
conditions.]

  Again, the thinness may be partial; thus Hunter describes a uterus, the
posterior Avails of which  exhibited this phenomenon in a remarkable degree.
  G. Density of the Walls. — The uterine parietes, in the non-gravid state,
are very  hard  and resisting, and have nearly the consistence of fibrous
tissue, but during pregnancy this density diminishes and the walls become
soft and flabby.  The ramollissement begins to sIioav itself  as  early as the
first month, and constitutes at that period one of the best signs for proving
a commencing pregnancy (see  article  on  Diagnosis), because, instead of
presenting the  fibrous  density of  the ordinary  state, the Avails  have a
clammy softness closely resembling that of caoutchouc  softened by ebul-
lition, or that of an oedematous  limb.  This decrease in the consistence of
the uterine Avails  constantly advances, so that, at a later period, a light
pressure made on  the anterior  abdominal' parietes will easily depress or
deform  them;  consequently, the extremities and  other .inequalities of the
foetus may be detected, and its movements may even cause an elevation of
some part or other; the child, therefore, is not placed in  a cavity having
immovable Avails. .
  The diameters  of  this cavity will vary with the position  taken  by the
foetus, which can, in some  cases, continue to change them until  the end of
gestation, the flexibility of the Avails permitting its long diameter to pass
through the small  ones of the organ ; and Ave can readily comprehend Iioav
this flexibility, this suppleness of the fibres  of  the womb, will aid in pre-
venting  the disastrous  consequences Avhich  othenvise might  result to the
child from any violent blows on  the abdomen, or from the shocks expe-
rienced by the mother.

  § 2. Modifications  in the  Neck  of the Uterus.
  The  modifications  Avhich the  neck  undergoes during  pregnancy, are
referable: 1, to the consistence of  its tissue;  2, its  volume;  3, its form;
4, its situation and direction.
  1. As the softening of the tissue of the neck of the  uterus seems  to be an
all-important fact, Ave therefore give it  the first place.
  Noav,  everybody knoAvs, that, in the  non-gravid state, the  uterine tissue
resembles the fibrous in its  consistence; but immediately after  conception,
and from  the  sole fact of the  active congestion Avhich the genital organs
then experience, this consistence begins to diminish,  although, from bein»
coincident with the hypertrophy of the uterine Avails, it is scarcely sensible 
             ORGANIC CHANGES DURING  PREGNANCY.         131

during the first few days, Avhatever may be the  extent of the neck exam-
ined.  But tOAvards the end of the first month Ave may ascertain that, inde-
pendently of this original general modification, the most inferior, or rather,
the  most superficial  part of the lips of the os tincse, begins to soften.  It
resembles more a swelling of the mucous membrane  than a true "raniol-
lissement" of the proper tissue of the lips; so that by pressing slightly on
tlii* thickened  membrane the finger first detects a fungous softness, but soon
reaches  the  proper  tissue of the neck, which still maintains its normal
consistence.  The sensation  then experienced  by the finger greatly resem-
bles that communicated Avhen it is pressed on a table coArered by a soft and
thick cloth, or, better still, a sheet of India-rubber; and it is only tOAvards
the end of the  third,  or beginning of the  fourth month, that the lips of the
os tincse are softened  throughout their Avhole thickness to the extent of a
line or a line and a half.
   At the commencement of the  fifth, the softening increases from below
upAvards, and at the sixth embraces the moiety of the  sub-vaginal  portion.
During the last three months it invades the superior part  by degrees, and
last of all the  ring of  the internal  orifice, so that, at the end of gestation,
the neck is so soft in  certain females, that I have frequently seen students
have great difficulty  in distinguishing it from the Avails of the vagina.
   This modification of  the neck,  Avhich authors  have scarcely spoken of, is
one of the most important signs ;  because, after a little experience, it affords
us one of the best means for ascertaining  the different stages of pregnancy;
being constant, and found in all females, unless the  neck  should  be  the
seat of some pathological alteration.   It  is Avorthy of notice, hoAvever, that
the softening is not so Avell marked, and is much  slower in its progress in
primipano, than in Avomen Avho have previously had children; but in all, it
steadily  proceeds from beloAV upAvards.
   As before remarked, A\re may judge very nearly of the  probable period
of pregnancy by the  extent of softening,  as it progresses from the inferior
to the superior  part of the neck; though  there is one important remark to
be made on this  subject, namely, that Avhenever  females  have had a great
number  of children, the sub-vaginal portion of the neck loses the greater
part of  its length;  the extremity  then  projecting into the vagina, and
capable  of  exploration by the finger,  being much shorter.  Now, as  the
softening of the supra-vaginal portion of the neck is of much more difficult
detection, it may be thought to be much less extensive than it is in reality,
whence Ave may expect  to find a great difference  in the extent of the  soft-
ened part, if a  comparsioii be made betAveen the  necks in two females, both
advanced to the sixth month, one of Avhom is pregnant for the second time,
and the other had previously borne ten children.   Wherefore it is necessary,
in making this  appreciation, to bear in mind the number of former preg-
nancies, as also the real length of the sub-vaginal portion of the cervix.
  2. )rolume. — Some singular ideas on this subject have been promulgated
by many authors, but the following appears to be the  most  constant rule:
the neck doubtless participates  in  the hypertrophy of the  uterine wails
during the earlier months, though its development is far less considerable.
The  neck becomes thicker and groAvs  more voluminous, especially at  the 
132
PREGNANCY.
superior part, but I have never observed its elongation to the extent of tAvo
inches, as Madame Boivin apparently believes, or to tAvo and three-quartera
and  three inches, as  M. Filugelli  has more recently advanced; for, as
elseAvhere observed, these opinions result, in my  estimation,  from an error.
The neck, in the commencement, being much lower, and directed  more in
front than in the ordinary condition, the finger can easily explore a larger
extent of it, and thus an impression is created of an increase in its length
which really does not exist; for frequent  post-mortem examinations of
females who  died  in  the early  months of pregnancy,  have convinced me
that, even if  the neck is increased in thickness, its length does not undergo
any appreciable augmentation.
  At the commencement of the  fifth  month, according to most writers, the
cervix begins to diminish.  In the sixth month (they say) it begins to spread
out at the superior part, so as to aid in the enlargement of the body of the
womb, and this spreading at  the upper part  continues to advance in pro-
portion as the  term of gestation approaches, and consequently the length
of the neck  decreases  from  above doAvnwards,  so as merely to present at
last, at the close of the ninth month, a ring of variable thickness.  In fact,
the diagnosis of the different periods Avas based on this  gradual shortening,
and,  agreeably  to the majority of the French accoucheurs Avho have adopted
the opinions of Desormeaux, the neck  has lost  at the fifth* month about
one-third of its length, one-half at the sixth, tAvo-thirds or three-quarters
in the seventh,  three-fourths or four-fifths in  the eighth, and  the remainder
is effaced during the course of the ninth month ; and yet, I do not hesitate
to pronounce all this an entire error, which Avas first pointed out by M. Stoltz,
in 1826, and  to Avhich I also  have constantly asked attention since the year
1839.  No ; the neck  does not  shorten in the way Avhich has so long been
described; it preserves its Avhole length until the last fortnight  of preg-
nancy ; and it is an easy matter, especially in women Avho have previously
borne children, to verify this remark, as we shall presently demonstrate.
But during the last feAV weeks, its length, Avhich  until that time Avas intact,
diminishes very rapidly, and even disappears by a total effacement; and
we shall in due season explain the simple mechanism of this phenomenon.
  But to return ; I have frequently been enabled  to prove, in primiparse, the
                  truth of M. Stoltz's assertions; for  in these Avomen the
                  neck does diminish a little in length,  during the last three
                  months, although by a process entirely different from that
                  described by  Desormeaux.  Thus, tOAvards  the seventh
                  month, the ramollissement has invaded the Avhole intra-
                  vaginal portion; the parietes of the neck, having lost theii
                  consistence, are easily separated by  the liquids secreted
 a sectioning the  «Pon their internal face, and  the upper part of this por-
neck of u.e uterus;  the  tion being turned outwards, enlarges  in  such a mannei
anterior and posterior lips  as to cause the Avhole neck to resemble a «l)indlp  in iu
are seen in  situ, being                  .          .               1 "^"^  "* *ia
separated from each other  shape; the superior extremity of which is formed by the
by the fusiform cavity of  internal  orifice  (still closed), and  the  inferior is con-
                  stituted by the external one, Avhich is scarcely opened in
primiparse, even at the end of gestation, as Ave shall hereafter show.
 
ORGANIC  CHANGES  DURING  PREGNANCY.         133
  Now, it is easily understood hoAv this bulging of the middle part of the neck
can only take place just in proportion as the tAvo extremities of the latter ap-
proach each other ; thus, of course, detracting so much from its total length.
I do not believe, hoAvever, with M. Stoltz, that the approximation of the two
orifices can be so great as to cause a material shortening of the neck, though
this  certainly does exist  to some extent.  The  shortening of the neck is
therefore real, though slight, in primiparae;  being accomplished, hoAvever,
by a different mechanism from that taught by most authors.  Its upper part
does not spread out so as to contribute to the enlargement of the cavity of
the body, but suffers  a sort of collapse, which brings the tAvo orifices nearer
together, at the same time increasing its central  cavity, and  extending its
transverse diameters  at the expense of the vertical.  What has been said
concerning the rapid effacement of the  neck during the last feAv days in
multiparas, equally applies to primiparce ;  the process taking place by the
same mechanism.
  3.  Form.—The  principal  modifications in the shape of the  neck have
already been presented, but they ought to be studied in a more special man-
ner,  according to Avhether they are found  in prirniparse, or in Avomen avIio
have previously been mothers.
  A.  At the commencement, in primiparse, the cervix appears  more con-
tracted and more  pointed, resulting, perhaps, from the augmentation of its
superior part in volume ; the orifice of the os tincte, Avhich, before conception,
presented  a  simple linear and  transverse fissure, now assumes a circular
form, constituting, as it Avere, a small lenticular  fossa.   A  little later, as
mentioned above, the middle  part of the cavity of the neck enlarges, so as
to give to the Avhole cervix the form of a somewhat elongated spindle, rather
than  that  of a cone, Avhich it previously  had.  It continues smooth and
polished on the exterior surface, and the periphery of its orifice is rounded,
without  any irregularities or  fissures; sometimes  presenting  a soft circum-
ference, at others a thin and  sharp border: the latter rarely happens, hoiv-
ever, before a very advanced stage. At this time, it  is  very easy to ascertain
what changes the  neck has undergone, for although the external orifice is
constricted, it is very much softened, and  sometimes alloAvs  the finger to
pass  Avith a very slight effort  and enter the cavity of the neck.  The base
of the last phalanx is then felt to be grasped quite tightly by the external
orifice, Avhilst the extremity of the finger is at full liberty in the fusiform
cavity of the neck.  It may also be readily observed that the two orifices are
still Avidely separated, for the entire length of the first phalanx and some-
times more, are capable of being contained in the cavity.
          Fig. 40.                  FIG. 41.                   Fig. 42.
These three figures give un idea of the gradual dilatation which the cavity of the neck undergoes at
                        various periods of pregnancy.
                                            f
 
134
PREGNANCY.
   B. The form of the neck is altogether different in women avIio have had
 children ; thus the inequalities and protuberances exhibited by the inferioi
 part Avill scarcely permit us to ascertain whether it  becomes more pointed
 or not, and it is  equally difficult to determine whether the external orifice
 has  become more rounded ;  because, having been someAvhat patulous before
 pregnancy, this orifice, in consequence of the  numerous cicatrices found on
 it, presents a very irregular opening.  The only point capable of demonstra-
 tion in the early periods is, that the partially opened orifice will  dilate still
 further, so as to admit readily the extremity of the fore-finger.
  This spreading out of  the os tincae, and the inferior part of the neck, con-
 stantly increases from beloAV upAvardsj as the gestation progresses ; it reaches
 the middle part of the cervix about  the seventh month, and  nearly gains
 the internal orifice by the ninth.
  The enlargement of the cavity of the neck advances simultaneously Avith
 the softening of its Avails ; and we can easily prove by experiment that the
 finger will each month penetrate deeper into it.  The shape of this cavity
 resembles in some women that of a thimble, in others, of a funnel, Avith the
 base beloAV and the apex abo\Te, the difference being due simply to the depth
 and  number of the ruptures AA7hich had existed on the external orifice before
 pregnancy.
  The part of the neck not yet softened and dilated constitutes the summit
 of the cone: that is, every portion of its length contributes in succession; so
 that the first, and often even the half of the second  phalanx of the finger
 can penetrate into its cavity towards the ninth month, the extremity of the
 finger being only arrested by the internal orifice, Avhich is still closed and
 puckered like the knot of a purse.   The. ring at this orifice finally softens,
 becomes dilated, and permits the finger, which  has passed through a canal
 an inch to an inch and a half in length, formed by the cervix, to come into
 direct contact with the naked membranes.  If the length of the external
 surface of the neck be compared at this period Avith  the canal in Avhich the
 finger is introduced, the  neck will be found much longer internally  than
 exteriorly, for it is self-evident that the finger is arrested on the outside by
 the vaginal insertion, Avhilst within it  traverses the whole space betAveen the
 two  orifices.
  The internal orifice sometimes opens too soon; thus Desormeaux declares
 that  he touched the membranes at the end of seven months, over a space of
an inch  and one-third in extent.  I also  have verified the same fact, but
only in women  who were subject to  floodings, or in those who submit to
" the touch," in  our public lessons, for, in  these  latter,  the frequently
repeated and careless introduction of a great number of fingers, has appeared
to me to greatly accelerate the softening and dilatation of the neck.
  On the whole, therefore, the neck is fusiform in priraiparse, the external
orifice is rounded, and so little dilated as to prevent the introduction of the
finger without some considerable effort.  In females avIio have had children
 the external orifice is Avidely open, and the cavity in the* neck  is funnel-
shaped,  the base  being  below, and  continues  to increase until its  ape  ;
 reaches  the internal  orifice.  This  latter remains closed in both in a vast
 majority of cases, until the beginning of at least the last month of pregnancy
% 
ORGANIC  CHANGES  DURING  PREGNANCY.         135
   These differences in the form of the neck in primiparas and of multiparas,
 are readily accounted for Avhen we take into  consideration the condition of
 the external orifice before pregnancy in both  cases.  The os tineas of Avomen
 who have already had children, has  the  continuity of its  circumference
 interrupted by a greater or less number of ruptures, so that as soon as a
 small  part of the neck has become softened, each of the divisions of the
 circumference being fixed only by its  upper  part, is turned outward, so as
 to give to the orifice the form of the large extremity of a trumpet.   In the
 primiparous woman, on the contrary, the integrity of the ring is  complete,  <
 and the  os tineas  may become softened  Avithout its  orifice being  much
 enlarged  in consequence.
   We have stated that the whole length of the neck disappears at the last, ■
 by being  confounded Avith the cavity of the body.   The mechanism of this
 fusion is very simple; the ring at the internal orifice  having at length lost
 all power of resistance from its ramollissement, opens so as easily to admit
 the extremity of  the  finger (see Fig.  42), and this  dilatation gradually
 augments under the influence of those feeble contractions  by  which the
 uterus, in the last fortnight of gestation, seems to prelude the labor of child-
 birth, and as soon as this is sufficiently advanced to permit the inferior part
 of the  ovum to engage in the cavity of the neck, Ave can understand that the
 latter is promptly trespassed upon.   Again, there is no projection found at
 the upper part of the vagina, unless, perhaps in those avIio have had children,
 a collar of variable thickness and softness, circumscribing an  opening large
 enough to permit the finger to  reach  the membranes; whilst  in primiparas,
 only a sharp, thin ring, in the centre of which is a much more contracted
 orifice,  will be encountered.
   4. We  have but little to remark concerning the situation  and  direction
 of the uterine neck during pregnancy, and our opinions do not differ from
 those held by the majority of writers on this subject; hence Ave shall merely
 state, in a feAV Avords, that during the first  three months the  neck is  loAver,
 is directed more in front, and a little to the left; and that this position is
 the necessary consequence of the inverse movement of the body of the  organ,
 by Avhich  its fundus is  carried backwards into the sacral cavity, and pushed
 to the right by the tumor, Avhich the rectum, habitually distended with fecal
 matters, forms behind and at the left part of the excavation.
  In the last six months, the cervix, necessarily folloAving the ascent of the
 body, mounts upAvard, and, at the same time, most generally looks  back-
 ward  and to the  left, whilst the fundus is nearly always carried  forAvards
 and to  the right.
  I cannot pass over, hoAvever, a disposition  of the neck occasionally met
 with at the end of gestation, that sometimes embarrasses persons not familiar
 with this kind of exploration :  namely, in the last month, the  head (if that
 is the  presenting  part) frequently presses  before it, in engaging  in the
excavation, the  anterior  inferior portion of  the  uterus, and in  case the
female has a large pelvis, this descends even perhaps doAvn to the inferior floor..
The neck  will therefore necessarily be carried  behind the tumor which then
fills the pelvis, and the plane of its orifice will look tOAvards the anterior
face of the sacrum, and, of course, in order to penetrate its cavity, the  fingei.
« 
L36                         PREGNANCY.
must be bent like a hook and be introduced from behind directly forAvards.
This posterior obliquity of the cervix, which differs  essentially from that
produced by an anteversion of the Avomb, sometimes renders it very difficult
of access, even when the  labor is someAvhat advanced.  The  difficulty i.s
still  further increased, in some cases, by the softening of the neck through-
out, in consequence of Avhich it becomes flattened and applied to this tumor,
forming a kind of  fold or doubling on its posterior part.
  Summary.—From what has been stated, Ave may noAV draw the folloAving
conclusions:
  1st. That the tissue of the  neck  begins to soften at the very commence-
ment of pregnancy, and the softening, although not very apparent in the
earlier months, and limited to  the most inferior  part,  gradually ascends, so
as to invade successively the Avhole neck from beloAV  upAvards, though it is
sometimes less marked and less rapid in its progress in primiparas than in
other females.
  2d. The cavity of the neck  dilates simultaneously  Avith the softening of
its walls;  and further, this enlargement causes  it  to  be spindle-shaped in
primiparas; and, in females Avho have  already borne  children, to resemble
a thimble, the finger of a glove, or a funnel with its base beloAV.
  3d. The external orifice remains either closed, or else very slightly open,
in primiparas, up to the very term of pregnancy, whilst in others it is Avidely
open, and constitutes the base of the funnel.
  4th.  The Avhole length of the neck disappears in the last fortnight, being
lost in the cavity of the body.  The effacement  beginning  by the internal
orifice and gradually involving the neck from above downAvard as far as to
the external orifice.
  5th.  Contrary to the opinions generally adopted before the  time of M.
Stoltz's publication, the neck preserves its Avhole length until the  last fort-
night ; it does not shorten from  above doAvmvard during the last four months,
but the fusion of the neck Avith the body takes place  only  Avithin the last
few Aveeks of  gestation.

  § 3.  Modifications in the Texture of the Uterus.
  Among the many changes Avhich the  Avomb undergoes during  pregnancy,
the most curious of all are those exhibited in its  texture;  and Ave  shall
study these by successively examining  the  different parts of its constituent
elements.
  1.  Serous Coat.—The peritoneum, forming the external membrane of the
uterus, spreads out in all directions.   The various folds formed by it in the
neighborhood of the Avomb, a species of mesentery, as M. Dubois calls them,
suich as the broad ligaments and the anterior and posterior ligaments, are
double.   Many  anatomists  believe  this  doubling is  even sufficient   to
accommodate the enlargement  of the organ.  But, to refute this opinion, it
is only necessary to examine that'portion of it comprised betAveen the com-
mencement of the tAvo tubes, which cover the fundus ; for this will afford a
convincing proof that it cannot be furnished by the accession of neighboring
parts of the peritoneum, because, as Desormeaux remarks, the insertion of
the tube and ligament of the ovary upon each side presents an obstacle that
ft 
             ORGANIC CHANGES  DURING  PREGNANCY.         137

 will prevent the gliding of the adjacent membrane.   The peritoneal  tissue,
 hoAvever, undergoes a  considerable extension, and a more active nutrition
 must necessarily take place to prevent  its attenuation, since that Avhich
 covers  the  uterus  during gestation quite equals in its thickness  the  serous
 membrane of the unimpregnated state.  This extension of the peritoneum,
 Avithout a decrease in thickness, is not a new fact in pathology, and it may
 be seen in every hernia of considerable size.
   The  tissue uniting this membrane to the muscular substance appears to
 have diminished in density ;  for the peritoneal  coat is movable  on the
 muscular Avails, according to M. Dubois, Avho has met with  difficulty from
 this cause every time he has performed the Cassarean operation.
   2. Mucous Coat. — Although the existence of this coat in the non-gravid
 state has been denied by many anatomists, it becomes very apparent during
 pregnancy.   It then groAvs  redder and more vascular, and its folds  dis-
 appear ; but this unfolding Avill not  alone account for the extension  Avhich
 it undergoes, and  it must, AA'hatever be said to  the contrary, recei\re, like
 the peritoneum, a more active nutrition.
   All the elements Avhich  Ave have mentioned (page 80) as entering into  its
 composition  undergo, in reality, a considerable development.  The nature
 of this Avork does not alloAV us to enter into all the  details Avhich the subject
 demands, and Ave prefer referring the reader to the  excellent Avork published
 bv M. Robin, in the Archives, for the year 1848, Vol.  XXV. of the Memoires de
 VAcademic de Medecine, and  in the Bulletin de iAcademie de Me.deei.ne, 1861.
   The  glands of the body of the Avomb share in  the general hypertrophy,
 and Ave shall be obliged to  recur to  this subject when Ave come to treat  of
 the  decidua, Avhich is  nothing else, as must  be finally acknoAvledged, than
 the  mucous membrane of the uterus modified by the progress of gestation.
 (See Decidua.)
   It is  easy to convince ourselves, after the accouchement, that the mucous
 membrane of the neck itself is also  hypertrophied, though much less so than
 that of the body.  Its  glands, also, have undergone an enlargement, their
 secretion is  much  increased, and  to it is due the gelatinous plug, that is
 to say,  the  elastic,  dense, semi-transparent, and almost insoluble  mass of
 mucus,  Avhich closes and  fills  the cavity of the  neck during  pregnancy.
 That such  is the case may be demonstrated  by examination of the  bodies
 of Avomen avIio die  during pregnancy, Avhen, if the mass be  detached, pro-
 longations will be  found  passing from it, and entering the  orifice of the
 glands.   (Robin.)
  3.  Middle Coat.— [The middle coat of the uterus is formed of muscular fibres of
 organic  life, as stated whilst describing the normal anatomy of the organ.  In the
 unimpregnated condition these fibres are hardly recognizable, but during pregnancy
 thev become verv evident.  Numerous microscopic researches have shed still more
 Ii "-lit on  the sul jeet, revealing the most intimate changes which the muscular tis.sue
 undergoes.  According to M. Ch. Robin, Avhose opinion is stated by M. Pajot, the
 muscular or cell fibres of the uterus are, in the empty uterus, remarkable for their
 small size and grayish color, making it difficult to distinguish them by the naked
 eve from the cellular texture Avhich surrounds them.  During pregnancy they
 enlarge in everv way, particularly in length, and new fibres are formed beside the
old ones, especially in the innermost layers of the middle  coat. 
138                           PREGNANCY.
  We quote the text in which Kolliker treats'of the subject, viz.: "The muscular
coat undergoes an  increase in bulk,  to which the enlargement of  the  uterus ia
principally due,  an increase resulting from the concurrence of two phenomena:
the increase in size of the pre-existing muscular elements, and  the formation of new
ones.  The first of these is  so marked that the contractile fibre-cells, instead of being
from .05 to .07 of a millimetre1 in length, and .005 in breadth, which is their usual
size, measure in the fifth  month .14 to .27 m. m. in length, and .0055 to  .01-1 and
even .02 m. nt. in Avidth ; in the second half of the sixth month .2 to .52 m. m. in
length, .009 to  .014 m.m.  in width, and .005  to  .006 m. m. in thickness; so that
they are about from seven to eleven times longer, and from  two  to seven  time;]
wider than at first.
  " '1 he formation of new muscular fibres is especially noticed during the  first half
of pregnancy, and in the internal layer of the muscular coat.   In this situation are
found a multitude of young cells of from .02 to .04 m. m. in  diameter, presenting
all the transition forms of cell  fibres of from .05 to .07 m.m. in length;  nothing
similar to  this being observable in the  external layers.
  " This generation of muscular fibres appears to cease at the sixth month  ; at least
I have been able to discoArer in the uterus during the  twenty-sixth week of preg-
nancy only enormous fibre  cells with no traces of preceding forms.
  " To this increase of muscular fibres corresponds that  of the connective tissue
which  unites them ;  tOAvard the end  of pregnancy the latter exhibits  in  some
places a distinct fibrillation."  (Human Histology.)
  In short, the increase in size of already existing muscular elements, and the forma-
fion of new fibres, concur in the production of the uterine hypertrophy.
  We have next to exhibit the arrangement and direction of the  muscular fibres,
and in so doing shall  state suecessiATely the result of  the dissections of  Madame
Boivin and of MM. Deville and Helie.]

  A. According to Madame Boivin, there are  tAvo planes of fibres in the
body of  the uterus—the one exterior, the other  interior; the  external
plane is composed of  fibres Avhich run  from the middle line outAvards and
doAvnwards to the inferior third of the  organ,  Avhere  they terminate  upon
                              and aid   in   forming   the round  ligaments
                              situated there,  Avhile the most superior ones
                              are  distributed to the Fallopian tubes  and
                              the  ligaments of the  ovary.  An exact idea
                              of the radiated disposition of the  external
                              fibrous planes,  at the  superior  and  lateral
                              parts  of  this organ, may  be formed  by im-
                              agining the long  hair of the human  head to
                              be parted  along the Avhole middle line of the
                              cranium, and then combed smooth  on  each
                              side in  front, and  tied very  tight   opposite
                              each ear.
                                Another muscular plane is found internally,
                              having an  entirely  different   arrangement;
                              these  fibres are circular and situated at the
                              superior angles of the Avomb.  They surround
                              the internal orifice of the tubes (a a, Fig. 43),
                              describing  concentric   circles,  at first  very
Fig. 43.
 Muscular fibres of the uterus,  a a.
The internal orifices of the Fallopian
tubes.
1 A millimetre is .0.039 of an inch. 
             ORGANIC CHANGES  DURING  PREGNANCY.        139

 iinall and close, but gradually separating  as  the  distance from the angle?
 increases, so that the  last and largest border upon the median line, and
 spread out  in the direction of its length.
   BetAveen these tAvo planes, the external one composed of longitudinal, and
 the infernal one of  horizontal fibres, some  other muscular fibres are found,
 the course of Avhich it is impossible to trace.
   Only a single order of fibres, which are semicircular, exists at the inferior
 part.   They commence at the median line  of this region, and reunite on the
 sides near the round ligaments.
   I "will remark, in terminating this short  account of the uterine structure,
 its great resemblance to that of all the IioIIoav organs, in  having, for instance,
 its longitudinal fibres  on  the exterior, Avhilst the circular  and horizontal
 ones are internal.   The fundus uteri is the part particularly concerned in
 the expulsion of the foetus, and  it is  there  also that the  muscular  appa-
 ratus is  the most developed; its disposition  is such, that all parts of the
 uterine surface  tend tOAvards the  centre during contraction.   Lastly, at the
 inferior part, where  the resistance should  be least, there are only the hori-
 zontal  fibres, constituting a  sort of sphincter muscle, Avhich  may be com-
 pared,  on more than one account, to the sphincter of the rectum or of the
 bladder.
   B. Quite recently, M. Deville,  prosector  to the hospitals, has studied the
 muscular arrangement of the uterus in a great number of  cases of females
 Avho died a feAV  days after  labor, and  the  results  at Avhich  he has arrived
 differ much from  those previously acknowledged.  This subject, in  my
 estimation,  requires  further examination ;  but  whilst  aAvaiting an oppor-
 tunity  of dissecting  for myself, the preparations  of M. Deville appear so
 satisfactory, that I  have obtained a draAving of them,  and  introduce here
 the description  furnished by that skilful anatomist.
   Examined on its  external  surface, after the removal of the peritoneum
 and the  compact resisting  layer that separates this serous coat from the
 muscular fibres, the uterus seems to he composed of tAvo orders of fibres, Avhich
 are  essentially muscular, one being transverse and the other longitudinal.
   The  transArerse fibres arise (this Avord to be received in a purely descrip-
 tive sense) from three sources : the found ligament, Fallopian tube, and the
 ligament of the ovary; also from the Avings of the corresponding broad
 ligament.   The mere removal of  the delicate peritoneal envelope of these
 organs  suffices to bring the transverse fibres into vieAV, and at the same time
 to reArcal their muscular character.
   The transverse fibres, together with certain vessels and nerves, constitute
 the  intimate structure of the round and  ovarian ligaments, as  also the
 middle  layer of the Fallopian tube, Avhich is therefore essentially muscular,
 like the internal membrane, improperly called dartoid,  of all the excretory
 canals.
   The presence of a great  number of transverse uterine fibres  lying in the
 thickness of the folds of the  broad ligament, and extending to its base, is
 an important fact to be borne in  mind; and  the question arises, Avhere do
 they terminate ?  I confess that I  have not  been able to  determine this in a
satisfactory  manner. 
140
PREGNANCY.
  Howevei the truth may be, the transverse fibres coming from these divers
origins spread out in a radiated manner over the Avhole exterior surface of
the uterus, the anterior and  posterior ones transversely, or a little doAvn-
Avards in an oblique direction, and the superior, obliquely upwards, so as to
cover the organ completely.   Near the median  line these fibres are crossed
perpendicularly to their course by a longitudinal  fasciculus,  more or less
sinuous in character, and three-eighths to three-fourths of an inch Avide, Avhich
arises near the point of union of the body with the neck, ascends upon the
fundus of the organ, and  descends on the posterior  face, to  be  lost at its
inferior part opposite to or  a little  beloAV the  point of  beginning, that  is,
near the union of the body  Avith the neck.  A positive  continuity Avill be
observed between the transverse fibres of  each side and the middle longitu-
dinal fasciculus, if the line of contact be  carefully examined.
  As the transverse fibres arri\re near the  median line, some  curve doAvn-
Avards, others  upwards, so as to become  longitudinal, and thus constitute
the median layer.   This is particularly evident at its termination, both in
front and behind, for the whole fasciculus  divides there into  two portions,
one of which  curves  to the  right,  the other to the left, and becomes  con-
tinuous with the most inferior transverse fibres of the body.
  This continual  exchange of the  tAvo series of uterine  fibres takes  place
Avith such great uniformity, that the longitudinal  fasciculus has nearly the
same thickness everyAvhere;  but if  this lamina be more patiently examined,
                                it  Avill be found to be  composed  of very
              Fm-u-             short longitudinal fibres, forming the cen-
                                tral part of a letter X,  Avhich the uterine
                                fibres describe, as I have verified on many
                                of  my  preparations,  in  the  folloAving
                                manner.
                                 • Let us take a layer of transverse fibres
                                on the right side of the uterus, at the an-
                                terior inferior part 'see Fig. 44);  this
                                fasciculus nearly approaches the  median
                                line,  then curves upward and  becomes
                                confounded with the longitudinal lamina;
                                then, after a vertical  course, varying
                                from one-third of an inch to tAvo inches,
                                it  again  curves to the left, to reassume a
                                transverse direction, thus  representing  a
                                Z, or  still more exactly, a branch of the
                                letter X.
  Thus, the longitudinal median layer is  produced by the union  of the
central and vertical branches of the X, described by the uterine fibres.
  It sometimes happens, hoAvever, that the transverse fibres pass directly
from right to left Avithout forming  the  vertical  branch, which fact should
be borne in mind lest this arrangement existing on the surface might  give
rise to a belief of the absence of a median longitudinal fasciculus • Avhereas
if the latter is not  evident, it will only be  necessary to raise carefully this
layer of median transverse fibres, to bring  it into vieAv.   The  uterus exhibits
The disposition of the muscular fibres on
    the anterior face of the womb. 
ORGANIC CHANGES  DURING PREGNANCY.
141
Fig. 45.
The disposition of the muscular fibres on
   the posterior face of the womb.
the same disposition of muscular  fibres  on the internal face, which  will
readily account for  the erro* of Madame Boivin, who described them as
circular.
  Notable differences, however, exist  be-
tween the fibres on the  two surfaces of the
 n-gan.  The most remarkable on the ex-
terior is the extreme breadth of the longi-
tudinal fasciculus, Avhich covers the whole
fundus, extending from the orifice of the
Fallopian  tube on one  side to the same
point on the other.   When this fasciculus
reaches the anterior and posterior faces,
it is  intersected at right angles  by  the
transverse fibres  occupying  the  lateral
portions  just  below the  orifice  of  the
tubes, Avhich act there  as on  the  exterior
surface : that is, some of the  fibres curve
upwards, others downwards, becoming con-
founded  with  the  longitudinal  layer.
Lower down, near the junction of the body with the neck, the longitudinal
fasciculus is very irregular.  Sometimes  it exists; sometimes, though more
rarely, it does  not.
   At this point, in fact, the continuation, or inter-crossing of the transverse
 fibres from one side to  the other, occurs in an irregular
 manner, either forming the vertical branches of an X,
 or taking an  oblique direction, or again going directly
 across, the fibres preserving a transverse course.
   A third layer exists between the two just described,
 but I am not Sufficiently acquainted with the disposi-
 tion of its fibres to give an exact account of them.
   All these particular  details do not interfere Avith the
 general  law  of inter-erossing, or passage of uterine
 fibres from one side to the other, and in this  respect,
 the uterus may justly be ranged  in the same class with
 all the other holloAV muscular organs whose structure is
 also  regulated by  the fundamental  law of muscular
 inter-crossing.   Hence, it would not be difficult to de-
 monstrate that the human uterus,  as  just described,
 approaches in its structure quite as well, perhaps better,
 to that of the same organ in other mammiferas, than the arrangement pointed
 out by Madame Boivin.  But such a discussion would be out of place here.
   In conclusion, I will observe, that the  same dispositions in the muscular
 arrangement are found in the neck and inferior part of the body.  Inter-
 crossings occur there also, the fibres  passing directly from one side  to the
 other, or becoming  more or less oblique at the moment of crossing, and still
 oftener forming the branches of an x with the median vertical parts.  This
' last disposition gives rise to the peculiar formation, which  has improperly
 been called the arbor vitce.
Fig. 46.
Shows the inter-crossing
  of the uterine fibres. 
142
PREGNANCY.
   [c. Lastly, M. Hebe, Professor in the  Medical School  at  Nantes,  has,  in a
remarkable memoir written after long and skilful dissections, discussed anew the
subject of the muscular structure of the uterus.
   As M. Helie seems to represent the true state of the case, and gives a better and
more complete  exhibition of the arrangement of the muscular fibres than has
hitherto been done, we shall follow his description  whilst pointing out the principal
results at which he has arrived.
   The fibres of the uterus, like  those of the heart, are disposed in layers, which
cover and envelop each other successively.  Fibres pass frequently from one layer
to the other;  their arrangement is intricate,  and their dissection very difficult.
These superposed layers form the muscular structure of the uterus, and Ave  shall
describe successively the external, the internal, and the middle layer.
   The external layer is composed of several alternate planes of longitudinal and
transverse fibres.  The most superficial  plane  is longitudinal, and  is formed of a
median fasciculus whose  middle  part is curved  like a loop upon the fundus of the
uterus, whilst  its two  extremities descend, one upon  the posterior and the other
upon the anterior surface of the  organ.  This loop-like fasciculus (Figs. 44 and 45)
always descends further behind  than in front.  Behind, it begins  where the neck
joins the body, and is composed of fibres Avhich, from being at first transverse, by
a sudden change of direction become vertical, as shown by M. Deville. As it ascends,
the fasciculus is reinforced by other fibres bent in like manner.  As it approaches
the fundus, the lateral fibres curve outward toward the Fallopian  tubes and broad
ligaments upon Avhich  they disappear.
   The middle fibres of the fasciculus are, therefore, the only ones which bend over
the fundus of the organ, and descending upon the anterior surface curve successively
outAvard to reach the broad and round ligaments.
   A portion of the fibres  Avhich  thus emerge from the loop-like fasciculus, reach
the lateral parts of the organ only after having traversed its median line and passed
from one side to the other.  From the right side, they proceed to the  left angle or
to the left side of the anterior surface ; those, Avhich  at their origin belong to the
left side,  go  to the right angle, or to the  right side of the anterior surface of the
organ.                                   '
   These crossed fibres follow, therefore, precisely the Z-like direction described by
M. Deville.  M. Helie, however,  regards  the crossings as far from constant, besides
being limited to very few fibres;  the greater number of the looped ones beginning
and ending upon the same side without crossing the median line.
   The loop-like fasciculus is almost never limited  to one plane only.   It is always
thick upon the posterior surface  of the uterus, sometimes, though rarely, forming a
single plane.  At other times, and most  commonly, its fibres are divided into two
planes separated by a  layer of transverse fibres, the  superficial layer  being  then
thin, and the deeper one much thicker.
   Let us study next those transverse fibres Avhich, with the preceding  fasciculus,
form the surface of the body of the uterus.  They constitute the greater part of the
external muscular layer, and contribute to the formation of the  loop-like fasciculus
as already stated;  the greater part, however, being foreign to its formation remain
upon the median line, passing below  it and between its two layers, sometimes even
upon its superficial posterior  layer.   They go from one side to the other, extend
outwardly into the broad  ligaments,  and especially into the ligament of the ovary,
the.round ligaments, and upon the Fallupian tubes.
   If Ave follow them in the opposite direction, they may he said to  proceed from all
these points, and  after reaching the sides of the uterus to divide  into two layers,
one of which passes upon the anterior, and the other  upon the posterior surfkce of
the organ, the uppermost  covering the fundus and making arch-like  curves  upon
the angles. 
ORGANIC  CHANGES  DURING  PREGNANCY.
143
Fia. 47
   Some of the fibres leave the external layer and pass into the middle one.
   It shouhf be observed that the anatomists Avho have studied the muscular structure
 of the uterus have failed to treat of the sides of the organ, mentioning  only those
 fibres Avhich extend to its annexes;  an omission which M. Helie  has supplied.
   If the  two layers of the broad
 ligament  with the muscular fibres
 distributed to it be separated, trans-
 verse muscular fibres going from
 one surface to the other, are per-
 ceived throughout the  entire ver-
 tical  extent of the  sides  of the
 uterus.   At the sides of the  uterus,
 these fibres are  so  cuiwed as to
 reach the surface  opposite to the
 one  from Avhich  they  took  their
 departure.  Such  at  least is  their
 general arrangement, though their
 course is a very complex one. They
 separate  to afford passage to the
 vessels, and do not  keep to  their
 primitive plane  throughout  their
 course.    Thus in front they are
 superficial,  but are  more  deeply
 situated behind, and vice versa.
   Above, and  on  a level with the
 Fallopian tubes, the fibres of the
 sides of  the  organ  are  arranged
 still differently.    The   transverse
 ones Avhich describe large curves
 upon the fundus  from  one  angle
 to the other, descend  and  curve
 again upon  the sides of the organ.
 A portion of these go to the Fallo-
 pian tube, and to  the round and ovarian ligaments, the  major  portion, however,
 descend upon the  sides  of the uterus.
   In their descent they meet the vessels Avhich interrupt their regularity, then they
 pass more deeply  and curve forward or backward  to become transverse upon  one
 surface or other of the organ.
   In  the  neck, the arrangement of the fibres is more simple,  for no  trace of the
 loop-like fasciculus is found.  Almost all the fibres pass someAvhat obliquely down-
 ward from  the sides of the uterus  terward  the median line, Avhere  they interlace
 with similar fibres from the opposite side.  They pass  upon the sides of the neck
 and curA'e round from one surface to the other in the same Avay as on the body, the
 most superficial passing outAvard Avith the A'esico-uterine and recto-uterine folds, as
 also with  some fibres of the bladder, and still loAver with the -muscular fibres of the
 vagina.
  Internal Layer. — When the uterus  of a woman deceased  just after delivery is
 opened, the  muscular fibres of the body are found deprived of the mucous membrane
 which had covered them, and which had  been transformed into  the decidua.  As
 the mucous membrane  had  not  undergone  this change  in the neck,  it there still
 covers the muscular fibres, and is closely united to them.
  When the uterus is opened by  incision, the middle of the posterior wall is found
 to present uniformly  a slightly projecting triangular fasciculus, the base of Avhich
extends from one Fallopian tube to the other, whilst the apex reaches to the internal
orifice of the neck.
      Second plane of the anterior muscular layer.
  A. Superficial layer divided and folded over upon the sides
of the uterus.  B. Deep  layer of the loop-like  fasciculus.
C. Transverse fibres emerging from the loop-like plexus.
D. Fibres of the neck.  0. Ovary. R. Rectum.  X. Fallopian
tube. X. Bladder. 
144
PREGNANCY.
  This triangular fasciculus  is formed as the loop-like one:  of horizontal fibre?
which curve suddenly upward, and what is singular, the new fibres Avhic4i reinforce
it are always added to its  left side, whilst from its right  side  fibres successively
emerge which become transverse by passing to the right side of the womb.   These
fibres have precisely the form of the letter Z.
                                           In approaching the  Fallopian  tubes,
                                         the triangular  fasciculus divides into
                                         twro small  thin  ones, of  which  one  on
                                         each side has its acute point inserted
                                         into the  corresponding Fallopian tube.
                                         where  it  suddenly  comes  to an  end.
                                         Finally,  transverse  fibres  extended  di-
                                         rectly from the orifice of one tube to the
                                         other, complete the triangular fasciculus
                                         by forming its base.  (D. Fig. 48.)
                                           A precisely similar  triangular fasci-
                                         culus exists upon the anterior Avail, with
                                         the single difference  that the transverse
                                         fibres Avhilst  curving to a vertical direc-
                                         tion enter its right side, whilst from its
                                         left side fibres emerge Avhich assume a
                                         horizontal  direction  in order to reach
                                         the left side of the womb.
                                           Upon  the  sides  of  these  triangular
                                         fasciculi, throughout the wdiole vertical
                                         extent  of the body of the  uterus, the
                                         muscular  fibres  of  the internal layer
                                         have a transverse direction,  and pass
                                         from one surface to the other. As they
                                         approach the middle of the anterior and
                                         posterior  walls,  some  undergo  an  in-
                                         flexion to form the triangular fasciculus,
whilst others in much  greater number pass beneath it, and continue their trans-
verse direction.   At the internal  orifice of the neck the transverse  fibres form a
projecting fasciculus, which defines sharply the cavity of the body and that of the
neck.
  At the fundus of the uterus, that  is to say, above the  orifices of the Fallopian
tubes, the muscular fibres form arches directed from before backAvard,  which con-
stitute the vault of the cavity.  Descending thus  upon  the  anterior  and posterior
sa faces, they pass beneath the transverse band of the triangular fasciculus which
covers them, and finally  curve and become blended with the horizontal fibres.
  At the orifices of the  Fallopian  tubes, the  fibres of the  internal layer are dis-
posed in  concentric rings :  the smaller being in contact Avith the orifice, whilst the
larger, often imperfect,  are continuous with the arches of the vault, touching back
to back those of the opposite side as described by Madame Boivin.
  At the neck, it is necessary to remove the mucous membrane in order to  see dis-
tinctly the muscular fibres.  It is  then evident  that the  projection of the arbor
vitse is formed  by muscular fasciculi  whose fibres  separate on  each side to form
superposed arches.  Near  the external orifice the fibres of the  neck are  almost
all annular and interlaced.
  Middle Layer. — When the progress of the  dissection has removed successiA'ely
the loop-like fasciculus and the different planes of transverse fibres which compose
the external layer, the middle layer, presenting an entirely different arrangement,
is reached.
Fig. 48.
    Internal muscular layer. (Anterior wall.)
  A. Section of the uterine walls.  B. Triangular
fasciculi.  C. Fibres passing to the Fallopian tubes.
D. Openings of the Fallopian tubes. E. Transverse
fibres.  V. Vagina. 
              ORGANIC  CHANGES  DURING  PREG^' LNCY.          145

  Between these two layers, however, there is no precise line of demarcation, the
deep fibres of the external layer assuming gradually the arrangement peculiar  to
the middle layer.   Therefore, only after the removal of these intermediate laminae,
can the middle layer with all its peculiarities be clearly  distinguished.  The same
observation applies to its exhibition by the entire removal of the deep layer.
  The middle layer, first indicated by the  great number of vessels which it con-
tains, is always thicker in the part corresponding to the insertion of the placenta.
It is composed of bands of variable width, crossing each other in  all directions,
some  being transverse, others oblique, and some again longitudinal.  Large orifices
traversed  by the veins or  sinuses separate these bands from  each other  or even
the fibres of the same band.  The muscular fasciculi are curved in loops around
the uterine veins, each loop  being crossed by another forming with it a complete
ring wrhich surrounds the vein ;  a succession of rings forming a canal for the vein.
Large rings produced in the same way inclose  several veins, each of which has its
special rings Avithin the  principal one.   Most frequently, the loop-like  fasciculus
forms but  the half or two-thirds of a circle, another fasciculus completing  it by
crossing its extremities, at the same time becoming closely attached to  them.
  Each vein is therefore surrounded by annular contractile fibres, and traverses a
true contractile canal in its course through  the  middle  layer.   The arteries, like
the veins,  are surrounded by muscular rings,  with this  difference,  however, that
the arteries are free within  the rings, whilst  the A'eins,  reduced to their internal
membrane, adhere  to the muscular fibres.
  According to M.  Helie, the middle layer is found only  in the  body of the uterus
and is absent in the neck.   The latter, therefore, is  formed simply by the super-
position of  the external and internal layers.]

  4.  Vascular Apparatus. — ToAvards  the end of pregnancy, the  uterus ex-
hibits an  astonishing development of its vascular system. My  friend, Dr.
Jacquemier, has for fifteen years  paid much attention to this subject; the
results of  his labor as found in his Avork are important, and  from  them I
draw  largely.  "In studying the  development of the vascular  system  in
its Avhole  extent,  Ave shall find," he says,  "that  the  augmentation  in the
size of the arteries only becomes considerable as they approach  the  uterus.
Whilst advancing betAveen  the peritoneum and the  external  face of the
organ, and before  giving off their  first divisions, they dilate and SAvell up,
and then  they furnish  branches to  the anterior and lateral parts, which
ramify ad infinitum; they are not situated  immediately beloAV the  peri-
toneum, but are separated from it by a delicate  layer of muscular tissue.
All these ramifications  anastomose  freely and  penetrate through to the
internal surface, Avhere  they  generally terminate; but a  large  number of
those, corresponding to the placental  insertion, traverse the mucous mem-
brane and enter the placenta.  The ramifications of the  arteries are con-
tinuous Avith  the capillaries, Avhich  in their turm give  origin to the veins.
That  the  capillary  vessels become  enlarged  during pregnancy has  been
proved by Virchow; and  Jacquemier found that they were more  readily
injected than capillaries are under ordinary circumstances.  This fact ex-
plains the activity of the uterine circulation, as also the rapid and profuse
discharge of blood from  the arteries into the sinuses.
  If the venous trunks be examined,  from the point of quitting  the uterus
to their terminations in the hypogastric vein and in the vena cava inferior,
a great increase  in  capacity  will  be  noticed  for  the ovarian veins are
       10 
146
PREGNANCY.
almost as large as the external iliacs, and the  uterine are but  little less,
In the substance of the womb, the venous system presents itself as a series
of canals, situated in the centre of the  muscular tissue, at nearly an equal
distance from the internal and the external faces: at this point, the uterus ia
traversed  by a great  number of canals coming from  all directions, which
anastomose, and form large sinuses at their junction ; the Avhole constituting
a grand plexus, several divisions of which  are large enough to receive the
extremity of the little finger.
  These canals are much larger opposite the insertion  of the placenta than
elseAvhere, and they diminish  in size as they recede from  it.   There is a
certain portion of the uterine Avails, determined by the placental insertion,
where the venous canals of the uterus  traverse the  mucous membrane in
order to be distributed to the placenta.  (See Decidua and Placenta.) There,
in the thickness of  the inter-utero  placental  decidua itself these vessels
form, through an enormous  dilatation of all their  branches, the large
sinuses which exist at the adherent surface of  the placenta.   These sinuses
communicate  so freely with  each  other as to  form, so to speak, a pool of
blood, divided up by  numerous partitions.   A proportionably small num-
ber of orifices exist  at  intervals,  through which this reservoir of  blood
communicates with  the sinuses of the  muscular walls.  When  the  after-
birth is detached, the whole placental  surface of the  uterus is found to be
riddled  with holes, Avhich look as though they had been made with a punch.
These orifices, Avhich  are oblique, like the  section of  a quill  in  making a
pen, close of themselves through the  depression of one of the membranous
lips of the opening against the other.   (See Placenta.)
  When Ave come to treat hereafter of the  decidua, we shall find  that the
arrangement of the  vessels of the mucous membrane properly so called,
undergoes changes  during the course of gestation ; the  vascular  netAVOrk
of the internal surface, Avhich is highly developed in the early stages, show-
ing signs of a commencing atrophy at the end of the second month, and
diminishing to vessels of very small calibre by the end of the pregnancy.
  A very delicate yet distinct web of areolar  tissue envelops the uterine
arteries.   The veins, on the contrary, have only their  internal coat, which
adheres intimately to the muscular substance, and  no valves are found in
their interior.
  So great an enlargement  of the arteries and veins  must  be due to some-
thing more than a mere unfolding,  since they preserve their flexuosities
which are increased rather than diminished.  They must, therefore, undergo
a change analogous  to that Avhich  takes  place in  the fleshy tissue of
the organ.
  From what has been stated, it is evident that the blood Aoavs to the uterus
in very large quantities, and consequently its nutrition  is augmented, for
such an amount of  blood  must certainly contribute  to the groAvth of its
walls.   But the question then arises, is the circulation much  more active
as many authors have  thought?   In reply, it would appear from the late
researches of M. Jacquemier, that the venous  circulation  especially must
exhibit an unusual slowness, but I confess  the reading of this last part of
his memoir has not convinced me on  that point.   (See art.  Hemorrhage.) 
            ORGANIC  CHANGES  DURING  PREGNANCY.         147

  The lymphatic vessels also  acuuire a very considerable calibre and form
several planes in the uterine substance, the superficial of Avhich are the most
developed ; they divide into two groups, those of the neck, which run to the
pelvic ganglia, and those of the  body, going to the  lumbar ganglia.   The
hypogastric absorbent trunks, according to Cruikshank, Avho has described
and figured them, are as large as a goose-quill, and  the  vessels  themselves
so numerous, that, Avhen injected with mercury, the uterus appears to be a
mass of lymphatic  vessels.  A common  dissection, made a few days after
delivery, will afford convincing proofs of their volume and number.
  5. The nerves  of the womb have, of latter time,  been  the  subject  of
numerous researches, among  others, by Drs. Robert  Lee, Jobert, Rendu,
and Boulard.  Agreeably to the latter anatomists, Avhose  conclusions closely
correspond with those of the  English accoucheur, the nerves are derived
from  three sources: 1st. From  the  ovarian plexus — feAV in  number, and
distributed to  the  angles and  fundus uteri.  2d.  From  the hypogastric
plexus — these are specially destined to the neck;  and 3d.  Some  filaments
of the great sympathetic, Avhich accompany  the uterine arteries, and  are
apparently lost upon the neck and lateral parts of the womb.   Among the
filaments  constituting  the ovarian plexus, there  are a feAV which seem to
follow the course of the blood-vessels passing near the ovary, and reaching
the border of the uterus at its superior part.  The filaments then penetrate
into its substance along Avith  the vessels, apparently for distribution to the
muscular Avails.
  The hypogastric plexus furnishes some nervous filaments as the urethra
crosses its anterior part; these nerves are few in number, and  ascend along
the lateral portions of  the neck (but not folloAving  the vessels), giving off
branches here and there Avhich enter the  uterine Avails, but M. Rendu  has
not been able to trace them  beyond  the  neck.  These nerves differ essen-
tially from the preceding, both in origin and distribution, for they come
from a plexus whose branches  are not distributed with the vessels, and Avhich
has frequent  anastomoses Avith the sacral nerves or nerves of animal life.
  The Avhole body of the uterus, therefore, receives the nerves of organic
life exclusively, Avhilst the nervous apparatus of  the neck alone has com-
munications Avith the spinal nerves.  Like the lymphatic and sanguineous
vessels, the nerves, according to some  authors, undergo a  considerable
development  during gestation.  In  the  preparations  exhibited  by Robert
Lee to the inspection of the Royal Society, and also in  the two figures given
by him, large nervous bands  are seen below the serous tunic, and  these
bands  are  so voluminous that many anatomists have doubted their  true
structure, and regarded them as furnished by a gelatinous or cellular mem-
brane, placed betAveen the peritoneum and the muscular coat.  Consequently,
in accordance with  this view,  the uterine nerves  do  not form an exception,
as Avas for a long time supposed, to the hypertrophy seen in all other parts
of the organ  during pregnancy — for they likeAvise  are developed in every
way, and return after  the delivery to their normal  size.  (See, for further
details, the memoir of Dr. Robert Lee, " On the  Ganglia and  the  other
Nervous Structures of the Uterus.")  It is generally admitted, hoAvever, that
the neurilema is the part chiefly affected by the hypertrophy. 
148
PREGNANCY.
  The preparations deposited by M. Boulard in the Museum of the Faculty,
and  the works of Robert Lee, Ludovic Hirschfeld, and  Richet, have con-
vinced us, that exceedingly fine filaments are prolonged even to the lowest
parts of the os tine*, and, consequently, that no  portion  of  the organ is
entirely destitute of them.

                          ARTICLE  II.
             CHANGES  IN  THE  PROPERTIES OF THE UTERUS.
  [Sensibility. — The sensibility of the uterus undergoes  little alteration.  It is
well  known that in the unimpregnated state the neck may be touched almost with-
out the woman being aware of it, and it may even be cauterized without giving
rise to definite pain.  The same obsenration is  almost applicable to the organ in
the pregnant condition, so that it  were wrong to suppose that its sensitiveness is
much increased  during gestation.   The sensibility varies, however, with the cause
which  excites it; a forced distention, for example, seeming to us to give rise to
considerable pain.   To avoid exaggeration,  it may be said that sensibility exists in
the neck, but is obscure during as well as before pregnancy.]
  The body of the uterus appears to be even  less  sensitive than  the neck.
I am aware that  most women feel the motions of  the child, but are these
movements perceived  by the  walls of the   abdomen, or  by the uterine
parietes?   The fact that in Avomen  affected with ascites, the active motions
are  much  more  obscure than  in  other females,  tempts us to  accept  the
former hypothesis.   I  have,  besides, frequently  known  women to pass
through  the whole  course of gestation Avithout feeling  the motions; for
instance, I saw a  patient at  La Charite, in August, 1839, who, although
advanced to seven  months, doubted her pregnancy because she had not felt
the child stir.  I saw her frequently afterward betAveen this time and near
the last of October, Avhen  her labor occurred, yet, although the child was
quite strong and healthy, she had never observed its motions.
  [The body of the womb must not, however, be  regarded as  entirely insensible,
for the contractions of labor or the introduction of the hand give rise to quite severe
pain.  We shall recur to this subject when studying  the subject of the pains of
labor.  (See Phenomena of Labor.)
  Irritability. — Having treated of its  sensibility, we have a few words to say of
the irritability or organic sensibility of the womb,  meaning  thereby the vital
activity peculiar to the nervous system of the uterus, and other parts supplied from
the same source.]
  This irritability is notably increased during gestation:  to it is due the
kind of sympathetic  relation Avhich is established betAveen the fibres of the
neck and those of the body of the uterus, and in consequence of which, any
rather active and prolonged excitement  of the neck of the organ reacts upon
the fibres of the fundus.
   Even the premature expulsion of the foetus is often a consequence of con-
tractions produced by excitations of the  cervix, and it is owing to this cause,
according to Delamotte, that repeated coition has frequently caused abortion,
and  that females Avho  are used in  our amphitheatres for practising " the
touch," are so often delivered before term.
   This irritability of the cervix, and its influence upon the contractility of 
ORGANIC  CHANGES  DURING  PREGNANCY.         149
   the body is in some cases turned to profit in the practice of our art; thus it
   is well known, that one of the surest and most generally employed methods of
   inducing  premature labor, consists in the introduction  and retention of a
   foreign body in the neck of the Avomb.

     [Contractility. — By this is  meant the power with which the fibres of the womb
   are endowed of closing upon the body which it contains for the purpose of expelling
   it from its cavity.  It is a true contraction, precisely similar to the muscular con-
   traction of all hollow organs,  such as the bladder, rectum, or stomach.
     The power of  contraction exists even in the unimpregnated condition, especially
   at the menstrual periods ; at which time, in exceptional cases,  it gives rise to the
   severe  pain  experienced by those who suffer from  dysmenorrhoea.  During  preg-
,   nancy, the uterine contractility becomes more evident though still feeble and  pain-
   less ; during labor only does  it acquire its full energy, and is then productive of
   intense suffering.]

     The pain which, during labor, accompanies the  uterine contraction,  is
   usually very great  in the human species, but does not exist at all in wild
   animals, and is only observed to a very feeble degree in our domesticated
   ones.  As a general rule, the uterine contraction is not painful in the differ-
   ent species  of animals, unless an accident or some disease renders a greater
   energy of action necessary on the part of the organ, and the  pains  then
   experienced by the female  are altogether similar to those of women.
     If, therefore, the contraction  is only painful accidentally, as it were, in
   animals and merely in consequence of a particular morbid condition of the
   uterine fibre, are we not justified in referring the pain in the human species
   to the same cause ?   Now can this predisposition be the result of the refine-
   ments of  civilization ?   It  would of  course be impossible to prove this,, but
   there are  strong grounds, at least, for believing that such  is the fact, when
   Ave reflect that our domestic animals, Avhich, like ourselves, have been trans-
   lated from their primitive normal condition, often suffer much more during
   parturition than those in a savage state.
     This contractility resides in all  the muscular  fibres  of the womb, both
   body and neck, though the great development of the muscular layers of the
   body causes the contraction to be most poAverful in that portion.   Its inten-
   sity is exceedingly variable in different females, being very strong in some,
   and scarcely existing  in others;  but its energy bears no relation to that of
   the  external  muscular  system, for  some  strong muscular  women  have
   extremely Aveak  contractions  during labor, and oftentimes the  contrary is
   observed.
     The exercise of this function takes place independently of the will, at  least
   in a great majority of cases, which indeed we can readily  understand  must
   be the fact, from the origin and nature of the nerves  distributed to the  body
   of the uterus, since Ave have just learned that  its  fundus receives filaments
   from the great  sympathetic alone.  I am Avell aware  the books furnish  some
   cases of Avomen  Avho had the  poAver of-suspending the contraction at  will;
   out if the facts have  even  been  Avell observed, they  have failed perhaps to
   receive the  most rational  interpretation.   In  the cases  related by Baude-
   locque and  Velpeau, in Avhich the labor ceased Avhen the  students Avere sum-
   moned to Avitness it and  began again Avhen these numerous observers retired,
                                     i 
150
PREGNANCY.
the will had probably less to do than the imagination and modesty, with ll.e
alternations of retardation and acceleration ; for though the influence of the
will may be reasonably doubted, it cannot be denied that moral disturbances
appear to affect the contractility of the uterus; thus, a violent emotion has
often sufficed to arouse it long before the ordinary term of gestation, and it
is  not  at all uncommon  for  the  contraction to diminish  or  disappear for
several  hours, or even days,  under the operation of such  causes.   DeAvees
kneAV the pains to be suspended in this manner for tAvo Aveeks in a woman
who Avas greatly affected by his sudden and unexpected arrival.   Betschler
cites a  case  in Avhich the pains Avere suddenly suspended  by a violent
tempest, so that  the  neck, though Avidely dilated, closed again, nor did the
labor recommence until nineteen days had  elapsed.
  Every day, indeed, Ave  witness a suspension of the pains for half an hour,
and sometimes even for several hours, upon visiting Avomen whose modesty
is shocked by our presence.
  The exercise of this function is seldom of long  duration, lasting for a feAV
seconds only—rarely beyond one or two minutes, and then the organ which
Avas so  strongly contracted and hardened, gradually regains its primitive
state, and remains in repose, until, under the influence of the same stimulus,
it  is again thrown into  action.  The organic contractility, like all  mus-
cular power,  is expended by a prolonged exercise, and hence we can under-
stand why  the pains so often become at once more  sIoav and  feeble or even
cease altogether after a prolonged  labor.   Lastly, opiates have  a marked
influence over them;  for by employing these preparations, Ave may suspend
the uterine contraction nearly at will, for several hours during labor at term,
and indefinitely, in a case of  premature delivery or abortion.
  This  contractility may be excited  by natural,  accidental, or artificial
stimuli: thus, all the causes of labor constitute the first; the  second are
those of abortion and premature labor;  and  the third comprise all irrita-
tion Avhatever of  the  neck or body of  the womb;  as electricity, ergot, and,
in a word, all the means  employed when it is desirable to deplete the organ.
   On the contrary, it may be Aveakened by an over-distention of the uterus,
by prolonged contractions, or vivid moral impressions.
  An observation of M.  Brachet's might  lead to the supposition that the
contractility  of the uterus would be weakened, or even  totally destroyed,
by lesions of the spinal marroAV.   Experiments upon animals have, besides,
shoAvn that complete destruction of the cerebro-spinal axis abolishes the senso-
motor functions of the great sympathetic  nerve.   The uterus Avould, there-
fore, be paralyzed in an experiment of this kind.  It is, hoAvever, proved by
numerous cases of paraplegia in  females, as well as by experiments on ani-
mals, that labor is in no  respect impeded by alterations of the cord, that the
uterus continues  to contract, and that the Avant of action of the voluntary
muscles is  largely compensated for by the paralysis of those of the perineum,
the slight resistance of which renders the  last stage of the foetal expulsion
both more easy and  rapid.
   This result might  indeed  have been anticipated  from the known absence
of all nerves of animal life from the body of the uterus.
   The contractility of the uterus, like that of all the viscera of organic life, 
             ORGANIC  CHANGES DURING PREGNANCY.          151

is retained for some time after death, and thus serves to explain toe occa
Bional expulsion of a foetus several hours subsequent to the decease of a
mother, as also the posthumous contraction of the uterus in Csesarean opera-
tions performed immediately after the mother has expired.

  [Retractility. — The  term retractility seems both to myself and M. Pajot much
preferable to that of contractility of tissue, by which it has often been designated.
  Retractility is a property in virtue of which the uterus, when relieved partly or
entirely of its contents, subsides upon itself.  It is a sort of elasticity, differing from
contractility in being permanent and keeping the walls of the organ closely applied
to the ovum, whilst the latter is intermittent and temporary.   A principal office of
this  retractility is that of  closing  the open orifices of  the utero-placental vessels
after labor, which without  it would give rise to mortal hemorrhage.]

  The retractility exists  chiefly in the fibres  of the body.  DeAvees supposed
it to be  seated more  especially in the  circular ones that  constitute  the
internal  plane of the uterine muscular layer, and it is scarcely observable
at the inferior parts  and in the neck.   It Avas  certainly a Avise  provision on
the part of nature to place it in a region where the habitual attachment of
the  placenta  causes a  more  considerable  development of the vascular
apparatus.   This holds so true,  that it is easy to detect the retracted fundus
in the hypogastric region after delivery, as  a hard, irregular tumor, whilst
to the vaginal touch, the neck  appears soft, flexible, and not the least  con-
tracted.   Therefore, Avhenever the placenta is inserted on the neck, a  hemor-
rhage is  not only to be dreaded during labor, but also at the time of, and for
a short period subsequent to, the delivery of the after-birth. In most females,
the retractility accompanies the contractility, and these tAvo properties are
successively in action at  the period of labor, and during the gradual deple-
tion of the uterus.   In fact, if after  the contraction Avhich  has caused the
expulsion of a certain  part of the  body inclosed in  the  uterine cavity, the
walls of this organ  did  not  retract promptly to fill up the void, it would
constitute inertia of  the  womb.
  The retractility acts slowly and continuously, and is prolonged throughout
the  period of the getting-up.   AVhen it takes  place in a regular manner, it
is unaccompanied by pain, as Ave see in the cases of many primiparous Avomen,
in Avhom the retraction is accomplished without  their being aware of it.
  The retractility is  not,  hoAvever, always equal to this effect, at least during
the  first  days after  labor.  Its insufficiency may perhaps be  due to over-
distention, or to a protracted or too rapid  labor, in Avhich cases the uterine
fibre loses its elastic  property, as Leroux expresses it, or  else it may  be  that
the presence of a foreign body, Avhether solid or  fluid, requires the interven-
tion of a more active force.  Here, then, the  contractility is called into exer-
cise, and the retraction of the uterus is effected  by a true intermittent  and
painful  contraction.
  This diminution of the retractility is generally, however, of short duration,
for  after four or  six  days at  the  furthest, the contractility  is no longer
required, unless  a neAV  clot should  happen to  form in the uterus.   The
elasticity of the uterine  fibres, assisted by the process of absorption, which
goes on   unceasingly, and also by  the lochial  discharge,  are thenceforth
sufficient to restore the organ to its normal condition. 
152
PREGNANCY.
   The retractility is far from being equally powerful  in  all women, nor ia
it always easy to give a good reason for the difference.  For example, it is
much less  active in multiparas than after a first labor, and this explains
why after-pains are much more common Avith the former  than in the latter
case, for the pains are a consequence of the exercise of the  contractility, and
the uterus returns more sloAvly to its habitual volume.  Great over-distention
of the Avomb,  and a too rapid  or  too prolonged expulsion, also seem  to
diminish its action.
  If it be  indisputable that there are circumstances which diminish the
elasticity of the uterine fibres, it is also fully proved that we possess certain
agents capable of exciting its action.  Thus, external or internal irritations
acting on the  neck and body (such as cold or frictions),  and  the adminis-
tration of ergot, often have this happy effect.

                          ARTICLE  III.
                CHANGES IN THE NEIGHBORING PARTS.
   We can readily imagine that the modifications just studied do not take
place in the uterus Avithout affecting the neighboring parts, and the changes
in these will next engage our attention.
   1. As the uterus gradually rises  in the  abdomen, its  surrounding  peri-
toneum is carried along Avith it; the folds, called the broad ligaments, then
disappear, and consequently  the Fallopian tubes and ovaries are  drawn
nearer to  the  body of the uterus, where  they lie very nearly in  a vertical
direction;  the fundus becomes rounded, its angles diminish  and  finally
disappear.   The Fallopian tubes, Avhich in the unimpregnated  state are
inserted at the apex of the angles, and on the same horizontal line with the
fundus, are no longer implanted upon the highest part, but correspond to
the  upper  fourth,  or even  to the middle of the total  length of the organ.
The round ligaments are then composed of short linear fibres, among which
a great number of muscular  ones, prolongations of those of the uterus, and
having the same contractility, may be distinguished.   M. Velpeau  asserts
that he discovered and watched their contraction in three different females,
during the efforts of the uterus to expel the after-birth.  The greater devel-
opment of the anterior than of the posterior wall of the uterus, removes the
insertion of the round ligaments from the lateral position which they occupy
in the unimpregnated organ, to a point so much farther in front, that they
are  implanted at about the  union of the anterior fifth with  the posterior
four-fifths of the antero-posterior diameter.
   2.  As the womb and upper part of the vagina are  intimately associated,
the latter is necessarily shortened as the former enlarges in the early  periods
of pregnancy,  whilst the vagina becomes longer  when the Avomb rises above
the superior strait.   The venous system in the vaginal walls is considerably
developed, OAving to the  greater activity of their circulation.   This dilata-
tion of the veins is, doubtless,  the  consequence of a greater vitality in  the
genital organs, but it is also  due in part to the stasis of the blood, which is
impeded in its course by the  uterine development.
   The varicose state, and the nodosities  frequently encountered  by  the
finger on  the  vulva and vagina towards the end of pregnancy  (described 
ORGANIC  CHANGES  DURING  PREGNANCY.         153
 by M. Deneux under the name of thrombus), which  certainly predispose
 females to hemorrhagic accidents, may probably be attributed to the same
 cause;  and this congestion even  affects  the capillaries;  for  othenvise it
 would be difficult for me to explain the livid spots or discolorations, resem-
 bling wine-lees, presented by the vaginal mucous membrane, and to Avhich
 attention has again  been  recently called as  affording  a sign of pregnancy.1
 But unfortunately this sign can only be serviceable in a medico-legal case,
 because in private practice very few females would permit such explorations.
    In practising  the "touch," the finger  frequently  detects some arterial
 pulsations at the upper part of the vagina, though they are more frequently
 found on some point of the  supra-vaginal  portion of the uterus, and  are
 evidently due to  the great hypertrophy of the vaginal and uterine arteries.
 Doctor Osiander, of Gdttingen, attaches great importance to this as a diag-
 nostic sign, and has  called it the vaginal pulse.2
    It is not uncommon to find the mucous membrane of the vagina covered,
 about the seventh  or eighth  month,  throughout  its Avhole  extent, Avith
 myriads  of little pimples as  large as a pin's head.   These  small granula-
 tions, Avhich I have  frequently met  Avith,  always coincide with a marked
 increase  of the vaginal secretion, and have given rise to the term granular
 vaginitis of pregnant Avomen.
    The vaginal mucosities  are  ahvays secreted abundantly during  preg-
 nancy, but the time of their appearance is very uncertain.  Usually, 1ioaat-
 ever, they are more  copious in the advanced stages, and the Avomen then
 say,  "they are  losing the milk;" an  opinion umvorthy of refutation.  In
 some, this Aoav appears in the early months, then ceases, and again reappears
 several times; though perhaps not at all, or  else only at a very late period.
    3.  The bladder is  gradually pushed above the superior strait, the meatus
 urinarius is draAvn out and elongated, and its orifice, from being so high up,
 is concealed behind  the border of the  symphysis pubis, thereby rendering
 the introduction  of  an instrument  very  difficult.   The urethral  canal  is
 more curved than usual,  and the curvature is sometimes so great that the
 male catheter can more readily be used; because the bladder being strongly
 pushed fonvards,  and above the pubis, by the developed  uterus, draAvs this
 canal upwards, and causes it to be applied against the posterior face of the
 pubic symphysis,  thus producing a curvature of the urethra having its con-
 cavity in front.   Lastly, as  the  upper part of this canal is compressed  by
 the enlarged womb, the circulation in its inferior parts is impeded, and the
 whole tube becomes  greatly tumefied.   It is  placed behind the osseous pro-
 jection produced  by the posterior part of the  articular surfaces of the pubis,
 and these two  superposed  eminences  form  a considerable  tumor in the
  1  This discoloration is evidently owing to the  greater activity of the circulation iu
 the  genital organs, and  consequently it ought, to be  met with in all cases  predisposing
 to a vascular congestion of the  genito-urinary apparatus.  Mr. Montgomery has de-
 tected it in a female at  the menstrual period, and it is a well-known fact, that cattle-
 breeders ascertain whether an animal is in heat or  not, by examining the orifice and
internal surface of the vagina, which is almost as black as ink under siuch circumstances.
  2  The hypertrophy of the vessels of the vagina and of the vulva sometimes renders
wounds of these parts very dangerous.  Profuse hemorrhage has been known to occur
in consequence of it. 
154
PREGNANCY.
interior of  the  pelvis.   I have frequently knoAvn students who Avere  prao
tising  the  touch,  to  be unable  to  explain  the remarkable tumefaction
encountered by the finger behind the symphysis.
  An annoying vesical tenesmus is often produced by the pressure exercised
on the body and neck of the bladder, tormenting the female with frequent
ineffectual desires to urinate; these demands are ahvays very urgent, and are
satisfied by the discharge of a few drops of urine, but are again reproduced
Avith equal  intensity some minutes after.   Some persons, judging from this
frequent micturition, have thought the urinary secretion Avas augmented.
  In certain cases, the sAvelling of the urethral Avails, and possibly also the
compression they sustain, produces  its  complete obliteration and  renders
catheterism necessary.
  M. A'elpeau avers, that he has frequently known the bladder, from the
fact of its being more compressed  above the fundus than below it during the
last fortnight of pregnancy, to project into the upper part of the vagina so as
to form a true vaginal cystocele.  I think,  however, that it is of rare occur-
rence during pregnancy, since I have met Avith but two instances of it.
  4.  The pressure of  the uterus  upon the vascular trunks, Avhich go to or
return from the inferior extremities, genital  organs, and loAver part of the
rectum, interrupts the venous and lymphatic circulation  in  those parts;
whence it frequently happens that a considerable oedema of the limbs and
sexual organs is produced, as Avell as the development of some hemorrhoidal
tumors.
  5.  Pregnant  Avomen are habitually costive ;  hence a voluminous tumor is
formed at  the  lateral  posterior  part of the excavation by the rectum dis-
tended Avith fecal matters.  The pressure of the uterus upon the entire mass
of the intestines, frequently  gives rise to colic and disorders of digestion.
  6.  The base of the thorax is enlarged and  projects  in front; the diaphragm
Is pressed upward  by  the uterus  and  intestinal mass, having  its concavity
increased in consequence; so much so, indeed, as to obstruct respiration, and
the circulation  in the heart and great vessels.
  7.  The skin of the abdomen is very much distended, and is marked, espe-
cially tOAvards its inferior part, by some streaks of a broAvn or bluish color,
which  form parallel curved lines  Avith the convexity tOAvards the pubis and
groins.  These  are very numerous in some Avomen, but in others they scarcely
exist;  they become paler, but do not disappear altogether after the delivery;
sometimes they are continued even  to the upper and internal part of the
thighs, and not unfrequently involve the  skin of the  lumbar and gluteal
regions.
  The muscles  and aponeuroses of the abdominal Avails become thinner, the
recti muscles are removed from each other, and the aponeurotic space Avhich
separates them, instead of being  a narrow band, as usual, is  at least four
and a quarter inches Avide, on a level with the navel. The umbilical depres-
sion, Avhich in  the tAvo first months seems deeper, disappears gradually as
gestation progresses;  the ring becomes distended,  and most  generally the
skin exhibits a protuberance instead of a pit in its place.   The eminence  is
particularly Avell  marked  Avhen the female  exerts herself, oAvino- to the
engagement of a small piece of epiploon  in it, constituting  a temporary
hernia. 
            ORGANIC CHANGES  DURING  PREGNANCY.         155

  Isot unfrequently an oblong tumor appears on the median line aftei de-
livery, produced by a projection of the boAvels in consequence of the great
separation of the aponeurotic fibres.  The tumor is especially evident dur-
ing any exertion;  and increases  in  size Avith each succeeding pregnancy,
until  it  finally becomes  an infirmity,  Avhich obliges  the  Avoman to have
recourse to a bandage.
  8. The relaxation of the pelvic symphyses is a frequent occurrence; when
existing to a  great extent,  it constitutes a disease  that will  be  more fully
detailed in the pathological  history of pregnancy.

                          ARTICLE  IV.
                      CHANGES IN THE BREASTS.
  The mammas, which must  also be considered as an appendage to the geni-
tal  organs, undergo, during  gestation, some modifications preparatory to the
accomplishment of the great function to Avhich they are destined after the
accouchement; thus, in the very commencement,  most women  find their
breasts to become tender and  larger, and Avith some, this is so constant a
sign that they do not hesitate to consider themselves pregnant as soon as it
is perceptible.  The enlargement is frequently attended by certain pricking
sensations or positive pains,  sometimes even by engorgements of the axillarj
ganglia.   It is by no means uncommon  for the SAvelling to diminish tOAvards
the fourth or fifth month,  but it reappears again near the end of pregnancy,
and is then considerably larger than before.   In some Avomen it may even
be carried  to the extent of  producing an inflammatory engorgement of its
substance, folloAved by an abscess.  More  rarely, the  breast, Avhich Avas at
first slightly enlarged,  subsides, and remains flaccid and soft until after de-
livery.  In general, this  is  an unfortunate circumstance, because, from the
obsen'ations of my friend, Dr. Donne, such Avomen prove very poor nurses
on account both of the bad  quality and the small quantity of their milk.

  [When the swelling of the breasts is very decided, it occasions so great a disten-
tion of the skin  as to give rise to markings which resemble precisely those described
upon the skin of the abdomen.]

  About the end of the second month, according  to Mr. Montgomery, but
in my opinion a little later, the nipple  SAvells, and becomes  more erectile,
sensitive, and  projecting; its color also is deeper.  The surrounding skin
becomes the seat of a larger afflux of liquid, and assumes an almost emphy-
sematous appearance.  This  skin is also discolored, exhibiting at first a light
yellowish tint, but in the  course of the tAvo succeeding months the areola is
completed, and the skin of  the mamma then presents the folloAving charac-
ters :  A circle around the  nipple, the color of Avhich varies in  depth of shade
according to the individual, being generally darker in persons  who have
black hair and eyes, and in brunettes, than in blondes, or  in feeble and
delicate women.  The  circle is from three-quarters of an inch to one inch
and- a quarter in extent, but, like the intensity of  the discoloration, it in-
creases Avith the advancement of gestation.  In the negress, the areola like-
wise becomes darker. 
156
PREGNANCY.
Fra. 49.
 [A Ni.jple.  B. Sebaceous tubercles scattered over the surface of the true areola. C. Spots of the d itted
                    areola. D. Markings due to distention of the skin.]

  | Here and there on the surface of the areola we find small elevations of about
one-sixteenth to three-sixteenths of an inch,  due to an  hypertrophied condition of
the twelve or tAventy  sebaceous glands already described.   When they are pressed,
a whitish fluid escapes which has been mistaken for milk.
  Toward the fifth month, another areola, knoAvn as the secondary, spotted or dap-
pled areola, is formed around the first one.  It extends  much farther than the first
one, often covering a large portion of the  skin  of the breasts.   When this spotted
areola is examined closely, we observe that the pigmentary coloration does not cease
suddenly at the circumference of the true areola, but that the coloring matter is so
deposited in the adjacent skin as to form a vanishing layer of greater or less extent
in different women.   This secondary areola is sprinkled Avith a considerable num-
ber of small white spots which give it  a  peculiar appearance.  The spots, which
have a rounded form, are merely so many points devoid of pigment, each one exhib-
iting in its centre a small black spot which marks  the orifice of a sebaceous gland
and the position of a minute hair discoverable by the assistance of a magnifier.]

  These changes usually persist  during lactation,  though when the woman  •
does not  suckle her infant they diminish after delivery, but do not wholly
disappear.   Consequently, they  are  more conclusive  in primiparce than in
others ; and although we must not ahvays anticipate their existence in preg-
nancy, yet, Avhenever they are found, they constitute an  almost certain sign
of that condition.   (See Diagnosis of Pregnancy.)

                             ARTICLE  V.
 [ANATOMICAL AND FUNCTIONAL CHANGES OF PARTS  NOT  IMMEDIATELY
              CONNECTED WITH  THE GENERATIVE FUNCTION.
  The entire organism  is  deeply  affected  by the pregnant condition.   Of the
 changes  observable  some are purely physiological and compatible with excellent
 health, whilst others are pathological.   Although indispositions and diseases so
 often fall  to the lot of  the  pregnant female, it  were an exaggeration to say that
 pregnancy is a disease of nine months  duration.  Some women are never better
 than when p *egnant, in which case it is eminently a physiological condition. 
              ORGANIC  CHANGES  DURING  PREGNANCY.          157

   Although it is difficult to draAV the line between these two orders of phenomena
we have nevertheless  endeavored to indicate it as  clearly as possible, and in this
intent shall  study at present only such  anatomical  and functional changes as are
observed in healthy pregnant females, leaving all that is pathological for discussion
in another part of the work.

   \ 1. Digestion.   Nutrition.
   The digestive organs are almost  always affected  by pregnancy;  but to those
functional changes which are familiar  to  all, Ave shall add a description of some
anatomical alterations of  more recent observation.
   Disturbances of Digestion.— Sometimes immediately after impregnation has taken
place, the digestive function indicates by unmistakable signs the impression pro-
duced upon it thereby. We may adopt Professor Pajot's very natural classification
of these changes, namely, stimulation, depression, disorder, and perversion.
   Stimulation of the digestive function, says this author, is the least frequent of
these classes, though it sometimes occurs.  The appetite is then greater, digestion
easier, the circulation  quicker, the face  of a fresher color, and the  mucous mem
branes redder.
   Depression of the function  is much  more common,  and  is indicated by some
emaciation, pallor, and alteration  of the features.   These are often followed  by
disorder and  perversion of digestion, vomiting being the most noticeable phenomenon
of all.  Although  the latter classes are  so commonly  attendant upon the pregnant
condition as  sometimes to have a real diagnostic value, they ought nevertheless to
be regarded as diseases, and studied as a part of the pathology of gestation.
   Fatty Condition of the Liver.— The liver is found to be increased in  size in almost
all women who die during or shortly after labor.  It was this fact which first drew
my attention to this organ, and led me to the discovery of the fatty condition
described in my inaugural thesis.  The  following is a brief statement of the facts
concerning it.  The  color of the hepatic  tissue is not  uniform, its substance being
sprinkled with minute yelloAv spots so  numerous as to give it the appearance of
granite.   The spots also seem to form so many projecting points, of a size varying
from that of a pin's head to that of a millet-seed.  Sometimes they are  disseminated,
at others aggregated,  forming  in  the latter case little insular patches, though
sometimes the agglomeration is such as  to give rise to a yellow spot  of an inch or
more  in diameter.   This  appearance is not limited to  the surface of the liver,  but
will be found in any section made  through the substance of the orgau.
   A microscopic examination of this tissue, made in connection with Dr. Yulpian,
exhibited hepatic cells in good condition mingled with an abundance of fat globules.
A fatty condition of  the liver in pregnant Avonien  is  therefore well determined,
although its causes and significance are,  as yet, but little understood.

  ji 2. Circulation.
  Throughout the period of pregnancy,  but especially during the latter half, the
Sieneral circulation becomes  more active; an activity  Avhich modern  research  has
shown to be connected with important changes in the composition of the blood and
with hypertrophy  of the heart.
   Changes in the Blood. — The conditions knoAvn as  the plethora and  hydremia of
pregnant  Avomen have been successively admitted by the profession, but as they
inA'olve a question  to be studied  in  connection Avith the  diseases of pregnancy, Ave
here confine ourselves  to the statement, that both  opinions, though perhaps excep-
tionally true, are  equally false in  the majority of  cases.   Though  the blood  be
altered during pregnancy, we see no reason for regarding the alteration as any-
thing  more than a physiological  phenomenon.
  To MM. Andral and Gavarret is due the honor of having discovered the changes 
158
PREGNANCY.
which the blood undergoes during pregnancy, and their investigations  have been
folloAved up by Becquerel, Rodier, and Regnauld.  As the experiments of all these
observers coincide, we have but to give the results at which they arrived.]

  Now, if we admit Avith MM. Andral and Gavarret, that the mean norma]
proportion of corpuscles is 127, or with  MM. Becquerel and Rodier, that it
is 141 for men and 125 for Avomen, it will be seen that all the analyses made
up to the present time give a much lower mean for a woman at an advanced
stage of her pregnancy.  Thus, of 34 bleedings examined by Andral  and
Gavarret, but one specimen exhibited,  at the end of the second month, a
proportion of corpuscles greater than the physiological  mean, namely, 145.
In one  only, pregnant  betAveen one and two  months,  did the corpuscles
reach the physiological standard of 128.   In  all the remaining 32 cases the
corpuscles were  beloAV this point, ranging in 6 cases from 125 to 120, and
in the other 26, from 120 to 95.
  The 34 bleedings gave different results as regards the fibrin,  the mean
physiological proportion of Avhich is 3, according to the period of pregnancy
at which the blood was drawn.   Thus, from  the first  month  to the end of
the  sixth, the amount of fibrin was always  below the average;  the mean
being 2*5, the minimum L9, and the maximum only 2*9.  During the  last
three months, on the contrary, the proportion of fibrin exceeded the physio-
logical average; it Avas  about  4, the maximum reaching 4*8.  Toward the
end of the last month, the average is 4*3.
  MM. Becquerel and Rodier  analyzed  the blood of nine pregnant women,
two of whom Avere 20 years of age, two 22,  one 25, one 27, one 29, one 34,
and  one 41.
  Five of these were of robust constitution, two Avere about the average in
this respect, whilst the other two were weak and apparently lymphatic.
  Six enjoyed excellent health, tAvo were not so well, and one Avas in the
hospital on  account of indefinite pains in the abdomen, and a cough of
rather long standing, though not serious in character.
  One was 4 months pregnant, four 5, one 5 J, one 6, and two 7.
  The folloAving represents the average composition of the blood, at least as
regards its principal elements: —
                              Average.        Maximum.        Minimum.
     Corpuscles,     .    .    .   111-8           127-1           87-7
     Fibrin,    ....    3-5             4-             2-5
     Albumen,      .    .    .   66-1            68-8           62-4
           (The average in non-pregnant women is 705.)
      Water.....801-6
           (The average in non-pregnant women is 791-1.)

  My colleague  and friend, M. Regnauld, has the folloAving table in his
thesis, and I think it so important that I give it entire: — 
ORGANIC  CHANGES  DURING PREGNANCY.         159
Table showing the Composition of 1000 Parts of Blood from 25 Women at
                     various Stages of Pregnancy.
  The table shows, evidently, that, conformably with the results already men-
tioned : —
  1. Corpuscles. — From the beginning of pregnancy, the proportion of cor-
puscles is sensibly diminished;  but that, though the diminution is small for
the first five or six months, since it yields an average of 121-04, it  is some-
times considerable in the second half, and especially at the end of gestation,
at Avhich period the average is 104-49.
  2. Fibrin.—The proportion  of  fibrin  is  not  increased in the blood of
pregnant Avomen until about the sixth month, but from  that time it increases
until delivery.
  3. Albumen. — Like MM. Becquerel and Rodier, M. Regnauld found a
decrease of albumen, which is loAvered from 70'5, the physiological standard
in the non-impregnated condition, to 68-6  in the first seven months, and  to
66-4 in the tAvo last.
  4. Water. — The  proportion  of water  in  the blood  increases  sensibly
tOAvards the end of the ninth month ;  thus, the average of the first  thirteen
analyses, corresponding with the first seven months, is  expressed by 816-01.
and that of tAvelve bleedings performed during the tAvo last, by 817-70. 
160                           PREGNANCY.
  We would also add with  M. Regnauld, that not only is the serum more
abundant relatively to the fibrin  and corpuscles, but that it  contains less
solid  matter, which  of course  helps to  increase the total amount  of water
contained in the blood.

  [If  the blood of a pregnant female  be examined by the usual mode of bleeding, a
contracted and buffy clot is sometimes obtained, all readily explained by the increase
of the fibrin.   Still, this appearance is less frequent than has been asserted, and
than one might be led to suppose would be the case.   Out of nearly two hundred
bleedings practised at an advanced period of gestation, M. Jacquemier discovered
the  buffy coat but once in six, and even then its thickness was very slight.  The
same  author also observed  that  most of the women whose blood was buffed had
fever,  and that but few were free from any apparent disease.
  The increase of fibrin in  pregnant women continues for a certain time after de-
livery.  None of these facts should be forgotten whilst studying puerperal diseases,
for without them one would be liable to explain the excess of fibrin by the inflam-
matory nature of the  disease, whilst  it is only the expression of a transient physio-
logical condition.
  The causes of all of the changes in the blood which Ave have  just studied elude
our  research.  It does not seem to us, however, unreasonable  to suppose that  the
increase of fibrin, by  rendering the blood  more coagulable, may have a  tendency
to lessen the hemorrhage which always accompanies delivery.  We shall,  however,
have occasion to revert to this  subject.]

  Hypertrophy of the Heart. — M. Larcher, long  ago (1828), called  atten-
tion to hypertrophy  of the heart as a result of pregnancy; and quite recently,
in a paper read at the Academy of Sciences, produced new observations in
support of his opinion.   According to  him, the  walls  of the left ventricle
become at the  least one-quarter, and at the most one-third, thicker during
the latter months of pregnancy or shortly after delivery ;  the right ventricle
and the auricles preserving their normal  thickness.   He considers this  the
cause of the precordial murmur so common during  gestation, and  the con-
sequence of the obstruction to the Aoav of blood tOAvards the loAver  extremi-
ties, occasioned  by the development of the Avomb.

  [Numerous observations by  M. Blot, confirm those of M. Larcher which have
just been mentioned.   He proved their correctness both by measurement, which is
always very difficult, and by Aveight determined Avith the greatest care. The results,
which he has obligingly put in my  possession, are as folloAvs:  The total average
weight  of the  heart  in 20 cases  of  puerperal women was  about 9 oz. 38  gr. tr..
whilst in the usual state the heart of a young Avoman weighs  but from 7 oz.  to 7
oz. 2 dr. tr.  It would thus  appear that the organ gains more  than one-fifth upon
its total weight during pregnancy.   This  hypertrophy affects the left ventricle
almost exclusively, and is remarkable for being  temporary like the hypertrophy of
the  uterus. (H. Blot.)

  \  3. Changes in the Urine.
  The urine undergoes great alteration during pregnancy —so that, beside  glyco-
suria, which will be studied in connection with the phenomena observed after delivery,
and albuminuria, which properly belongs to the diseases of pregnancy, we have
now to treat of kyesteine whose presence in the  urine appears to be a result of the
pregnant condition.] 
            ORGANIC  CHANGES  DURING  PREGNANCY.         161

  Kyesteine. — For several years past the attention of a number of physicians
has been  directed to  the peculiar  phenomena exhibited by the urine of
pregnant  Avomen.  Thus, M. Nauche, and after  him, Messrs. Eguisier and
Tanchou,  in France, Dr. Letheby (london Med. Gazette, December, 1841),
and  Mr. Stark  (The Edinburgh Med. and Surg. Journal, January, 1842),
in Great  Britain, and Dr.  Elisha Kane, in  America  (Am. Journal  of the
Medical Sciences, July, 1842), have  submitted the result of their observa-
tions to the public, after arriving at the conclusion that pregnancy may be
detected by the  inspection of the urine alone.   This question, hoAvever, is
not of such recent origin as many seem  to believe, for several of the  ancient
authors, Avicenna in particular, had previously described the characteristics
of this  fluid in gestation, and their Avritings frequently exhibit a  special
attention to the  subject.   But Ave may add, that their observations Avere far
less precise, and, in fact, had become altogether forgotten, Avhen M. Nauche
undertook his researches.  "We shall now present  the principal results which
have been recently obtained.
   If the urine of a  pregnant Avoman be received in a Avineglass, and then
be permitted to settle in a light, airy place, the folloAving peculiarities will
be observed:  When  first excreted, the urine is acid, whitish, somewhat
clouded, and of a nauseous odor; frequently little white corpuscles,  readily
distinguishable by a glass, are held  in  suspension, but, in a  feAV moments,
these subside in the form of  cloudy  flakes, either on  the bottom  or sides of
the glass, the urine  meanAvhile becoming more limpid and transparent.
Agreeably to the observations of Dr. Kane, this primary deposit does not
ahvays  occur, nor is it peculiar to the pregnant  state, for it cannot  be dis-
tinguished from the  mucous deposits so often seen in the ordinary urine.
No change is visible on the surface during this period, but, in the course of
eighteen  or  tAventy-four hours,  a number of small, brilliant,  crystalline
granules,  irregularly  isolated, appear  there, in numerous  cases;  and in
some instances,  these granulations unite so  as to constitute a thin, trans-
parent,  and iridescent layer, which is only visible in  certain positions.
   The urine remains  in that state for several  days, though it soon begins to
manifest the peculiar signs of gestation ; thus, upon  the  second day, or
during  the course of  the third, according to M. Eguisier, sometimes sooner,
but rarely later, its transparency diminishes, the original clouded appear-
ance  returns Avith increased intensity, the odor becomes stronger, and a
pellicle may be  discerned forming, at first like a nebulous streak, but soon
acquiring larger dimensions.  All of these characters  are more evident on
the third and fourth  days, and  some small debris fall from the pellicle to
the bottom of the glass.  By the fifth  or sixth  day the  pellicle is almost
entirely destroyed; its debris precipitate and form a Avhite crust upon the
sediment.   It is, hoAvever, replaced  successively by new pellicles less white
than the former, and  studded Avith minute brilliant points having a crystal-
line lustre;  a greenish tint also supplants the milky appearance.
   In  the  succeeding days, as  the evaporation of the urine  progresses, its
turbidity and green color increase; putrefaction commences, and the second
pellicle  is destroyed to give Avay in its turn to  a third, which resembles  more
or less that Avhich putrefaction engenders upon ordinary urine.
       11 
162
PREGNANCY.
  Dr. Kane, Avho has observed these  changes almost hourly, furnisnes the
folloAving account of their  progress:  The pellicle appears at a  variable
period ;  I have seen it sometimes at the end of thirty-six hours — at others,
as late as the eighth day; it is scarcely perceptible at first, but soon a light
cloud of a milky or bluish-Avhite appearance is seen at the  centre or sides
of the glass; at the beginning, in some cases, it is uniformly deposited on
the surface, constituting there a transparent layer, which becomes more and
more distinct;  at  other  times, it is not so well characterized in the  early
stages, presenting only a feAV striated, irregular circular lines, resembling a
web, but these striae become condensed, and about the fifth day are resolved
into a true pellicle.   It  noAV presents a creamy, opaline layer, of a light-
yellow  color, which groAArs  thicker and  thicker; its  external  surface  is
rendered unequal and ragged by the presence of small  granulations, Avhich
are Avhiter in color and crystalline.  The  pellicle  then resembles the layer
of fat that floats on the surface of cold broth, and it retains these characters
for  a long time.   On the subsequent days, the sides of the glass are covered
with small whitish streaks, varying  from a line  to a fourth of an inch in
extent,  Avhich attest the descent  of  the  pellicle   during the evaporation.
The pellicle, especially Avhen thick, gives off a  strong  cheesy odor, accord-
ing to Dr. Bird, and thus facilitates the diagnosis;  but  Dr. Kane has
verified  this  observation in only seven cases out of tAventy-five, and he has
not remarked that any relation exists between the thickness of the pellicle
and the intensity of the odor.
  After standing for several days, the pellicle seems first to give way at the
centre, and fissures  extend, someAA'hat later, from  this point  tOAvard the cir-
cumference.  Gradually, small particles separate  from the  debris and fall
to the bottom of the glass;  the pellicle thus diminishes in thickness, but it
seldom  disappears  altogether before the putrefaction  of the liquid takes
place; and the  primary deposit at the bottom is  thus increased by all the
detached portions of pellicle, Avhich gradually settle doAvn.
  The substance forming the pellicle has been denominated  kyesteine (from
xvvjaii, fco$, gestation), by M. Nauche.  The globules, held in suspension Avhen
the urine is excreted,  gradually aggregate, mount  to the surface, and con-
stitute  the pellicle above described.  This pellicle rarely  fails to develop
itself in the urine of pregnant women;  thus, for instance, in  eighty-five
cases examined  by Dr. Kane, it appeared in  sixty-eight  with  all its
characteristics, in eleven it  was not well  marked, and  in six only it failed
to appear.  One of the  last  six  had a  mammary abscess, and  Avas con-
valescent from  typhoid  fever; another was  very much enfeebled by pre-
vious hemorrhages, and  only four could  be regarded  as true exceptions to
the  rule.
  Without denying the existence of the modification which we are studying,
1 cannot  accept the opinion of the American accoucheur in regard to the
frequency of its occurrence.  With  the vieAV of determining this point, I
have examined the urine of a great number of pregnant females,  and I can
certify,  that, although it did present the  characters indicated in a certain
number of cases, yet very frequently, and  especially in the later months,
nothing of the kind Avas discoverable. 
             ORGANIC  CHANGES  DURING  PREGNANCY.        163

   I confess, also, that were I to depend upon the result of my latest inves-
 tigations, I should be inclined to regard the  existence of'this  pellicle as
 altogether exceptional in the last six weeks of gestation; for I have exam-
 ined  (September  and October, 1849)  the urine of  fifteen AAromen Avithout
 observing it.  I do not, hoAvever, forget that I have, in former years, proved
 the correctness of the observations of  my predecessors, and I am unable to
 explain this difference in the result of experiments performed in  absolutely
 the same manner.  Can it be due, as  M.  Regnauld  supposes, to the preser-
 vation of its acidity much longer than usual, instead of becoming  alkaline
 within tAvo, three, or four  days, as is customary ? I acknoAvledge that my
 attention was not directed  to this point.
   The urine  of  healthy women who  are not pregnant, exhibits  nothing
 similar to this, and if at any time it furnishes a pellicle, it has not the dis-
 tinctive  characters of kyesteine.  Some years ago, it was my custom to ex-
 amine comparatively the urine of non-pregnant  females, which I placed in
 the same kind of vessels, and under the same conditions of temperature and
 atmospheric  exposure;  and every time  that I met Avith kyesteine in the
 urine of pregnancy, that of the other  Avoman presented nothing similar.
   In certain pathological  conditions, the urine is sometimes  covered Avith a
 pellicle which  might  prove a  source  of  error, though some  authors  haAre
 pretended to be able to distinguish it from that Avhich is due to pregnancy.
 For instance, the pellicle which occasionally forms on the urine  of persons
 laboring under phthisis, articular diseases, vesical catarrh, or a  metastatic
 abscess, does not  appear before the fifth or sixth day, that is, at about the
 period Avhen  putrefaction begins, and  having once commenced, its develop-
 ment is completed in the course of a feAV hours; Avhereas,  the true kyesteine
 appears on the second day,  is then developed but very slowly, and apparently
 quite independent of putrefaction.   Again, this latter has a greater specific
 gravity than that produced by any pathological state Avhatever.
   According to the vieAVS of M. Regnauld, which Ave shall give  shortly, it
 will be seen, that, inasmuch as  it is due to the same  cause, the pathological
 pellicle ought to  present the same characters,  and that Avriters have been
 deceived as to the value of the different signs just mentioned.
   The chemical characters of kyesteine will  serve to distinguish it from all
 the mucous or albuminous  matters found in the urine.  These properties,
 agreeably to M. Eguisier, are nearly all  negative;  thus, it  is neutral, in-
 soluble in  alcohol, ether, water, and  ammonia, and, unlike  albumen, it is
 not soluble in alkaline  fluids, nor, like  mucus,  in a  mixture of soap and
 ammonia, neither in boiling alcohol and ether like fat.   Further, the urine
 containing it will  not coagulate  by boiling,  as albuminous urine does, but
 deposits a copious Avhite  powder on  cooling; nor will  it coagulate by the
 addition  of nitric acid.
   Kyesteine has, hoAvever,  many of the properties of these substances;  fir,
 being evidently of an organic nature, it is  precipitated by the  deutc-chlorid'e
 of mercury, by most  strong acids, and the astringent solutions.   Finally,
 in the present state of our knoAvledge, it must  be regarded as a neAv sub-
stance, which is  considered by MM.  Bonastre  and  Nauche as gelatino-
albuminous.   (Eguisier.)   We shall find  further on, "that the researches >.i
M. Regnauld tend to establish the contrary. 
164
PREGNANCY.
   Although writers on the subject agree very nearly as to the physical and
 chemical properties of kyesteine, they differ widely in regard to its micro-
 scopical characters.  Thus, MM. Eguisier, Golding Bird,  Kane, and Donne*
'disagree as to the size, form, and number of the  globules.  M. Simon, Avho
 has very frequently subjected the pellicle to microscopic examination, gives
 the folloAving as  the result of his researches.  It is found to contain the
 following elements: 1, an amorphous matter, formed of small opaque points;
 2, numerous vibriones in active motion; 3, crystals of ammoniaco-magnesian
 phosphate; 4, if the examination be made at a still later period, it will con-
 tain an abundance of monads.
   The most difficult point of the subject to determine is the following: To
 what is the presence of  kyesteine in the  urine of pregnant females  to bo
 attributed ?
   After having  endeavored to prove that it could not result from a par-
 ticular action in  the kidney, from the functional derangement of the respi-
 ratory apparatus, from any modification Avhatever in the digestive action, or
 from the new functions of the mammary glands, M. Eguisier concluded that
 it must be OAving to the passage of the amniotic liquor, or a part of its ele-
 ments, into the urine, and he thought that the two following propositions
 (which are more fully detailed in his memoir) proved  the correctness of
 his conclusions in a satisfactory manner, namely:
   A. There is  a  continual  exhalation and  absorption going on upon the
 external face of the amnios, the  products of which are removed from the
 organism through the urinary passages.
   B. The admixture of a certain  quantity of the liquor amnii with the urine
 of a healthy person, not pregnant, confers upon it many of the properties of
 kyesteinic urine.
   The truth of this proposition being admitted, it readily explains, he says,
 1, why the urine  only begins to  be charged with it  at a  period when the
 amniotic liquor is abundant enough for us to suppose that its passage into
 the urine Avould be appreciable; 2, why the kyesteinic characters are not so
 evident  at the end of  gestation, a period  when the liquor  amnii is less
 abundant, or less charged Avith animal matters;  and 3, why they suddenly
 disappear after the evacuation of the waters.
   But Dr. Kane does not admit this explanation, plausible as it seems; for
 he believes that the kyesteine is intimately associatecb^with the lacteal secre-
 tion, and appears to attribute it to an admixture, of milk Avith the urine.
 " In fact," he continues, " I have frequently proved the presence of kyesteine
 in  the  urine, at different periods of lactation, notAvithstanding  the formal
 proposition of M. Eguisier; for in forty-four nursing women, out of ninety-
 four, the perfect kyesteinic pellicle Avas  developed, with  all the characters
 it exhibits during gestation; and it was nearly always in those cases where
 the flow of milk is limited, or rendered difficult by some particular circum-
 stance, and in which the breasts were consequently more or  less engorged,
 that kyesteine appeared in the urine; but it was found much more rarely
 whenever  the  mother  nursed her infant,  and her  breasts were  properly
 draAvn.  In a word,"  says  Dr. Kane, "the existence of kyesteine during
 pregnancy, and  even  after the  accouchement, up to the  establ ishment of 
            ORGANIC  CHANGES DURING PREGNANCY.        165

the mammary secretion ; its rare existence during lactation, and its reappear-
ance, when the latter is suspended or impeded, at the time of weaning; for
instance, establish an intimate relation between the functions of the mammas
and the kyesteinic urine."   Golding Bird, Simon, and Lehman entertain
nearly similar views.
  An attentive study of the facts pertaining to this  subject has led my
colleague and friend, M. Regnauld, to the following opinion:
  Normal  urine  holds  in solution a certain amount of azotized matter,
originating, probably, in  an  incomplete  combustion  of albuminous sub-
stances, Avhich in  the blood  are transformed  into uric acid, or, by a higher
degree of oxygenation, into  urea.
  Noav we  may readily assure ourselves, that during  pregnancy there is a
hyper-secretion by the kidney of an  analogous, if not of an identical
matter; and  it is to the action of the air  upon this  azotized  matter in its
abnormal proportions, that the several phenomena before described  appear
to be due.
  The first cloudiness of the fluid is due to the separation of carbonate of
lime, formed  by the reciprocal reaction of the carbonate of ammonia, re-
sulting from  the decomposition of the  urea, and of  the  phosphate of lime
which  already existed in  the  urine.   In proportion as the  decomposition
giving rise to ammonia  progresses, the fluid loses  its acidity, until the bril-
liant  crystals of ammoniaco-magnesian phosphate, which are  so readily
recognized  by microscopic examination, begin to appear upon its surface.
  It is singular, that whilst these  reactions are going on, such a multitude
of microscopic animalcules  (vibriones)  should be developed in the urine
as to cause the Avhitish layer, Avhen  examined with a proper magnifying
poAver, to seem composed entirely of them, in connection with crystals of
ammoniaco-magnesian phosphate.
  In  order to prove that the formation of the pellicle of  which we are
speaking is really due to the action of the oxygen of the air upon  one of
the elements of the urine, it Avill only  be necessary to observe Avhat takes
place in two  equal quantities of the same  urine, one  of which is exposed to
the air, whilst the other is removed from  its  influence by being placed in
an atmosphere of hydrogen, of carbonic oxide, &c.  The first will present
the characters described, Avhilst the other will exhibit no  such phenomena.
  M.  Regnauld does not regard these properties  of the urine as due to a
special  matter contained  in it, but as a consequence of the presence of an
over-proportion of  an element Avhich is common to all urine; whence it
6eems  reasonable to suppose, that this excess of azotized  matter  might
exist under other circumstances, and then  give rise to the same phenomena.
  The period at Avhich the kyesteine  appears  in the urine of pregnant
Avomen, is stated  by Avriters to be exceedingly variable.   M. Eguisier says
that the characters Avhich Ave have described usually  begin  to sIioav them-
selves in the  course of the second month, and acquire their greatest  devel-
opment from  the third to the sixth month ; after the seventh, they generally
decline until  the end of gestation, so  that in  the  course of the  ninth, and
sometimes e\en of the eighth month,  they are hardly more marked than in
the second.  M. Tanchou has observed them in women Avho had missed 
166
PREGNANCY.
their courses but once.   Dr. Kane saw them on  one occasion before the
fourth Aveek, once before the fifth week, and often  before the  end of the
third month.  (Dr. Elisha Kane, American  Journal  of  the  Med. Sciences,
July, 1842.)
  I think  that the  facts which I have observed, and the details Avhich I
have given, justify the folloAving conclusions :
  1. That the pellicle described by Nauche is not composed of a matter of
neAV formation.
  2. That it is due  to an over-secretion of azotized matter which exists in
Bmall quantity in normal urine, and to the action of the atmospheric oxygen
upon it.
  3. That it is far  from being always  present  at any period of the preg-
nancy, and that  it is very rare in the latter months.
  4. That it may appear in certain pathological  conditions, and then differs
in no respect from that which is observed  during pregnancy.

  [§ 4. Osteophytes  of the Cranial Bones.
  There is formed during pregnancy, and may be found  after  delivery, between
the internal table  of the bones of the skull and the  external  surface of the dura
mater, a newly-formed product which is at first fluid, but  grows gradually denser
and finally ossifies, thus adding to the thickness  of  the cranial walls.   At first it
forms plates of a spongy tissue inclosed between  tAAro compact layers.  At a later
period the plates are  no longer  separate but  unite so as to form a supernumerary
bony arch covering the entire dura mater, but  growing thinner as it approaches the
occipital foramen  to which it finally extends.
  M. Ducrest describes it as follows.   I  examined the  surface of the cranium of
231 women who died  in the puerperal  state,  and of these 90, or  more than  one-
third, presented the  osteophyte.  The  researches of M.  Alexis Moreau,  Interne
of the Maternity Hospital, give a still larger proportion.   Out of 40 crania, he
found that  27  presented it to a greater or less  degree.  On the other hand, not one
of 71 cases, 35 being male and 36  female, Avhose death had  no connection with
pregnancy, examined  either by M. Cossy, hospital Interne, or by myself, afforded
a single instance of the affection.
  To Avhich then, of these three  conditions (pregnancy,  the  puerperal  state,  or
puerperal disease) can the production of the osteophyte be referred?  Sixteen of
the women Avho had it died between three and  seventy-two  hours after delivery, and
in several of these the plates extended throughout the whole extent of the cranium,
and resisted the edge of the scalpel almost as  much as the original bone.  It were
difficult to suppose  that  such  extensive formations could have  originated and
acquired an almost bony hardness in so short a time  as two or three days.
  As this objection applies equally to the puerperal  condition and to the diseases
of which  the  women died, pregnancy would appear to be the only  cause of its
development.  (Ducrest.   Theses de Paris, 1844, No. 12.)
  An anatomical alteration such  as this, appearing under the influence of preg-
nancy and afterward disappearing, is certainly very curious. Though we may fail to
determine  its causes  and importance, its existence  is sufficiently  proved.  It had
been, indeed, already described  by Professor Rokitansky of Vienna, who also
regarded it as peculiar to gestation and not as a pathological condition.

  § 5.  Pigmentary Deposits
  We have already stated that the breasts acquire during pregnancy a much lacker
brown color.   Other  regions then  also receive a deposit of coloring matter.   Thus 
OF THE  DECIDUA.
167
many women will have on the median line of the abdomen a brown streak as dark
as the areola, from the T'F to the J of an inch in width, extending from the mons
veneris to the umbilicus, and sometimes even to the xyphoid appendage.  This line,
drawn as with a brush, as M. Pajot expresses it,  is especially marked in brunettes,
in whom, indeed, it is not uncommon to find the entire skin of the abdomen and
of the upper part of the thighs of a deep bistre-like hue, and sprinkled with little
white spots precisely resembling those of the dotted areola.
  The perineum also, and the  labia majora almost always haATe a darker brown
color  during pregnancy.
  In connection with these normal colorations, we might mention other spots which
appear more especially upon the face;  but as they appear to us rather of a patho-
logical character, we defer their description to a  later period.]
                          CHAPTER III.
                            OF THE DECIDUA.
   [The study of the decidua intervenes naturally between the history of the changes
 undergone by the maternal organs and that of the development of the ovum.  It is
 now admitted that the decidua is formed of the uterine  mucous membrane which
 undergoes changes, and becoming  detached from the A\romb adheres so closely to
 the surface of the  ovum as to be expelled with it during labor.  Although at the
 outset it belongs to the mother, it is at the last a mere appendage of. the ovum.
   Before giving the most recent description of the decidua, it will be necessary to
 state the  old  and generally accepted  theory concerning it, at the  same time
 endeavoring to indicate the cause of the erroneous views entertained by almost  all
 who have investigated its history.]

   The Old Theory.—If an ovum  Avhich  has  been  expelled intact in con-
 sequence of  an abortion  Avithin the first tAvo months  be examined, it will  be
 found surrounded by a sort of pouch Avith Avhich it lies in contact by nearly
 four-fifths of its external surface, whilst the other fifth is free, and provided
 with the floating villi developed  upon the vitelline membrane, knoAvn  as
 the villi of the chorion.
   This pouch, Avhich is  pyriform  in shape, like the uterine cavity upon
 Avhich  it seems to be moulded,  generally presents  but  a  single opening,
 situated at the apex of  the cone,  which it represents, and  evidently corre-
 sponding to the  orifice of the neck  of the  uterus;  sometimes, hoAvever, I
 have found it perforated  on at  least one side at the  point corresponding  to
 the opening of the Fallopian tubes.
   The Avails of this pouch are  formed by a membrane knoAvn to embryolo-
 gists as the  decidua.  It has two surfaces, one external and  the  other
 internal.   The  internal  surface  is smooth,  covered Avith epithelium, and
 when examined Avith a lens, presents small  elevations, in form  not unlike
the circumvolutions of the cerebrum, and  each  furnished Avith several oval
openings.  The cavity limited  by this surface sometimes contains a muco-
albuminous fluid,  and in  certain  pathological cases, fluid or  coagulated
blood,  though ordinarily  they do  not exist in it.
  The external surface of the  decidua  may be divided  into tAvo portions, 
168
PREGNANCY.
the smaller of which is in contact with the ovum, and surrounds the greatei
part of  its external surface;  the other, and  by far  the larger portion, ia
entirely free, and must, when the ovum was  still Avithin  the uterus, have
been applied to the internal surface of the womb.  This external surface is
very irregular, and thickly studded with small and tender filaments.
  The portion of this membrane in  contact  Avith the ovum, was at  first
termed the ovular decidua, and aftenvards, as suggestive of the way in Avhich
                   it was supposed to be formed, the decidua reflexa; the
      fig. 50.        other was  called  the uterine or parietal  decidua, on
                   account of its relation with the wall of the uterus.
                     Noav, what is the  nature of this membrane?   What
                   is the mode of its formation?   At what period is  it
                   developed?   To furnish replies  to  these questions the
                   following theory  Avas  imagined, which  theoretically
                   furnishes quite a good solution of all the difficulties of
                   the  case.
  a section of the womb    As previously stated, the uterus, like  all the other
exhibiting the decidua in    enital organs becomes  the seat  of a  more" active
situ, before the arrival of  o        o    »                 _       ...
the  ovum (old theory),  vitality immediately after  a fruitful  coition; in  con-
i?$££££Z£  sequence of which the blood Aoavs  there in increased
pian tubes,  c. The de-  quantity, occasioning a congestion and turgescence of
cidua.  D. The cavity of  tigg      t  far  remove(i from inflammation.  This ab-
the deciduous membrane.
                   normal excitement is always accompanied by the secre-
tion of  coagulable  lymph, a sero-albuminous  fluid, which  soon fills up the
uterine cavity.  In the course of  a  feAV days  the fluid thickens, and its
exterior particles,  by becoming  more consistent, form a  soft pulpy mem-
brane, Avhich  lines  the Avhole internal surface of the womb; thereby con-
stituting a true  sac, that is in contact externally with  the mucous mem-
brane throughout,  and  is filled by the uncoagulated portion of the fluid.
From its position, this pouch must evidently assume the shape of the uterine
cavity upon which  indeed it seems  to be moulded (Fig. 50).
   The fecundated ovule  does not reach the cavity of the Avomb  until after
the lapse of eight, ten, or even twelve days, from the time of fecundation,
but the membrane  just spoken of begins to form much  earlier.  The  con-
sequence is, that after the ovule has traversed the tube, it finds the internal
orifice closed by the  decidua, and  evidently can only pass betAveen  it and
the uterus by pushing the membrane before it.  From this  time, the decidua
presents two distinct  layers, the most  extensive of which  lines the internal
surface of the uterus, except at the  point occupied by the ovum; it is called
the external or uterine decidua.   The other, which is pressed imvard  by the
Dvule, and is therefore in contact with a greater or less extent of its external
surface, is termed the internal or refiexed decidua, the ovular decidua, and
the epichorion of Chaussier.
   These tAvo  layers are at first widely separated from each  other;  but  as
the ovum increases in size, the extent of the reflected decidua is necessarily
augmented  and the  cavity diminished, so that by  the fourth month the
latter has disappeared, and the parietal and ovular layers come in contact.
   The  ovum is  in  immediate contact with the uterine  mucous inenibrana 
OF  THE  DECIDUA.
169
Fig. 51.
 The decidua after the arrival of
the ovum (old theory),  c. Th«
external, or uterine decidua. E B.
The  internal or refiexed layer.
d. The cavity of the decidua. f.
The chorion, g. The amnion. The
other references the same as in
the preceding figure.
 by a small  part of its surface;  all  the rest of its  external  surface  being
 separated from it by the refiexed layer, the cavity,
 and the  parietal layer of the decidua.   All the
 villi of  the ovum  Avhich  are  covered  by  the
 decidua,  after a time  become atrophied and dis-
 appear; but those which are in immediate contact
 with the uterus become greatly developed, and con-
 tract more or less intimate  connections Avith the
 innermost layer of the Avomb, at the point where
 subsequently the placenta will be developed.
   We see that  thus far this hypothesis coincides
 very ingeniously Avith  the appearances  presented
 by ova Avhich have  been expelled  uninjured by
 abortion.  It enables  us  to  understand perfectly
 hoAV that, notAvithstanding the complete integrity
 of the  decidua, the ovum is yet covered by it in
 but a part of its extent.
    Subsequently, hoAvever,  at  the  autopsies  of
 women avIio  died in the third or fourth  months of
 gestation, a  membrane Avas  discovered  upon  the
 external  surface of the placenta, resembling precisely the parietal decidua,
 and continuous Avith it, Avithout there being any discoverable line of demarca-
 tion betAveen it and this inter-utero-placental membrane; so that this uterine
 decidua,  Avhich  in aborted  ova  was in contact  Avith but a portion  of the
 surface of the   ovum, Avas found to surround it completely, as the shell
 indoles the  egg of a bird, Avhen opportunity offered for examining it in situ
 in the uterus.1   This apparent contradiction with the theory Avas accounted
 for by the folloAving hypothesis.
   The arrival of the OATule does not at once suspend the former secretion in
 the uterus;  and it continues to  go on, more particularly from the surface
 that is directly in relation with the ovum, in consequence of the greater
 vitality Avhich the latter maintains;  and the secreted matter, being precisely
 similar to that Avhich formed  the primitive decidua, thickens in turn, thereby
 constituting  a layer of plastic material, precisely like the first, betAveen the
 ovum and the Avomb, Avhich  bathes both the chorial and the uterine villosi-
 ties; and Avhen  this  deposit  finally coagulates, it contributes  to the forma-
 tion of the  placental mass, the external surface of  which is in this manner
 necessarily covered by an albuminous layer.   This lamina has been called
 the secondary, or the  inter-utero-placental decidua (decidua serotina).  Al-
 though limited at first  to the external surface of the placenta,  it soon unites
 so  intimately with the uterine layer of the  primitive  decidua, that their
 separation becomes quite difficult at a more advanced period.

  1 In 1851, I  exhibited to the Academy of Medicine, and afterwards  presented to M.
 Coste, who has had it engraved in his great Atlas, an aborted ovum, presenting a per-
 fect decidua, surrounding the ovum as the shell surrounds  the egg of a bird.  The
 examination of this ovum revealed an arrangement entirely similar to  what will be
 desoribed hereafter from  specimens observed in the uterus.  This is, I believe, the
first perfect aborte. ovum which has ever been studied. 
L70
PREGNANCY.
  According to this vieAv, the decidua serotina and the primitive de idua
have a common origin and  texture, and only differ  as regards the time of
their formation.
  In adding, finally, that the decidua was by some supposed to be destitute
of vessels (anhistous membrane of Velpeau), whilst others considered it to
be perforated and traversed by arteries and veins in considerable number,
Ave  shall have briefly reviewed the most generally received opinions upon
this subject.
  With the exception of some disagreement in regard to unimportant details,
all  authors Avere unanimous as respects this capital fact, namely, that the
decidua is a newly-formed membrane superadded to the uterine mucous mem-
brane, from which, hoAvever, it is entirely distinct.  So evident, indeed, did
this fact appear, that no one, notwithstanding the  old assertions of Sabatier,
Mayer, Seiler, and Weber, could  bring  himself to admit that the decidua
was only a development of the lining membrane of the uterus.  And even
at the present time, notwithstanding the  numerous preparations of M. Coste
(1842), who was the first to sustain the truth of this proposition in France,
many honest minds  still hold to the theory of  Hunter, which I  mylelf
supported so long.
  In the second edition of this work, after having  stated the opinions which
have been successively advanced, respecting the origin, nature, and mode of
development  of the decidua,  I  said: "I have  examined, Avith M. Coste,
several of the preparations on which he relies for the support of his view,
that the decidua  is nothing else than the uterine  mucous membrane itself,
Avhich is hypertrophied by the progress of gestation ; unfortunately the ovum
in all of them had advanced to the third month at least, and it seems to me
that the question can only be determined when  an  opportunity shall be
afforded of examining an ovum of not more than five or six weeks.   I am,
therefore, far from having a settled conviction, though I am willing to con-
fess that the last uterus examined by us together, has singularly shaken my
belief on this point  of ovology ;  and this, conjoined Avith the descriptions
given by Weber and Sharpey, restrains  me from  speaking with the same
degree of confidence as formerly.  I therefore think  it a question requiring
further examination."  (Page 176, trans, of 2d edition.)
  My desires  expressed in 1844 have been realized ; and, thanks to the kind-
ness of M.  Coste, I have had the opportunity of  examining an  admirable
collection of specimens of all ages, which, I take the opportunity of acknowl-
edging, have not left the remotest doubt  in my mind, at least as regards the
principal fact.  I therefore reject  the more or less  ingenious hypotheses pro-
posed hitherto, — hypotheses Avhich, it is true, Avere  rendered very probable
by the  examination  of a large number of ova expelled  by abortion, — and
Avith the sincerest conviction of its truth  adopt the opinion, that the decidua
is nothing else than the hypertrophied mucous membrane.  The evidence
of anatomical demonstration is not, hoAvever, to be resisted, and I doubt not
that all  Avho,  like myself, shall have studied  the beautiful preparations at
the  College of France, will be convinced of the error of their vieAvs.  For
the  benefit of those who may not have the good fortune to see these prepara- 
OF  THE  DECIDUA.
171
tions, I think it proper to give further on the description and the figure
borroAved from the magnificent atlas which he is publishing.
  Present Theory of the Decidua. — The history of the decidua is, at the
present time, merely a continuation of the account of those modifications of
the uterine mucous membrane, the study of Avhich Avas begun Avhilst treating
of menstruation.   They are, in fact, so intimately connected, that, in order
to understand what  remains to be said on the subject, it is necessary to
recall the condition of the mucous membrane of the uterus at the menstrual
period.
  Whilst the evolution of the ovarian vesicle is going on in the ovary, the vas-
cularity of the uterine mucous membrane is, as Ave have stated (p. 95), greatly
increased, and  the highly congested vessels  are discoverable beneath the
epithelium.  The  utricular  glands also become visibly enlarged.   By this
development of its principal elements, the mucous membrane is so thickened,
that in consequence of its restriction to the small cavity of the uterus, it  is
throAvn into folds  and circumvolutions of  variable depth, Avhich are espe-
cially well marked at the angles, and give forth secondary ramifications
from the sides', so as to occasion some uniformity of appearance. This state
of turgescence, and  the violet hue which often accompanies it,  is main-
tained, in a greater or less degree, until the ovule is discharged ; it dimin-
ishes during the  last  days of the menstrual period, and  disappears almost
entirely some time after the catamenia have ceased.
  But if the ovule, before leaving the ovarian vesicle, or during its passage
through  the tube tOAvards the cavity of  the Avomb,  receive the vivifying
influence of the spermatic fluid, the fecundation will maintain and increase
the abnormal excitement of the genital organs, produced  by the simple de-
velopment of the Graafian vesicle.   Then, instead of  subsiding, the uterine
mucous membrane becomes still more turgescent, and of a deeper violet color,
and the folds and Avrinkles increase so as to more than fill the cavity of the
organ.  Its vessels are engorged and distended to such a degree as to cause
small effusions, which are perceptible  beneath the epithelium, and also to
produce ecchymosis, AA'hich give to the internal surface of the uterus a striking
marbled  appearance.
  Notwithstanding this great turgescence, the internal surface of the mucous
membrane is smooth and polished, and never presents the villous projections
described by Baer, neither is there any fluid secreted, nor any trace of a
neAvly-formed false membrane.   The orifices  of the glandular tubes, Avhich
are much more visible than  in the unimpregnated condition,  are alone seen
upon the surface.
  For a short time after it has entered the womb, the ovule is free from all
adhesions, but soon becomes permanently fixed at the point Avhere it Avas
arrested at the outset. Before studying the means by which at a later period
it becomes adherent to a  circumscribed portion of the uterine  parietes, let
us examine the facts,  and  see Avhat  can be  learned respecting the youngest
ovules Avhich it has been possible to observe up to the present moment.
  In the beautiful Atlas of M.  Coste, is figured and described the uterus of
a young primiparous woman, who committed  suicide about the tAventieth or
twenty-first day of her pregnancy, and whose body was opened at the Morgue 
172
PREGNANCY.
of Paris.  The size of the organ was nearly double that of the normal con-
dition.  A longitudinal incision was made through  its posterior Avail, after
which it was opened and spread out, so as to exhibit the whole extent of the
cavity.  The latter Avas free as in the unimpregnated condition, and con-
tained no fluid.  The mucous membrane Avas, hoAvever, much thickened and
tumefied, presented numerous irregular folds, and Avas furnished throughout
Avith a rich netAvork of vessels.  NotAvithstanding  the general hypertrophy
of the mucous membrane, a  sort of soft tumor was discoverable, situated on
the anterior surface of the uterus  betAveen  the two Fallopian tubes, as
though  the  membrane Avere thicker there than elsewhere.  (See Plate III,
Fig. 1.)  Upon incising this elevated portion, the ovum was recognized  by
the villi of its chorion.  The internal orifices  of the  tubes and of the neck
were free and permeable as usual.
  Another woman Avas examined at the Morgue, who had committed suicide
about the fortieth day of her pregnancy. The uterus, which was much larger
than in  the preceding case, was incised longitudinally on its anterior surface,
and so disposed as to exhibit the greatest  possible  extent  of the  internal
surface.
  As in the  foregoing specimen, the mucous membrane, which was very vas-
cular throughout and greatly hypertrophied, Avas in  some points still more
puffed up, and furroAved with folds and wrinkles.
  The upper two-thirds of the cavity Avere occupied by a soft, fluctuating
tumor, situated upon the posterior surface between the tAvo Fallopian tubes.
Externally,  this tumor presented  altogether the appearance and organiza-
tion of  the  mucous membrane lining the  remainder  of the Avomb.  The
lower third of the cavity was free, so that  the cavity of the  neck could  be
entered  Avithout any obstacle presenting.   The openings of the tubes were
also permeable.   An incision upon the  most  prominent part of the tumor
revealed a cavity inclosing an ovum.
  The most superficial  examination of these two pieces convinced us:  1.
That  the internal surface of the uterus is lined  by a thick, soft membrane,
which presents numerous Avrinkles and folds at several  points.  2. That the
ovum Avas situated  in the upper part of the womb,  and apparently lodged
in a cavity perfectly distinct from that of the remainder of the oro-an.
  Noav,  in order to solve the problem which Ave are investigating, Ave shall
have to  ascertain, first,  the nature of  the membrane v\7hich lines  the cavity
of the uterus, as also of those  forming the walls of the pouch Avhich  in-
closes the ovule.     •
  The decidua Avith its  three parts, (parietal, ovular, and intermediate ) is
simply the mucous membrane in a state of hypertrophy.  1.  WThen a preg-
nant uterus  is compared Avith the description given (page 95) of the  changes
which the organ undergoes at the menstrual period,  it will  be readily per-
ceived that the internal layers of the uterus present in both  cases the same
physical properties, the former  being, hoAvever,  more tumefied, vascular
and folded.   It will also be seen, especially after  the uterus has been  im-
mersed  in spirits and water,  that the  numerous  small openino-s  are merely
the glandular apertures enlarged, Avhich are observable upon the mucous
membrane in the unimpregnated condition (page 80).  Finally, the demon- 
OF  THE DECIDUA                       173
 Btration is  completed by  the  researches of M.  Robin,  shoAving that this
 membrane, like that of the unimpregnated uterus, is composed of the same
 anatomical elements, that is  to  say:  1, of embryo-plastic  elements;  2,
 of laminated  fibres, both  in the  embryonic state  or  that of fibro-plastic
 bodies, and in that of fully developed  filaments; 3, of special cells; 4, of
 an amorphous  matter;  5, of glands; 6, of vessels; 7,  that  it is  covered
 with cylinder-epithelium becoming tessellated during gestation.  All these
 elements are, to be sure,  in a  hypertrophied  and changed condition, but
 inasmuch as M. Robin has folloAved  their changes step by step, there can
 be no doubt as to their identity.
   2.  The ovum is inclosed in a distinct cavity, separated from that of the
 uterus by a membranous partition, Avhich has  to be incised in order to ex-
 pose  it.  This is the membrane hitherto  described as the decidua reflexa;
 noAV  Avhat is  it?  It presents,  throughout,  the characters of the uterine
 mucous membrane; it has the  same  physiognomy, the same  arrangement,
 the  same vascularity, and the same  glandular orifices; only there is upon
 its most prominent portion a small circular space, around which the vessels
 disappear.  This space, which is Avhiter, or of a lighter rose  color than the
 remainder, is  the largest in the most advanced ovum.   The membrane is
 distinctly continuous Avith  the  uterine mucous membrane at its base, and
 the vessels traversing it are absolutely the same Avith those Avhich  ramify
 in the latter.  Finally, microscopic investigations leave no doubt that the
 structure of  the tAvo membranes  is identical.  With the same physical
 qualities, continuity of  tissue, and identity of  structure,  the  membrane
 surrounding the ovum, the decidua reflexa of authors, can be nothing else
 than  a portion of the mucous membrane of the uterus.
   3.  If the ovum be removed from the cavity Avhich inclosed it, the bottom
 of the latter  is  found to  be lined by a membrane which is  thickly sown
 with  anfractuosities or  irregular  lacunae of various sizes, in Avhich  those
 villi  of the chorion Avere  engaged which subsequently form the placenta.
 It is the portion of the mucous membrane to Avhich the  fecundated ovule
 adhered at  the outset, and is consequently continuous with  that covering
 the parietes, and identical  in regard to structure.
   Therefore, the ovule,  Avhich  upon  entering  the  Avomb lies  free in the
 cavity, becomes, after the lapse  of a period as yet unascertained, enveloped
 by and lodged in a sort of fold of  the mucous membrane.
   The manner in Avhich this inclusion of the ovule is effected is a subject  of
 hypothesis;  for, although  the ovule has  been observed Avhen free, at the
 outset, as also when completely enveloped after  the third week of gesta-
 tion, observations are Avanting  for  the intermediate period.   Therefore,  in
 the absence  of direct information, we give the explanation proposed by M.
 Coste, and, indeed, it is difficult to conceive how the phenomenon could take
 place otherAvise.
   After traversing the Fallopian tube, the ovum escapes from its internal
 orifice, and falls into the cavity  of the uterus.  On account of the SAvelling
of the mucous membrane, this cavity is almost obliterated, and the ovule
is consequently supported betAveen  two opposite points of the hypertrophied
and  softened  membrane.  Therefore,  it  rarely progresses very far,  and 
174
PREGNANCY.
 usually becomes fixed upon the fundus near  the  middle  of the interval
 between the orifices of the tAvo tubes.
   Noav,  notAvithstanding  its minuteness,  it is  impossible  that  the ovum
 should not  depress  the softened tissue Avith which  it  is in contact, and it
 soon excavates, so to speak, a cell in their substance.
   As the ovule increases in size, the swelling of the mucous membrane also
 progresses, especially at the point where the former is arrested.  As a con-
 sequence of this simultaneous development, the depression produced by the
 ovule in the substance of the  mucous  membrane becomes deeper, and it is
 gradually buried, first one-quarter of it, then one-half, until at  last it  is
 almost completely hidden and inclosed.   (Richard, Extract from the  Les-
 sons of M. Coste.)   In proportion  as  it becomes more deeply  buried, the
 edges of the cavity excavated by it seem to groAv up around it, at first to
 the level of the most projecting portion, and' then approach each other, so
 as gradually to contract the opening  by which a communication is  main-
 tained with  the remainder of  the uterine  cavity.  The  borders  of the
 opening  draAV  still nearer, and finally circumscribe  a minute orifice, the
 trace of Avhich remains for a short time only in the form of  a central de-
 pression or umbilicus.  The umbilicus  itself at  last disappears, and  from
 this  time the ovum is completely imprisoned in a sort of  cyst, whose walls
 are composed exclusively of the mucous membrane.
   Whatever may be thought of this theory, Ave  find in the uterus, five or
 six weeks after conception, an entirely free space, the ovum occupying but
 a  portion of the cavity, and a  greatly hypertrophied mucous membrane,
 which at the point where  the ovum is fixed, seems to fold upon itself in
 order to embrace the latter.  We have now to  ascertain what becomes of
 the uterine  mucous membrane  during gestation, as also of the tAvo layers
 produced by its folding.


                  EXPLANATION OF  PLATE  III.
  Fig. 1. Uterus at the twentieth or twenty-fifth day of gestation.  Half the natural
 size.
  c, c. Mucous membrane of the uterus,  with its rich vascularization.
  c/.  The portion of mucous membrane which covers the ovum.
  z. The small circular space around which the vessels disappear, and whose  centre
 presents the appearance of a recently closed umbilicus.
  u, u Muscular structure of the uterus, exhibiting, upon the cut surface, a multitude
 of venous sinuses in various degrees of development.
  m, m. Muscular portion of the neck,  distinguished  from that of  the body by the
 absence of venous sinuses.
  I. Vaginal portion of the neck.
  V.  A gland of  Naboth, greatly distended.
  q, q. The ovaries.  On the one to the right is a highly developed corpus luteum, g;
its surface is very vascular, and on its apex is perceived, g',  the cicatrix of the opening
 through which the ovule escaped.
  t, t. Fallopian  tubes.
  p, p. Fimbriated extremities of the tubes.
  Fio. 2. Is the same specimen as  the preceding, except that a circular incision has
been made in the porticn of mucous  membrane upon which the ovum is situated and
 the flap turned back, so as to exhibit its deep or ovular surface. 
PI. HI.
M6.1

^ig2
Jig IE

"Sf-SS»»t''*? '
^.f ■

 
 
OF THE  DECIDUA.
175
  h. Section of the  mucous membrane covering the ovum, exhibiting its thickness
 relatively to that which lines the remaining portion of the womb.
  c//. Internal surface of the flap of the uterine mucous membrane (decidua reflexa)
 which covered the ovum.
  or. The ovum, with its surface thickly set with short but considerably branched
 villi, which come into direct contact with the maternal blood.
  Fig.  3. The  uterine  mucous membrane of the  specimen represented by Fig. 1,
 divided  on a level with the neck, and seen separately.  The blood which distended its
 vessels  having  escaped,  in consequence of its  immersion in spirits  and water, the
 vascular network which it exhibited has disappeared, and permits  us  tp see that its
 entire surface is perforated with minute openings, which are the glandular apparatus,
 observable upon the  mucous membrane of the uterus in the unimpregnated condition.
 The portion  of mucous membrane beneath which the ovum was situated, is incised as
 in the preceding figure, but the ovum is here removed, so as  to exhibit completely the
 walls of the  cavity which contained it.
  /. The cell or cavity Avhich contained the  ovum,  strewn with anfractuosities and
 irregular lacunae, in which  the villi of  the chorion were inserted.
  c"'. Internal surface of the flap of mucous membrane which covered the ovum.   The
 same lacunae are observable in it as on the opposite surface,/, but they are smaller,
 less numerous, and less pronounced.
  a. Sections of the venous  sinuses of the mucous membrane  of the uterus.
  t'', t''.  Internal orifice of the Fallopian tubes, rendered visible in the preparation by
 the greater unfolding of the mucous membrane.  There is no indication of their ever
 having  been obliterated.

   Description of the Three Portions of the Decidua. — From  the foregoing
 account, it  appears that  the different portions of the decidua  are the result
 of  the  successive phases  of development of the uterine mucous membrane,
 and in  order to folloAv Avith greater ease the metamorphosis of the latter, Ave
 shall describe consecutively the three portions of the  decidua.
   A. The Intermediate or Utero-epichorial Membrane. — If, after the removal
 of  the  ovum,  the  cavity Avhich it  occupied be examined  during  the  first
 month, or the first half of the second, a multitude of irregular  grooves or
 lacunae, of  variable  size  and depth, in Avhich the villi of the chorion Avere
 engaged (see PI. III., Fig. 3), will be perceived upon the mucous membrane
 which forms its bottom.   These lacunae,  into Avhich smaller ones enter, and
 which  are  so  numerous  as to give to this portion  of the membrane the
 appearance of an  areolar, erectile  tissue, are supposed by  M. Coste to be
 produced by the Avearing aAvay, or corrosion of the vessels, Avhich are more
 hypertrophied at this point than elseAvhere, by the  invading groAvth of the
 chorion; so that the  lacunae, by communicating directly in this Avay Avith
 the subjacent  uterine  sinuses, permit the  maternal blood  to flow into the
 cavity occupied by the ovum, and  come into direct  contact Avith  the villi
 of the  chorion.
  The presence of the ovum  determines at this point a considerable hyper-
 trophy  of all the  elements of the  mucous membrane.  The corresponding
 villi of the chorion also  become greatly developed,  and all together con-
 stitute at a  rather  later period the  mass of the placenta.  (See Placenta.)
  B. The ovular  decidua or  epichorial  membrane presents  very different
appearances according to the  period at  Avhich it is examined.  Sliortly
after  its  formation is completed,  that is to say, after  the  umbilicus  is
obliterated, it differs in no respect from the parietal mucous membrane: its 
176
PREGNANCY.
uterine surface has the same color, the same thickness, the same profuse
supply of vessels, and is perforated in like manner Avith numerous glandulai
orifices.  Its ovular surface presents at the same period irregular cavities
or lacunae of variable depth, resembling precisely those described as belong-
ing to the inter-utero-placental layer, and which are  penetrated in like
manner by the villi of the portion of the chorion covering the ovum.   (See
PI. III., Figs. 2 and 3.)  But as the ovum enlarges, it elevates and extends
it, until about the end of the first month,  when commencing  atrophy is
observed at its centre, in consequence of which its vessels and glands dis-
appear, and the whole of this portion of the membrane gradually loses  its
thickness.  (See PI. III., Fig. 1.)  The result is, that, either in consequence
of the distention Avhich it undergoes,  or of the pressure exerted upon  its
most  prominent  portion through the  growth of the  ovum, a  small but
gradually enlarging circular space, deprived of vessels, appears in its centre,
whilst the remainder of the surface presents  the same vascularity as the
parietal mucous membrane.  This central  portion becomes very thin, even
at periods Avhen the circumference of the membrane preserves a considerable
thickness.
   The obliteration of the vessels and the atrophy of the glandules progress
from the centre tOAvards the circumference, so that by the third month the
epichorial membrane differs so materially from the parietal mucous  mem-
brane that, except at the parts adjacent to the points where the tAvo become
continuous, the glandular orifices and vessels are no longer discoverable.
   The lacunae described as existing upon the ovular surface, are still further
effaced by the atrophy, and as the villi of the chorion, Avhich Avere inserted
into them, can no longer derive thence the means of nutrition, they become
useless and atrophied in like manner.
   As  the de\relopment of the ovum progresses, it tends naturally to encroach
upon the caA-ity of the womb, and consequently to bring the epichorion and
the uterine mucous membrane nearer together, until, at the end of the third
month, the tAvo are in contact.   At a rather later period, they become so
adherent as to be separated Avith difficulty.
   It is  hardly necessary to state, that Avhen thus deprived  of its vascular
elements, the ovular portion of  the membrane can no longer  accommodate
itself  to the distention produced by the ovum, othenvise than by a progres-
sive thinning of the membrane, and that its extreme delicacy in advanced
ovums, or at  maturity, is to be thus  accounted for.  It  is found, hoAvever,
even after  labor, adhering either to the chorion or to the  parietal mucous
membrane.
   C. The uterine or parietal decidua retains the characters already described
until tOAvards the end of the second month; but from this  time it begins to
groAV thinner, and its numerous and deep folds are gradually effaced.   This
first period of degeneration progresses, hoAvever, very slowly, for at the third
month, the state of the  membrane is very nearly the  same as at the men-
strual periods.  (Richard. Thesis.)
  [Together with  this  atrophy begins also a transformation of  the epithelium,
which gradually passes from  the cylindric to  the tessellated form. There is  no
proof,  however, that the  prismatic cells assume directly the pavimentous form; 
OF  THE  DECIDUA.
177
indeed Robin says that, on the contrary, some time after fecundation  takes place,
the epithelium of the cavity of the body of the uterus exfoliates, as it were, cell by
cell, or at the most by little shreds, and is replaced by the pavimentous form.
  This metamorphosis  of the epithelium  is true for both the uterine and ovular
decidua, and when the two come in contact, we  have, as a result of their adher-
ence, a layer of epithelial cells in the very substance of the  membrane.  So inti-
mate, indeed, is the adhesion between the so-called uterine and reflected portions
uf the decidua, that at the time of delivery they seem to form but a single layer.]

   From the fourth month, the uterine decidua begins to lose  the marks of
energetic vitality Avhich had characterized  it  hitherto, and  its  external
appearance (perforation and vascularity) is  altered; it  becomes atrophied
to such an extent as to be reduced by the seventh month to the one-tAventy-
fifth of an inch in thickness, and is still thinner at the termination of preg-
nancy.   Though inseparable at the outset from the subjacent tissue, it  is
noAV, in a measure, an independent membrane, and may be isolated and de-
tached in strips of considerable size.   This ready separation is due, accord-
ing to M. Robin, to the commencing development, near the end of the fourth
month, betAveen  it and the muscular tissue of a neAV membrane, which  is at
first soft, doAvny, and homogeneous, the first trace,  in fact, of the  mucous
membrane Avhich is to replace the decidua that falls after labor. It thickens
gradually during the latter half of gestation, and lines the internal surface
of the uterus, Avhose  muscular fibres are not therefore left exposed by the
complete decollation and  expulsion of the  uterine decidua, Avhich  takes
place after labor.

   [Of the Decidua at the end of Gestation.—At  the end  of gestation  the decidua
is thin, and of a grayish or rose-colored appearance ; it has an areolar texture, and
an irregular surface.  The outermost of its two surfaces is throughout in relation
with the internal  walls of the uterus, now covered by the first  elements of the
newly forming  mucous membrane.  Its  internal surface adheres closely to the
chorion, and at the point of insertion of the placenta becomes involved in the struc-
ture of the uterine surface of that organ.  (See Placenta.)
  When the after-birth is delivered, a  rupture takes place between the mucous mem-
brane of the body of the uterus and that  of the neck.  The latter remains, whilst
that of the body,  now the decidua, is  expelled Avith the  ovum, of Avhich  it  forms
the exterior envelope.
   It is soft and easily torn ; and although the  vessels which  traversed it whilst  it
adhered to the uterus,  are for the most part obliterated and atrophied, some of them
may yet be found full  of blood.  By scraping with the nail, it may be removed in
little shreds.  Its  softness  and opacity serve to distinguish it from the other envel-
opes of the ovum, which are  stronger and transparent.
  The inter-utero-placental mucous membrane is duplicated, so to speak, by being
separated into tAvo layers: the thinner is removed with the placenta, into the forma-
tion of which it enters (maternal  placenta, see Placenta) ;  the thicker remains
adherent to the uterus, and is soon blended with the newly formed mucpus mem-
brane of the adjacent parts.  The inter-utero-placental mucous membrane does not,
therefore, entirely fall away; no  newly formed mucous  membrane is to be found
beneath it, so that it cannot be properly called a decidua.
  If, therefore, we consider the Avhole uterine  mucous membrane at the time of
delivery, we find that the portion lining  the neck  is not detached, and  that the
greater part of the inter-utero-placental portion  remains adherent and assists in
the formation of the new membrane.   (See Phenomena appertaining to the lying-in
       12 
178
PREGNANCY.
Hate.) The parietal and ovular mucous membrane constitutes the only portion which
is Avholly expelled and which really deserves the name of Decidua.]
  From the details into which we have entered, it is evident:
  1. That, excepting the  membranes proper of the ovum, the amnion and
chorion, the uterus contains none other than its OAvn mucous membrane.
  2. That at the moment when  the ovule enters  the cavity of the uterus,
this  membrane has throughout  a thickness equal  to, if not greater than,
that Avhich it possesses at the menstrual period.
  3. That this abnormal thickness is Avholly due to the hypertrophy of its
constituent  elements, and especially of peculiar cells,  as  proved by M.
Robin.
  4. That  immediately after the arrival of the ovule, the vitality of the
uterus seems to be concentrated, in a great  measure, at  that point of the
mucous membrane where the ovule is arrested.
  5. That, as a consequence of this  concentration of the vital forces, the
point mentioned of the mucous membrane becomes thickened, grows up
around the ovule, investing  it Avith a  circular ring, which soon incloses it
completely.
  6. That from this moment the ovule is separated from the uterine tissue
by the intermediate mucous membrane, and from the remainder of the uterine
cavity by the ovular mucous membrane.
  7. That, after the  first  month, the ovular mucous membrane becomes
atrophied  from the centre towrards the circumference, loses  its vascularity
and glandular openings.
  8. That  this atrophy involves that of  the  corresponding villi  of the
chorion, whilst those Avhich are in relation "with the intermediate mucous
membrane become, like the latter, considerably developed, and subsequently
form the placenta.
  9. That, from the fourth month, the parietal mucous  membrane begins
to degenerate, groAving gradually thinner, in consequence of the diminution
of its tissue, and of the obliteration by atrophy of its vessels and glands.
  10. Finally, that a new mucous membrane is formed  by Avhich the old
one is removed  farther and  farther  from the muscular tissue to which it
adhered so  closely at the outset, and that after  labor it  is completely
detached and expelled Avith the ovum.
  This exfoliation of the mucous membrane of the uterus after parturition
is explained, to a certain  extent, by the formation of a new mucous mem-
brane ; but  it is much more difficult  to understand how it should occur in
abortions during the early months, when the adhesion betAveen the mucous
and muscular tissues is so  very firm.  It is true,  that the exfoliated decidua
is much thinner than that which may be  observed  still adhering to the
uterus at the same period, and that we may suppose a part only of the pari-
etal membrane to have been detached. 
DEVELOPMENT  OF  THE  HUMAN OVUM.          179
                         CHAPTEE  IV.

            OF  THE HUMAN  OVUM AFTER FECUNDATION.
   The human ovule, prior to fecundation and at its full maturity, is com-
 posed, as previously stated (page 90): 1st. Of the vitelline membrane, or the
 envelope.  2d. Of  a granular liquid  contained  in  this  membrane, and
 called the vitellus (yolk).  3d. Of a little vesicle inclosed in the first, and
 situated in the midst of the granular liquid.  This is the germinal vesicle,
 originally discovered by  Purkinje, in the  eggs  of birds, and subsequently
 proved by M. Coste to exist in those of mammalia.  4th, and lastly.  Of
 the germinal or proligerous spot (macula  germinativa), which is detached
 from  the clear contents of the  germinal vesicle, and is held in suspension
 in the fluid which the latter contains.
   If  the ovule be examined several weeks  after  the fecundation has taken
 place, it will be found to have undergone  some very remarkable transfor-
 mations; for it is then composed of such different parts, that if comparative
 anatomy had not furnished us opportunities of observing, step by step, and
 hour  by hour, the divers modifications it passes  through before the organi-
 zation is fully completed, Ave Avould  not believe it to be one and  the same
 product.  Thus, at the end  of the second or third Aveek after fecundation,
 it exhibits some very different elements to the  observer: for example, Ave
 encounter, in passing from without inAvards :  1st. The chorion, a thick exterior
 membrane, studded Avith  numerous villosities.   2d. A much thinner mem-
 brane, situated more internally, and designated as the amnios.  3d. A more
 or less considerable  space betAveen  these tAvo envelopes, that is filled by an
 albuminous liquid,  in the  midst of Avhich a little vesicle (the  umbilical
 vesicle) is situated.  And 4th.  A liquid fills the cavity of the amnios, the
 quautity varying Avith the period of pregnancy, and in this fluid is the embryo.
   Finally,  let us add  that the ovule is  enveloped nearly throughout by  a
 double membrane, Avhich at first is entirely foreign to, but  subsequently
 contracts intimate relations Avith it; this is the deciduous membrane.  But
 before studying  the  constituent parts of the ovum at an advanced  period
 of its  development,  let us  sec what is  their proper commencement, and
 hoAV they can  arise out of the  simple elements  that  form the ovule prior
 to conception.
   When the ovule has attained its  full  maturity, the vesicle in which it is
 inclosed becomes the seat of an excitation Avhich determines  there a  con-
 siderable afflux of fluid, and causes  its progressive distention.   This hyper-
 trophy may, as Ave have seen, be either spontaneous, or produced by coition
 or other venereal excitement.  As a  consequence of  the  distention, the
 vessels on that portion of  the vesicle Avhich  projects  the farthest  from the
 surface of the ovary become atrophied, its Avails groAV thinner,  and soon
 give Avay, thereby permitting the ovule  to  escape, Avhich, in passing  out,
 draAvs along Avith it a part of its granular  cumulus.  The ovum then en-
gages  in the tube, whose enlarged extremity had been applied to the ovary.
It must not be supposed that the period for the ovule's arrival in the tube
is invariable in the same species of animals, and  it probably varies in the
human rare also, though nothing positive is knoAvnonthat point.  Pending 
180
PREGNANCY.
its stay in  the ovary, the ovum  underAvent no appreciable  modification,
but as soon as it enters the oviduct, the beginning of those changes it must
necessarily  pass through, in order to give birth to a new being, is observed,
and hence, to study these modifications in due course, Ave must first  examine
those manifested in the tube, and then such as do not appear until after its
arrival in the uterine cavity.
                             ARTICLE  I.
                  CHANGES OF THE  OVUM IN THE  TUBE.
   It has heretofore been ahvays impossible to  study these changes in the
human ovum, and  the description we are  about to give  is the result of
observations  made on the ova of mammalia, especially  of the dog and
rabbit; but analogy favors the belief that similar phenomena take  place
in the human species;  indeed, the strongest resemblance exists between the
ovum of the latter, and  the unfecundated  ovum of a bitch; besides, the
youngest  ova that have been studied in the female, exactly resemble  those
which have arrived at a certain degree of  development in animals.   It is,
therefore, extremely probable that if they are endowed with the  same
organization before conception, and still exhibit a perfect resemblance after
the fecundation, they must have passed through similar successive transforma-
tions.  From analogy as well as observation, it is supposed that in the human
female ten or twelve days are occupied in the passage of the ovum  through
the tube.
   [Disappearance of the  Germinal Vesicle. — By the time the ovum has reached the
oviduct, it has become impossible to find in it either vesicle or germinal spot; and
this disappearance  of the vesicle and  of the collection of granules at its centre, con-
stitutes the first change  perceptible in the ovum subsequent to its departure from
the ova it.
   The disappearance shows that the ovum is mature, but occurs independently of
fecundation.
   Condensation of the Vitellus. — During the early part of its passage through the
tube, the vitellus becomes  more dense (Bischoff) and compact, in consequence of
which it no longer fills the vitelline  membrane, but leaves an intervening  space
occupied by a clear and transparent fluid.  So great is this condensation, that if its
envelope be opened, the vitellus is found to be a solid body, capable of division by
means of a very fine needle into twro, four, and six portions.   (See BischofTs Atlas.)
  Appearance  of Polar Globules. — Succeeding  the  disappearance of the  germinal
vesicle and during  the condensation of the vitellus, there is formed on the surface
of the latter  a transparent globule, ^ of an inch in diameter, to which the  name
polar globule has been given.  From the point of its formation and during the time
of its appearance, there is a retrocession of the  granules of the vitellus and  conse-
quent separation from the hyaline and transparent substance which  united  them.
It Avould thus  seem that the polar globule  is produced by a sort of exudation or
accumulation of the hyaline substance of the vitellus, and the point at which it ia
formed indicates Avhere Avill take place the first furrow of segmentation, and where
at a later period the cephalic extremity of the embryo wdll make its appearance.
  Within a few minutes  after it is first perceived, the polar  globule constitutes a
hemispherical  projection on the surface of the vitellus, and finally  separates from
and remains  simply contiguous to it.
  In some species  of animals, two, three,  or four  polar globules are  thus suc<
cessively produced,  all taking their origin from the same point.   When the last of
them is formed, all  unite to form a single one, which soon  exhibits distinctly an
inA'esting membrane and a cavity. 
DEVELOPMENT OF  THE  HUMAN  OVUM.
181
  The polar globule  thus produced remains beneath the vitelline membrane and
unconnected  Avith the phenomena which  are to  take place in  its vicinity.  It
becomes  useless, in  fact, as soon  as  formed,  being  intended only to prepare the
way for the segmentation of the vitellus, which we are soon to study.
  Whether fecundation  has occurred or not, the germinal vesicle disappears, the
vitellus condenses, and the  polar  globules form ;  but the changes which we are
next to study take place only in fecundated ova.   (Memoirs of Prof. Ch. Bobin.)
  Formation  of the Vitelline Nucleus  and Segmentation of the Vitellus. — Both the
layer of albumen which  ^urrounds the fecundated ovum, and the vitelline  mem-
brane become thicker during the passage through the second half and internal third
of the Fallopian tube ; but the most remarkable changes take place  in the vitellus
(Barry,  Bischoff,  Bobin).
  Whilst  the vitellus is undergoing its condensation, a  clear spot appears  in its
centre and increases  so  rapidly in size by crowding aside the vitelline  globules,
that in about one hour it has attained a diameter of from ^. of an inch to the 5-fg
of an inch (Bobin).   The  spot  is called the vitelline nuclei/*, and has  nothing in
common with either  the  germinal vesicle or the polar globule.  It is composed of a
thick fluid without a cavity or distinct walls.
  The vitelline nucleus  has barely attained the above-mentioned diameters before
it is seen to become elongated and constricted near the middle, and finally separates
into two halves.  This separation  is the signal for the segmentation of the vitellus
which itself divides  into two  halves, in the centres of.Avhich are found the  corre-
sponding halves of the vitelline nucleus.
                Fia. 52.                                   Fio. 53.
 
182
PREGNANCY.
found in the tubes as late as the tenth, twelfth, or even  fifteenth day; and
we have formerly stated that, in the human species, no one case.has  ever
proved its existence in the Avomb prior to the  twelfth  day.  However, it ia
well to remark, that, as a general  rule, the passage is very rapid through
the external half of the tube, whilst its progress  through  the  second half
and  especially through the last third is  exceedingly sIoav, in consequence
perhaps of the extreme narrowness of this portion of it.
  Finally, the ovum augments someAvhat in volume during its course, being
probably nourished  at first  at the expense of the granulations which accom-
pany it, and subsequently by absorbing  the albuminous liquid secreted  in
the oviduct  itself.1
                           ARTICLE  II.

MODIFICATIONS OF^THE  OVULE FROM  ITS  FIRST ARRIVAL IN  THE  W0M3
         UNTIL AFTER THE  DEVELOPMENT OF THE ALLANTOIS.
  [Formation of the Blastodermic Membrane. — At the time of its entrance into the
cavity of the  uterus, the ovum is, therefore, composed of the muriform body, the
thickened vitelline membrane, and a thin layer of albumen surrounding the latter.
Each little  sphere of the muriform body nowr undergoes an internal change by
which its outer portion is transformed into a membrane, so that each  segmentary
sphere represents a cell with a homogeneous envelope and granular tissue.   Shortly
after this, fluid collects in the centre of the muriform body and presses to the cir-
cumference the spheres or cells of which the body had been composed.   In con-
sequence of this pressure the cells become flattened and applied to the vitelline
membrane  so  as to form a sort of  lining thereto, and by their  mutual adherence
form a second membrane enclosed within the primary one.]

  This  second membrane is not easily recognized; but if the example of
M.  Coste be  folloAved, and the ovule be placed  in water, it 'will become quite
apparent.  In fact, a very curious endosmotic phenomenon then takes place;
                          the Avater passing through the vitelline membrane
           FlG-55-           detaches the second  vesicle in such a manner that
                          the latter,  being  completely isolated,  as  also
                          puckered  and  corrugated  in  every  direction,
                          floats or hangs  suspended  in the  new liquid
                          which distends  the  vitelline membrane;  and to
                          this  M.  Coste  has given  the title  of the blasto-
                          dermic membrane.   But  while this  blastodermic
                          vesicle, or membrane, is  being developed, the
                          layer of  albumen which  surrounds the ovum on
                          its first arrival in the uterus, disappears and con-
                          sequently the vitelline vesicle loses  much of its
                          thickness.
                            Hitherto, the  ovum still remained free  and
                          Avithout  any adhesion  to  the uterine walls; but
 The ovule shortly after its arrival
in the womb.  A. The diminished
albuminous layer, v. The vitelline
membrane,  b. The blastodermic
membrane.
  1 This layer of albumen which surrounds the ovum of the rabbit and of the roebuck,
whilst it remains in the tube, does not exist around the ovum of the bitch  and of the
sow.   On  account of these differences, it will remain uncertain whether  it envelopa
the human ovum until observations which, as  yet, it has  been impossible to make,
BhaU settle the question. 
DEVELOPMENT OF THE  HUMAN  OVUM.
183
it commences about this period to contract more intimate relations with the
latter, and hence  can no longer be displaced by blowing upon it.   At the
same period a rounded, Avhitish spot begins to appear on some pc int of the
blastodermic vesicle, Avhich seems to be detached, or to stand in relief; this
has been  called the tache embryonnaire (the embryonic spot)  by M. Coste,
and  it, like the blastodermic vesicle, is composed of cellular granulations,
excepting that these latter are more  contracted, and are  aggregated in a
larger quantity at this  point.  (Figs. 56  and 57.)  At the same  time, a
Fio. 56.                             Fig. 57.
 Fig. 56. The blastoderm, with the embryonic epot seen in front.  V. The vitelline membrane,  e. The
external layer of the blastoderm. F. The embryonic spot.
 Fig. 57. The same figure in profile, to show the two layers of the blastoderm, v. The vitelline membrane.
E. The external;  and I, the internal or intestinal layer of the blastoderm.
minute examination is all that is necessary to convince us that the vesicle,
as also the  embryonic  spot, is composed of tAvo laminae, lying in contact
with each  other, but Avhich may be separated by a couple of fine needles.
To render this doubling  of the  blastoderm more evident, Ave  present two
theoretical figures, exhibiting it at the same stage of development.  In the
first (Fig. 5(5), which is a front vieAV of the ovum, the blastoderm with the
rounded  embryonic spot  is seen.   The same figure,  in profile (Fig.  57),
shoAvs  the tAvo blastodermic  lamina?,  both presenting a SAvelling near the
embryonic spot.  One has been called the  external, serous, or animal layer,
and the  other is  denominated the  internal, mucous, or the vegetative one.
Shortly after this period, the embryonic spot enlarges by the further  addi-
tion of granules, but more in  one of its diameters than  in the others, so as
to exchange its rounded for an elongated form.
   A considerable projection above the external face of the blastoderm may
be simultaneously noticed, Avhich exhibits a convexity tOAvards the vitelline
membrane and a concavity looking to the central part of the  ovum (Fig.
58); and thenceforth the cavity of the blastodermic vesicle is divided into
tAvo  distinct portions, the  one  embryonic, -the other, Avhich is  the larger,
forming the umbilical vesicle.
   A line of greater obscurity may soon be recognized at the centre of this
spot, being  the  first trace of the embryo.   The  margins of this  spot  fold
inwards,  as do  also the  extremities, thereby giving rise to an elongated
body curved like  a boat  Avith  the ends swollen, in  consequence of their
doubling up, and a cavity of some depth  at its  centre.  The body of the
embryo is then readily distinguished.
  The extremity that is most swollen  is called the cephalic, and the other,
or less voluminous one, the caudal extremity; about that time the serous 
184
PREGNANCY.
Fig. 58.
 A section of a more devel-
oped ovum, in which the two
portions, the embryonic and
the umbilical vesicle, begin to
appear, o. The umbilical ves-
icle,  i. The internal layer of
the blastoderm,  e.  The exter-
nal layer,  v. The vitelline
membrane.
Fig. 59.
laminse of the blastoderm can be traced as continuous Avith  the most  ex-
ternal layers of the embryonic  body, whilst the  mucous one forms its
                      internal plane.   In proportion as the embryonic spot
                      loses its distinctive characters, numerous little eleva-
                      tions, irregularly scattered over the  external surface
                      of the  ovum, are seen to develop themselves, being,
                      in fact, the commencement of those villosities Avhich
                      subsequently stud the exterior surface of the chorion.
                        During  the progress of these  phenomena, the ex-
                      ternal, or serous layer of the blastoderm (Fig. 59)
                      forms a fold  around the part Avhich  has been trans-
                      formed into the embryo, and curved as already stated ;
                      the fold of the  serous layer being  especially so at
                      the caudal and cephalic extremities.   The fold grad-
                      ually enlarges above, beloAV, and on the sides, in such
                      a manner as  to form a true hood over the head and
                      caudal termination; hence named from this  resem-
                      blance the cephalic and caudal hoods.   These folds
                      elongate rapidly (Fig. 60), passing along the dorsal ■
                      regions of the embryo, and ultimately coming into
contact on the  median  line,  unite  so as to form a pouch  surrounding  the
embryo, and continuous with it along the Avhole circumference of  its large
                          ventral  opening.   Although at first almost in
                          direct contact Avith the embryo, it is soon after
                          separated  from  it by  a certain  quantity of
                          liquid, becoming its  immediate envelope, and
                          receiving the name  of the amnion, and the in-
                          terposed fluid, that of the amniotic liquor.
                             As  to the external layer of the fold, it is
                           manifestly  continuous with the serous lamina
                          of the blastoderm, and although primarily ap-
                          plied  to the preceding, it is speedily separated
                           therefrom by the interposition of a liquid Avhich
                          removes  them  farther  and  farther from each
                           other, until at last its exterior  face  is brought
                           into contact with the vitelline vesicle.  Accord
                          ing to some authors, these tAvo  become  con-
                          founded, and by uniting form  the outer  mem-
                          brane of the ovum; but others  teach  that the
                          vitelline vesicle will be  gradually absorbed (as
we have endeavored to represent  in the plates Figs. 61, 62, and 63), while
the external lamina of the blastoderm is being developed, and the  latter
alone will then  constitute the enveloping membrane.
   At the  point of junction, the  cephalic  and caudal hoods constitute, by
their union, a kind of membranous bridge, which there joins the amnios to
the chorion.   This bridge is  gradually absorbed,  and the  tAvo membranes
become completely isolated.   (See Figs. 61 and  62.)
   Such is the vieAV most generally received on the mode  of formation of
 A section showing the origin and
first traces of the amnios,  o. The
nnbilical vesicle^ I. The intestinal;
ain I E, the external layer of the blas-
toderm, v. The vitelline membrane.
c c. Origin of the cephalic and cau-
dal amniotic hoods. 
DEVELOPMENT OF  THE  HUMAN OVUM.
185
Fig. 60.
the amnios.  "We must mention, however, one  other, Avhich, Avithout  being
neAV, has latterly acquired considerable importance by the discussions which
it has created at the Academy of Science-.
  We have just seen that the amnios is directly
continuous at the umbilicus Avith the abdom-
inal Avails of the embryo, Avhich is in fact so
manifest, that  no just ground of  belief  is
afforded that the latter Avas ever independent
of the amnios, as some have recently supposed.
Messrs. Oken, Pockels, Serres, and  Broschet
have  endeavored,  notAvithstanding,  to prove
that the amnios once existed as an independent
vesicle, distended by a fluid; and that after-
Avards the foetus, by coming into contact Avith
it, caused  its  depression,  and became  envel-
oped by it, like a double night-cap, but having
no other relation Avith it  than that of simple
apposition ; or,  in other Avords, that the amnios
had the same connection with the embryo as
the serous membranes with the viscera they
cover.
  Messrs. Coste, Velpeau, and  Bischoff have  combated this vieAV success-
fully, in my estimation, by contending for  the existence, at all periods, of
the continuity Ave have just described, and
they cannot possibly admit an opinion Avhich
is founded solely on pathological alterations.
For my  own   part, after  examining the
preparations of M. Coste, I  can have no
doubt  as to  the little value of such asser-
tions.
  Immediately  after the amnios is formed,
the margins of the embryonic  spot,  and
especially  its true extremities, become more
and more turned  imvards, thereby aug-
menting the concavity Avhich it previously
exhibited ; and at the bottom of the groove
thus constituted, the mucous lamina of the
blastoderm is observed to concur in forming
the intestinal canal, Avhich is represented at
this early period by  an  elongated  gutter,
communicating  freely Avith  the  interior
cavity of the  blastoderm.  But, in propor-
tion as  this constantly  increasing inversion
of the lateral Avails, and of the extremities
of the  embrvo, progresses,  this communication  becomes  more and  more
contracted, so that in a short time the  intestinal  cavity only connects with
the blastodermic vesicle  by a contracted  pedicle;   and thenceforth, this
latter receives  the name of the umbilical vesicle,  and the vessels Avhich arc
  The amniotic hoods more developed.
o. The umbilical vesicle.  I. The internal
or intestinal;  and E, the external layer of
the blastoderm, e'. A portion of the ex-
ternal layer converted into the amnios.
e". The embryo, c. The limit of the am-
niotic hoods,  v. The vitelline membrane.
Fig. ,61.

  This figure shows the amnios almost com-
pleted, and likewise the origin of the allan-
tcis. o. The umbilical vesicle.  I. The in-
testines,  e. The amnios,  e'. The externa
layer of the blastoderm, or the non-vascular
chorion,  v. The vitelline membrane.  C. Tli8
amniotic hoods ready to close up. A. The
allantois. 
186
PREGNANCZ.
distributed to its vascular layer, consisting of two veins  that  enter, and aa
artery that emerges from the embryo, are called the omphalo-mesenteric ves-
sels.  (Fig. 61.)
  As the contraction of the ventral opening  in the embryo, and the circum-
scription  of  the  umbilical vesicle go on, we may  observe at  the  inferior
part of the intestinal canal, just in the region where the bladder  and rectum,
during the earlier days of embryonic life, are confounded  under the  name
of cloaca;  we observe, I repeat, the intestinal parietes to  form there a  slight
                                   elevation.   Noav, this little  tumor (Fig.
               FlG-62-               61) gradually elongates,  so as  to con-
                                   stitute a minute vesicle, which commu-
                                   nicates by its narrow  pedicle with the
                                   intestinal cavity; this is  the allantoic,
                                   which has been known for a long time
                                   to exist  in  mammalia, but which  M.
                                   Coste was one of the first to  detect in
                                   the  human  ovum.  The  allantois  is
                                   scarcely  formed before it  is provided
                                   both with venous and  arterial vessels,
                                   consisting of the  two umbilical arteries,
                                   and  one umbilical vein;  the  former
                                   arising from the primitive iliacs, the
                                   latter going  to the liver, as may be seen
                                   someAvhat later.
                                     This little vesicle passes through the
                                   umbilicus at first alongside  of the pedi-
                                   cle belonging to the umbilical vesicle,
                                   and  soon undergoes a rapid  develop-
                                   ment.  The groAvth of  the allantois and
                                   its vessels is so rapid that it soon comes
                                   into contact with the external membrane
                                   of the ovum.    In  some  animals, the
                                   allantois  comes  into juxtaposition by
its base with only one point of the chorion, and becomes  attached there;
and then the terminal  extremities of the  umbilical vessels not only  reach
this membrane, but even extend for  the most part to the  villosities devel-
Dped on its external surface, and acquire there a considerable growth.
  In others (see Figs. 62 and 63),  the allantois spreads out like an umbrella
around the embryo and umbilical vesicle, and  supplies  itself to the  whole
external face of the amnios, as well as  to the internal one of  the chorion, then
the two laminae are fused into'each other in such a way as  to loave no trace
of the allantois.   (Figs. 62 and 63.)
  The development  of  the allantois completes the  essential  part of the
ovum, although by reference to Fig.  55,  Plate IV.,  it will  now  be  found to
consist:  1, of the embryo; 2, of a variable  quantity of liquid  in which it
swims; 3, of the amnios, already considerably distended, and forming a
Bheath to the parts that pass through  the ventral aperture;  4, of the umbil-
ical reside situated betAveen the amnios and chorion, Avhose delicate pedicle
  This figure shows the rapid progress of the
allantois, and how it spreads over the foetus, the
umbilical vesicle, and the amnios. This latter
begins to ensheathe the pedicle of the umbilical
vesicle and that of the allantois in such a way
as to form a commencement of the cord.  The
vitelline membrane disappears more and more.
0. The umbilical vesicle,  e'. The amnios,  e".
The external layer of the blastoderm,  c. The
point where the two hoods come into contact.
v. The vitelline membrane almost entirely atro-
phied, a. The allantois. 
DEVELOPMENT  OF  THE HUMAN  OVUM.           185
with  the omphalo-mesenteric  vessels
appertaining to it, hoAvever, still com-
municate Avith the intestinal cavity;
5, the pedicle of the allantois  vesicle
still charged Avith the umbilical ves-
sels ;  6, the space betAveen the amnios
and  chorion, partly occupied  by the
umbilical  vesicle,  but   principally
filled with a liquid called by M. Vel-
peau  the reticulated or the vitriform
body, according  to the degree  of its
consistence;  and 7, of the  outer  en-
velope, or the chorion.
  The phenomena yet to be studied
have special reference to the enlarge-
ment of the  ovum, and the  develop-
ment of the  embryo.
                            ARTICLE III.
                       OF THE  FCETAL  APPENDAGES.
   These  comprise  the allantois, the umbilical  vesicle, the amnion, and  the
 chorion.
   § 1.  Of  the  Allantoid  Vesicle.
   By the time  the amnion  has become a completely closed  sac, a little
 pyriform vesicle,  Avhich Ave have denominated the allantois, is  observed,
 about the tenth  day, to spring from the inferior part of the intestinal canal,
 and taking on a rapid growth soon becomes applied by its base to the in-
 ternal surface of the chorion.   The terminal branches of  the two  umbilical
 arteries and vein,  as previously stated, ramify  on the Avails of this vesicle;
 and hence the urachus, Avhich is nothing else than the  pedicle of  the allan-
 tois, is  accompanied in its  course by three blood-vessels  (see Fig. 3, Plate
 IV.), tAvo of Avhich (ii) are arterial, coming from the iliacs, and called  the
 umbilical arteries.   They run  to the chorion, Avhere  they  ramify,  and ulti-
 mately  reach the villi  that  form the foetal  placenta.   The third  trunk is
 venous, and is known as the umbilical vein.
  The umbilical vein j leaves the right auricle  of the heart at the point /,
 and soon after receives the  contents of the vena  cava inferior &; it then
 traverses  the under surface of the liver m, to Avhich it sends a copious vas-
 cular supply, and, before passing this organ, receives the omphalo-mesenteric
 vein  at the point  o;  then, after leaving the  liver, it gains the left side
of the abdomen betAveen the Avails of this cavity and the intestinal fold E;
Fig. C3.
  In this figure, the allantois has spread over tl?
whole internal surface of the ovum, and but ver/
slight traces are left of the continuity between tl.e
amnios and that part of the external layer of the
blastoderm which formed the non-vascular chorion ;
the amnios incloses the umbilical cord more and
more.  o. The umbilical vesicle,  e'. The  amnios
C. The point where the  two hoods are  fused into
each other, and form but a single membrane, t".
The  external layer of the  blastoderm.   a. The
allantois.  v. The vitelline membrane. 
188
PREGNANCY.
next, by turning abruptly towards the umbilical cord, it  gets to the left
side of the urachus, and  accompanies the  latter to the chorion, where it
folloAvs the umbilical arteries into the villosities.
  After the earliest periods of development are over, there  is but a  single
umbilical vein left, although during the first part of the embryonic exist-
ence tAvo are met with, one upon each side of the urachus (and consequently
one for each umbilical artery).  That on the  right side becomes efface 1,
but its traces may still be found at the thirtieth or even the fortieth  day;
indeed, some such existed and were perceptible  on the embryo I am noAv
describing.
  When the umbilical vein has actually passed  the  liver, it  gives off no
branches whatever, in its course along the urachus, nor does it  divide and
subdivide until it reaches the chorion.  But, in the earlier periods of ges-
tation, Avhen the two exist, they are observed to spread over  the Avails of
the chest and abdomen in the form of a large vascular plexus, extending
as far as the vertebral column;  hoAvever, this new apparatus soon vanishes
and leaves no vestige of its former existence.
  The body of the allantoid vesicle disappears very rapidly, and scarcely
a trace of it can possibly be found  after the  lapse of a few days from its
first  appearance.  In fact, nothing more is seen than a cord  of variable
length, extending from the embryo to the chorion, and having the umbilical
vessels inclosed  Avithin it.   This likeAvise becomes gradually atrophied in
such a Avay as to disappear altogether  in  the substance of the umbilical
cord; nevertheless, a portion of it still persists in the abdominal cavity of
the embryo, forming there the  cord  subsequently known as the urachus;
and  just as this  latter terminates in the rectum, it exhibits a small swelling
Avhich is  afterAvards converted into the urinary bladder.  We may remark,
in anticipation, that  this  rudimentary bladder communicates with the
rectum, and constitutes there  that  transitory cloaca,  Avhose existence in
the human species may be positively verified  by direct observation.  It is
this early disappearance of the allantois Avhich has induced  some ovologists
to doubt  its existence  in  the  human race.  It is  exclusively destined to
bring the embryonic vessels into  contact with the  external membrane of
the ovum, Avhence they are soon placed in their  proper relation with the
internal surface  of the womb.

  § 2.  Of the  Umbilical Vesicle.
  This vesicle is formed exclusively by the internal or mucous layer of the
blastoderm ; at  first,  it is very voluminous,  occupying nearly the  Avhole
cavity of the ovum, and communicating so freely Avith the intestinal cavity
as to form Avith  it apparently but a single vesicle.  But the gradual con-
traction of the ventral opening serves to separate the tAvo, as Ave have already
demonstrated, leaving only a pedicle of variable thickness, according to the
size of this aperture.
  The umbilical vesicle contains a yelloAvish-Avhite  liquid often of a  vitel-
line  yelloAvness,  in which  numerous  granules and  fat globules  are seen
floating.   It seems to be formed of tAvo laminae, betAveen Avhich the vessels
are distributed (see Robin, Journal de Physiologie, 1861).  As  the amnion 
DEVELOPMENT  OF  THE HUMAN OVUM.
189
becomes  developed, the vesicle is croAvded by this membrane, and  is then
found placed between the external face of the latter  and the internal sur-
face of the chorion.
  In consequence of the development of the allantois, the umbilical vesicle
loses much of its importance in  the human species, as it so soon becomes
an organ of little value either to the groAvth of the  ovum or the embryo:
and furthermore, it  dAvindles away speedily ; thus,  during  the first  three
Aveeks, it is as large  as an ordinary pea, but  after the fourth, it begins  to
collapse and diminish in size, and  at  six weeks subsequent  to  the  concep-
tion, it does not exceed a coriander-seed  in bulk ; then it remains stationary
for  a time, not disappearing altogether until tOAvards the fourth month.  I
have observed it several times of later  years on ova of three to three and
a half months, in Avhich it generally still  retained the volume and shape
of a small lentil, being of a yelloAvish color, and having its surface wrinkled.
HoAvever, I may remark, that its size appeared very variable in several ova
of the same age.
  In proportion  as the umbilical vesicle becomes atrophied, it is removed
farther and farther  from the trunk of the embryo, in consequence of the
development of the  amnion, and its pedicle is also  elongated in a  marked
manner; thus, the latter is from two to  six lines in length, being continuous
at one end Avith  the  intestine, and at the other Avith the vesicle by a kind
of an infundibuliform expansion.   The pedicle is apparently separated into
two portions by  the amnios, before the abdominal Avails  are  completely
closed up; one  part lying  betAveen the spine, or rather the intestine, and
the spot afterwards  occupied by  the umbilicus, Avhile the other  remains
exterior to the abdomen.  This pedicle  is traversed by a small canal for the
first five  or six weeks of its existence, and through  it the fluid in the vesicle
may be pressed back into the intestine, but it is obliterated after that period.
About the same time, also, it becomes  more and  more delicate, and offer
ruptures from its great elongation ; and  its umbilical  portion being lost in
the cord, can no longer be traced  into the abdomen.  When  broken, the
vesicle may be found more or less removed from the root of the cord, and
lying betAveen the chorion and amnion.
  The umbilical vesicle has  a rich vascular  apparatus, the  blood of Avhich
is carried to and from the embryo by the intervention of tAvo  trunks, one
venous, the other arterial; both, hoAvever, accompany the pedicle, and form
a constituent part of it.  The first, n (see Fig. 3, PI. IV.), called the omphalo-
mesenteric vein, enters the abdomen, Avinds around the duodenum, and then
opens into the umbilical vein at the point o, just  as the latter is emerging
from the liver.   As  it passes the  duodenum, branches are given off to the
stomach  and intestines, and Avhen it discharges into the umbilical vein, it
sends a voluminous  trunk to the liver.   That  portion which furnishes the
branches just described, persists in the adult under the name of the ventral
or hepatic-portal vein, Avhilst  all the rest will disappear Avith the umbilical
vesicle and its pedicle.
  The arterial trunk p, accompanying the pedicle, has been designated as
the omphalo-mesenteric artery.  Arising  from the aorta, it gains  the summit
ot the intestinal-convolution, and gives off branches to the mesentery and 
190
PREGNANCY.
to the intestine itself;  then it reaches the pedicle, and folloAvs the latter to
the umbilical vesicle,  upon Avhich  it ultimately ramifies.  The part that
supplies the  mesentery is converted in  the adult into a mesenteric artery.
all the rest being  effaced.  From all which, it appears  that  the vascular
system of the umbilical vesicle represents the primitive  circulation in the
embryo, corresponding in it to the sanguiferous apparatus of the  yolk of
foAvls.  Of course, these vessels  will become atrophied  Avith  the organ to
which  they belong.
  The umbilical vesicle seems to be intended to serve as a reservoir for the
fluid designed to nourish the foetus during the first weeks of intra-uterine
existence.
  § 3.  Of  the Amnion.

  The most  internal membrane of the ovum,  or the amnion, is formed  by
the inner lamina of the fold,,  or the cephalic and caudal hoods Avhich con-
stituted the external  serous layer of the blastoderm surrounding the embryo.
Being continuous,  as Ave have shown, with the margins of the  ventral open-
ing, it seems  at first to be attached  by its middle part to the skin on the
dorsal region.
  The internal amniotic surface subsequently exhales a liquid into its cavity,
in Avhich the embryo SAvims freely;  hence the amnios constitutes a little sac
around the foetus,  having smooth and transparent Avails.  Its inner surface
is bathed by  the liquid inclosed  in the cavity, whilst  its external one is
separated from the  chorion  by a space of  variable  size,  Avhich  is  likeAvise
filled Avith a  fluid  and  the expansion of the allantoid vesicle.
  Originally, this  membrane was not concentric Avith the chorion; but in
proportion as the development advances it presses back the exterior  liquid
and the allantoid vesicle more and more, thereby condensing it, and finally
comes in  contact  Avith  the external envelope of the ovum. ■  Noav, since it
adheres to the periphery of the umbilical opening, it must furnish, by such
an extension, a sort of membranous sheath to the pedicles of  the allantoid
and the  umbilical vesicles, as Avell  as  to their accompanying vessels, sur-
rounding them throughout their course from the umbilicus to the chorion;
and all the parts thus  inclosed constitute Avhat is called the umbilical cord;
Avhence it folloAvs that the abdominal  cavity itself must be in connection
with  the  canal represented by this  cord, and  consequently that the foetal
appendages may communicate Avith it  through the  route thus opened to
them.  It  is  thus that the pedicle of the umbilical vesicle becomes united
to the ileo-coecal  fold of intestine, Avhilst  the  allantois  connects Avith  the
rectum by the intervention of the urachus.
   As Ave have just stated, the amnios is separated from  the chorion during
the earlier Aveeks by a filled  space, Avhich space is  larger in  proportion as
the wum is the more recent.   This extra-amniotic liquid  forms a gelatinous
or albuminous mass, of a Aveblike arrangement, and having  the umbilical
vesicle in its  midst.  The mass becomes  more and more compact by pressure
of the amnion, which has a constant tendency to approach the chorion, thus
acquiring  the aspect of a membrane  (the membrana media of Bischoff),
which is  situated betAveen the  chorion and the amnion, where, says this 
DEVELOPMENT  OF THE  HUMAN OVUM.           191
 author, it may be readily distinguished tOAvards the end of pregnancy, as a
 gelatinous, though continuous  membrane.  M. Velpeau gave it the name
 of the vitriform or reticulated body, but Robin has shoAvn its structure to be
 identical with that of the allantoid vesicle.  Velpeau was, therefore, correct
 in regarding  the reticulated body as the analogue of the allantoid, of Avhich
 it is really but the remains.
   The amnion undergoes no important change during the ulterior deA^elop-
 ment of the  ovum, nor does its texture.  Of course,  it Avould be more firm
 and consistent, acquiring by  time a greater resemblance to the serous mem-
 branes, although it  neither  incloses nor possesses  vessels at  any  period.
 Nevertheless, says Duges, it probably has some openings, AArhich  permit the
 Avaters, exhaled by the uterine capillaries, and received by the A-essels of the
 decidua and the villi of  the chorion, to be diffused around the  foetus; but
 this perspiration of the liquids secreted by the internal uterine surface, may
 very possibly be a simple phenomenon of endosmosis.

   § 4.  Waters  of the Amnion.
   The amniotic cavity is filled Avith a liquid,  in Avhich  the foetus is im-
 mersed.  At the commencement of pregnancy, this fluid is of slight density,
 and more or less transparent and limpid, but tOAvards term it becomes viscid,
 unctuous, and more consistent than pure Avater: sometimes it is as clear as
 serum ; at others, it is of a light yelloAv or greenish color.  It frequently be-
 comes lactescent, turbid, and interspersed with yelloAvish-gray, or even black
 albuminous flakes ; again, in certain cases, it is strongly tinged with yelloAv,
 when the membranes  are ruptured, from the admixture of a quantity of
 meconium ;. it exhales a  disagreeable odor, analogous  to that of the sper-
 matic  fluid, and its taste  is slightly saline.
   The  quantity of the amniotic fluid  varies  greatly; thus, in  the early
 months it is, relatively to the foetus, more abundant,  in proportion  as the
 embryo is younger.   Riolan found four ounces in an ovum containing a
 foetus of the size of an ant.   The Aveight of the foetus and that of the fluid
 at the middle of gestation, are very nearly equal.  Again, dating from  this
 period, the difference is generally in favor of the foetus, and the Aveight of
 the latter at term is four or five times greater than the Avaters, which seldom
 exceed a pound or a pound and a quarter; consequently, if the assertion is
 true, that  the Avaters  augment in their absolute quantity until  term, it  is
 equally so to say they increase relatively to  the foetus in  the first,  and
 diminish  in the second half  of pregnancy.  In fact,  the variations in  this
 respect are infinite, even at the time of  the accouchement.
  According  to the analysis of Vauquelin, 100 parts of amniotic  liquor
 consist: of Avater 98-8 ; of albumen, hvdrochlorate of soda, phosphate  of
 lime, and  lime,  12.   The interesting question iioav arises:  What  is  the
 source  of the amniotic fluid ?  Some assert that it comes from the mother ;
 others, that it is  produced by the foetus.  Chaussier, Meckel, and Beclard,
 adopting  an intermediate opinion, suppose  that its secretion takes  place
 simultaneously from the female and her product.
  Everything proves, says M. Velpeau,  that the  liquor amnii is  the  result
of a  transudation or of a  simple exhalation, like the serum of the pleura, 
 192                         PREGNANCY.

 pericardium, etc., and that this process requires no particular canals for ita
 accomplishment, being a phenomenon of pure vital imbibition.
  According to Burdach, the amniotic waters cannot be  secreted by the
 foetus, because they exist prior to its formation,1 and therefore they must be
 exclusively furnished by the internal uterine surface, and reach the cavity
 of the amnios by traversing its walls.  We also believe, that  the. greater
 part of this liquid comes from the mother's organs; yet we must add that
 it also contains  certain products, secreted by the  foetus: for instance, it  is
 frequently colored by some meconium, and besides, it is almost  certain that
 the urine  may be discharged  into the amniotic cavity  during the latter
 months of pregnancy.  A feAV incontestable facts prove that  such an evacua-
 tion is necessary to the maintenance of foetal life: thus, Billard and T. W.
 King record having seen  cases of ruptured bladder, resulting from imper-
 foration  of the  urethra;  and further, Desormeaux and P. Dubois have
 obsen^ed an obliteration of this canal in t\vo stillborn children, Avhich had
 given rise to an  enormous distention of the bladder, ureters, and both kid-
 neys ;  indeed, the latter Avere found transformed into two multilocular cyst?.
 Similar facts have been presented before the Academy of  Medicine by MM
 Depaul and Moreau.
  According to  some authors, the principal use of  these waters  is to contri-
 bute to the nutrition of the foetus,  during at least a great part of gestation.
 (See Nutrition of the Foetus.)   Howe\Ter this, may be, the  waters of the am-
 nios serve during pregnancy to maintain the insulation of  the external foetal
 parts  before the  skin becomes covered with the sebaceous coat  hereafter to
 be described ; to promote the active movements of the foetus  and its develop-
 ment,  both of Avhich would  have been greatly  incommoded Avithout this
 intervention, by the pressure of the uterine Avails; to protect the foetus from
all external violence, and  to afford it the means  of conforming to the laws
of gravity.   They likeAvise  favor  a uniform expansion  of the Avomb, and
 remove all pressure from the umbilical cord, thus assuring  the integrity of
the foeto-placental circulation  both  during pregnancy and labor.  In the
latter, they seem destined to guard  the child from the violence of the uterine
contractions, which, without them, Avould certainly compromise its existence;
to aid in forming the amniotic bag,  the engagement of Avhich renders the
dilatation of the neck more uniform and easy ; to lubricate the pelvic canal,
and thus facilitate the descent of the foetus ; and lastly, they render manipu-
lations of every  kind less  difficult  than they otherwise Avould be.

  § 5. Of  the Chorion.
  The chorion is the most external envelope of the ovum.  Writers are by
no means unanimous in their vieAvs  as to  the elements of which it  is com-
posed.  Thus, some of them, as Ave have had occasion to state, suppose that
it is formed by the vitelline membrane, the external lamina of the  blasto-
derm, and the allantoid vesicle, uniting to constitute a single layer. Accord-
ing to others, on the contrary, the vitelline membrane will  disappear soon

  1 It  is only necessary to recall our remarks  on the development of the amnios  to
refute  this opinion. 
DEVELOPMENT  OF  THE HUMAN OVUM.           193
after the doubling of the blastodermic vesicle, and the external  lamina of
the latter, conjoined with the allantois, will then form the chorion.
  [M.  Robin's view  of the subject  is as follows:  According to M. Coste, three
kinds of chorion appear successively, one of which, however, disappears in conse
quence of the  development of its successor which is substituted for it.  The first
 horion, which  lasts for  a few days only, is formed by the vegetations which
cover the vitelline membrane  at the  time of the entrance of  the ovule into
the uterus.   No  vessels  have yet   appeared, but they carry nutritive  matter
from the  uterus to the  vitellus  by endosmotic  action.  The second chorion is
formed  by the  external  layer of the  blastoderm, which  is composed of cells
resulting  from the segmentation  of the  A'itellus.  This  layer, by gradual pres-
sure against the vitelline membrane, at first lines it, and  then causing its ab-
sorption  becomes itself the external envelope of the ovum or  the second cho-
rion.   The third chorion is formed by the allantoid, which is  applied to the inter-
nal surface of the preceding chorion,  and causing its atrophy by pressure, becomes
the external membrane of the ovum which remains until the end of gestation. This
membrane is at first covered entirely by vascular villi which, at a later  period,
remain only at the place where the placenta is developed.
  We thus find that these three parts are developed in the order mentioned;  but
the second chorion is not absorbed; it remains, on the contrary, until the foetal evo-
lution  is completed, lined on its  internal surface  by the allantoid. the vascular
loops of which enter the villi of the second chorion.
  Consequently the allantoid never becomes a  chorion, meaning thereby the exter-
nal layer of the ovum, nor is there any other  chorion  properly so called than the
second one formed by the external layer of the blastoderm ;  inasmuch as the vitel-
line membrane does not deserve the name, although after  the example of Baer and
Coste,  it has been  applied to it by some authors.  The vitelline membrane exists,
indeed, only before the formation of the embryo, and disappears as soon as  the lat-
ter and its amniotic membrane become perceptible, leaving exposed the imperforate
layer of the blastoderm,  Avhich takes the name of chorion.   (Robin.  Journal de
 rhysiologie, 1861.]

   But be that as it may, the chorion certainly does  not exhibit the same
aspect at the advanced stages  of pregnancy:  for during early embryonic
existence the external membrane of the  ovum is thin, transparent, and per-
fectly smooth on its outer surface, whilst about the second Aveek this surface
presents  some  minute granular elevations, Avhich increase in  length very
rapidly, and the chorion soon becomes studded Avith numerous villi.  But at
that time neither the chorion nor the villi haA-e a proper vascular apparatus,
since it is not until after the allantois, together Avith the umbilical vessels,
has become applied to the chorion, that vessels can be detected going from
this membrane to penetrate the villi.
   The chorion  is enveloped in a great measure by the refiexed  or epichorial
decidua, which separates it from the parietal decidua;  and is in contact,by
a restricted surface, with a portion of the mucous  membrane which con-
stitutes the utero-epichorial or  inter-utero-placental  decidua.   There is at
theoutset a considerable space between its external surface and the internal
one of the pouch containing it, Avhich space is occupied by its villi, and may
become, as Ave shall see, the seat of a considerable effusion of blood.
   Those  villi which are in contact Avith  the reflected decidua,  penetrate at
first, as they increase in size, into the substance  of that membrane; they
        13 
191
PREGNANCY.
Boon, hoAvever, become atrophied, and dwindle aAvay almost completely, the
interval disappears, and  the  tAvo membranes come  into immediate contact.
  As regards the villi of the chorion, not covered by the reflected decidua,
so far from being atrophied, they speedily undergo  a considerable develop-
rrent, Avhen they are  in  contact with  the thickened and  softened uterine
mucous membrane (utero-placental decidua),  and, intercrossing  with  the
numerous vessels developed in its substance, contribute to the formation of
that essentially vascular  mass Ave are about  to describe under the name of
placenta.
  The chorion  is in apposition by its internal face with the amnios  at an
advanced period of pregnancy ; but, as previously noticed, these tAvo mem-
branes are not concentric in the earlier months, being then separated by  a
considerable space that is occupied by the umbilical vesicle and an albumi-
nous liquid, which is  the more abundant and limpid as the gestation  is  less
advanced.
  After the development of the placenta, the chorion is a thin, transparent,
colorless membrane, united outAvardly to the decidua by some short, delicate
filaments, the  remnants of the atrophied villi, and  imvardly to the amnios
by an albuminous layer  (tunica media, reticulated body).   The part corre-
sponding to the placenta is no longer in immediate contact with the decidua;
it is thicker, and adherent to the foetal surface  of  that vascular body, and
the attachment is more intimate near the root of the cord.   After what has
already been stated, it were  idle to discuss the vascularity of the chorion,
for it evidently has no vessels until after the allantois has been developed;
but from that period  it consists of two laminae, the external or primitive of
which, also called the exochorion, is wholly destitute of vessels,  whilst the
internal  or allantoid  is essentially vascular, and has been  denominated the
endochorion.

                          ARTICLE IV.
                   OF THE ORGANS OF CONNECTION.

   § 1. The Placenta.  (After-birth, Secundines.)
   The placenta is a soft, spongy mass, constituting  the principal connection
betAVeen the ovum and uterus, being destined to the hematosis, and perhaps
also to the nourishment  of the foetus.
   It is a flattened body, about three-quarters of an inch in thickness at the
centre; but tapering off towards the circumference, Avhich does not often
exceed tAvo or three  lines; in some cases it is very thin, but then it is very
large, and further, its figure and dimensions are exceedingly variable ; thus,
the ordinary diameter of the placenta varies from six to eight and  a half
inches, at times one diameter is longer than the others, and the shape, there-
fore, is circular, oval, &c, according  to  circumstances.  The term  battle-
door-placenta has been applied to that variety in which the cord is inserted
on the border.  As a general rule', only  one placenta exists in simple preg-
nancies.  However, a very curious exception Avas observed quite recently at
the Clinique of the Berlin Hospital, namely, a double placenta for a single
child.  Dr. Ebert furnishes  the following description of this  anomaly 
               DEVELOPMENT OF THE  HUMAN  OVUM.           195

When displayed on a  table, it Avas found to be  divided  into  tAvo exactly
equal rounded parts,  which were  entirely distinct, having  no connection
whatever Avith  each other, excepting through the intervention of the cord
and membranes;  an interval of about three inches separated  the tAvo por-
tions.  The cord Avas tAventy-one inches long, containing, as in the normal
state, the three vessels  spirally arranged, but this spiral form ceased nearly
tAvo inches  from the bifurcation of the umbilical  vein, at this point the tAvo
arteries were placed, one on each side of the vein, and only communicated
by a trifling anastomosis.
  The vein bifurcated  about four inches from the placenta; the tAvo result-
ing branches Avere of unequal length, and the longest sent a branch to the
opposite placenta.   The arteries had a similar arrangement, one being sent
to each after-birth.  The  one corresponding Avith the longest vein likewise
sent a branch  to the other placenta, but  the interior subdivisions of the
vessels offered no further anomaly.
  The membranes formed a single cavity for the foetus and amniotic Avaters;
they invested the two portions of the cord, the foetal face of both placentas,
and  passed from  one  organ to the
other, thus establishing a kind of                 fio. 64.
membranous bridge  betAveen them,                  c
regularly formed placenta.                        cotyledons.
  A much more  singular case has been obligingly communicated to me by
Dr. Blot.  In this instance, the placental mass presented nearly the usual
appearance, but around it Avere distributed several entirely distinct cotyle-
dons, which  Avere connected  Avith  it  only by the vessels proceeding  from
them to join the ramifications of the cord.  (Fig. 04.)
  The after-birth presents a fcetal, or internal, and an external, or uterine
surface;  also a circumference, or border.  The internal surface is covered
both by the chorion and amnion, and exhibits numerous ramifications of the
umbilical arteries and  vein, which  generally converge  about the centre of
this body to  form the  umbilical cord.  The uterine surface is  much less
smooth, polished, and uniform than the preceding, and is slightly convex,
wh'xht the former is a little concave.   It is subdivided into a variable num- 
196
PREGNANCY.
ber of lobes, or irregularly rounded cotyledons, held  together by a laniel
lated, apparently albuminous tissue, which is so easily lacerated, that a rup-
ture may occur during the  separation  of the placenta, so that after its

             Fig. 65.                                       Fig. 66.
                  Fig. 65.  The internal, or foetal surface of the placenta.
                  Fig. C6.  The external, or uterine surface of the placenta.

 expulsion, the cotyledons appear to be separated  from  each other by deep
 furrows or fissures.   This surface  is covered by a thin layer  of adhesive
 matter through Avhich the reddish and sanguinolent appearance of the coty-
 ledons is perceptible.
   The placental circumference is thin and irregular, and its extent, although
 very variable, is generally about twenty-five inches.   The margin, accord-
 ing to M. Velpeau, is continuous, without a Avell-marked line of demarcation,
 with the double lamina formed by the folding of the  deciduous membrane.
 But in  the opinion of other anatomists, the periphery of this vascular mass
 is continuous Avith the chorion, and only contiguous  to  the  double fold of
 the decidua, which is there thicker and more dense, and presents  a kind of
 triangular sinus for the reception of the placental  border.
   Our future remarks upon the structure of the  placenta will serve to show
 that its circumference is continuous with both the chorion and the decidua;
 with the chorion by its fcetal portion, which, after all, is  formed by the
 hypertrophied villi of the chorion; and with the  decidua or parietal mucous
membrane by its maternal portion, Avhich is  but a thickened part of this
 same uterine mucous membrane.
   [Structure. — That we may not be misled whilst studying  the  structure of the
 placenta, I think it best to state briefly the manner in which it is formed.
  The history of its development  shows that it formed of the villi of  the chorion,
 the growth  and ramification of which give  rise to innumerable filaments which
 ingraft themselves  upon the intermediate mucous membrane to which they soon
 adhere  closely.   The  maternal vessels  undergoing an inverse development form
 vast  numbers of loops, which descend between the villi of the chorion and  extend
 to the  foetal surface  of the placenta.  An  amorphous matter  is  soon deposited
 between the villi of the chorion  uniting them together,  and the placenta thus
 formed  is at the same  time a maternal and foetal organ.
  The separation of the placenta after delivery takes place at the  most  superficial
 portion of the intermediate mucous membrane.  (See Inter-utero-placental Decidua.)
 
               DEVELOPMENT OF THE  HUMAN  OVUM.           197

 The foetal placenta comes entirely away, bringing with it the epithelial layer of the
 inter-utero-placental decidua and the placental distribution of the maternal vessels.
 The thickest part of the intermediate mucous membrane remains, on the contrary,
 attached to the uterus.  (See Decidua, and Lying-in state.)
   Such, in short, are the principal phenomena which occur during the development
 and seianiti'in of the placenta, and they will serve  to guide us amidst the different
 opinions which have been advanced respecting the structure of the organ.]

   The structure of the after-birth has been a theme of numerous discussions
 among embryologists; but  the researches of  MM.  Blandin, Jacquemier,
 Flourens, and Bonami, in our OAvn times, and even yet more recently those
 of Reid, Weber, Coste, Eschricht, and Robin, have throAvn much light on
 this subject.
   We have sought laboriously for the truth amongst these different opinions;
 and in believing that Ave  have found it in the facts established by M. Robin,
 we are no less convinced that the task has been  greatly facilitated by the
 researches of his predecessors.   In order to render justice to all, Ave consider
 it our duty to give an analysis of the principal  investigations Avhich haA'e
 been made  in reference to this interesting point of ovology.
   If, while the placenta is still adherent to the uterine wall, a careful effort
 be made to detach it, Ave can easilysee that this detachment takes place at
 the expense of a  particular tissue, which at once separates and holds the
 two surfaces in contact.  Noav, this utero-placental substance is of an albu-
 minous or membranous nature, and is composed, according to Robin, of the
 epithelium  o  the intermediate decidua.  This  membranous layer (that has
 also been accurately described by M.  Jacquemier) is moulded, as it  were,
 on the irregular surface of the placenta, to Avhich the adhesion is more per-
 fect than to the corresponding part of the Avomb; it dips into  the fissures
 that separate the cotyledons, unless these should happen to be very deep, in
 which case it merely passes from  one lobe to another, thereby forming a
 species of membranous bridge; but a partition of the  same  nature  much
 thicker  than the  preceding  penetrates deeply  betAveen  the  lobes.   The
 lamina clothing the external surface of the placenta is continuous with the
 decidua, Avithout exhibiting any other difference, says the same author, than
 a considerable augmentation of thickness; a disposition that  is apparently
 mechanical, being due  to the  relief made by the  projecting circumference
 of the after-birth, and which thus  determines around that organ a greater
 accumulation of plastic material.   According  to  that able anatomist, this
 membrane offers all the physical characters of  the decidua; and  he  seems
 quite disposed to consider them both as being one and the same.
  This inter-utero-placental tissue is traversed by a great number of venous
 and arterial vessels, Avhich pass from the internal  surface of  the uterus to
 the placenta  (utero-placental  vessels); but it  does not appear  to be the
 ultimate termination of a single blood-vessel.   No  trace of the  injection
 remained, in this  tissue,  in  the  preparations just  alluded to, made by M.
 Bonami.
  Let us proceed,  hoivever, to  the  vascular structure of the placenta, pro-
 perly so  called ; and, as  1 have Avitnessed the injections of M. Bonami, I
cannot do  better  than transcribe  here the following parts of his thesis: 
198
PREGNANCY.
"An injection, composed of spirit-varnish, colored Avith  red-had, Avas firsi
thrown into the venous system of the uterus through the primitive iliac and
one of the ovarian veins.  A second, consisting of spirits of turpentine and
indigo, was then made of the uterine arteries through the inferior extremity
of the aorta, ligatures being previously placed on all the vessels capable of
transmitting the injected fluids to the inferior extremities.
   " The uterine  cavity having  been  opened at some distance from the
placental insertion, and the  foetus  stripped of its membranes,  a blackish
liquid, Avhich Avas nothing but the blood, Avas next squeezed from the vessels
of the cord; then injections, having linseed-oil colored with white-lead and
yellow ochre as their base, were throAvn into the umbilical vein, and into
one of the arteries."
   These injections were made Avith the greatest possible precaution, and the
following results were aftenvards  obtained from a careful  dissection: " At
first, the red liquid injected into  the uterine veins could be distinctly per-
ceived on the foetal surface of the placenta.  But, by Avhat  canals could the
injection  have penetrated so far  as  this?  Here was  a new subject of
research;  but, by carefully  turning  the placenta  aside,  a  considerable
number of small vessels  could  easily  be recognized, leaving the  internal
surface of the womb, traversing the inter-utero-placental tissue just described,
and  plunging into the substance of the placenta.  These consisted of arteries
and veins, readily cognizable as such by the different colored injections."
   1st. Arteries.—The number of these is large, and they are more abundant
near  the centre of insertion than anyAvhere else; still, a few very delicate
ones are found about an inch from the placental circumference.  Generally,
they are quite  small, varying from  a fourth of a line to  a  line in diameter.
They assume very sensibly a spiral arrangement, and their course is oblique,
almost always creeping along for a third of an inch, sometimes more, before
their terminal  extremities  are directed towards  the anfractuosities of the
placenta; and they evidently penetrate the  proper substance of the latter,
though towards the  uterus they  are  clearly  continuous Avith the  uterine
arteries.  Lastly,  they have but few ramifications, and these rarely anasto-
mose Avith each other.
   2d.  The  veins pass from the  uterus,  through the  inter-utero-placental
membrane, towards the placenta, but they have not the same disposition as
the arteries.
   The calibre of these veins, says  M. Bonami, is nearly equal to that of the
arteries, sometimes even a  little  larger, some of  them being  from  two  to
three lines in diameter.   The characters by  Avhich we could  distinguish
these from the arteries, Avere conclusive in  the  piece  under  examination.
Thus, these veins Avere penetrated  by liquids  thrown into the uterine venous
system ;  they were rectilinear, and their exceedingly numerous ramifications
anastomosed freely with each other, thereby forming vast  plexuses  on the
cell-walls, which penetrated the uterine surface of the placenta at all points;
and, on the other hand, by further dissection, could be seen with the naked
eye terminating in the  large uterine veins.   Besides  these,  according  to
Meckel and Jacquemier, there exists a vein Avhich encircles the periphery
of the placenta; but this coronary, vein  is rarely complete, as it nearly 
              DEVELOPMENT OF THE  HUMAN  OVUM.            199

always exhibits  one or more interruptions of an  inch  or  tAvo in extent,
although its continuity is sustained by a series of veins  anastomosing Avith
one another, and its course exhibits numerous varicose-like dilatations.  It
communicates, at short  distances, with the uterine veins, and receives con-
tributions both internally and externally;  some of these spread  over the
uterine surface of the placenta, and anastomose Avith the veins that penetrate
this body at its centre;  the others, Avhich are less numerous, ramify in the
substance of the decidua, two or three inches from the  circumference of the
placenta.  M.  Robin says that it resembles a uterine sinus, and  is more
properly one of the latter excavated in the mucous membrane than a true
vein.   The presence of this coronary vein is not constant, for neither Vel-
peau  nor Bonami have ever met with it.
   There are, therefore, certain arteries and veins that penetrate the placenta,
belonging to the maternal vascular system ; but before  studying their dis-
tribution, let us  examine that of the umbilical vessels.   These, consisting
of the umbilical arteries and vein, having  arrived at the foetal surface of
the placenta, divide into several large branches that are found betAveen the
amnion and  chorion.  The first of these  membranes may be detached with
great  facility; but  the second intimately adheres  to  the vessels, Avhich it
completely envelops, thus forming a sheath  in Avhich one  artery and  one
vein are always found, the vein being much the larger;  sliortly after, each
trunk divides into two  branches, each of these into two others, and  thus
they  go on  subdividing  dichotomously almost  ad infinitum.   The  two
umbilical arteries communicate freely with  each other in the substance of
the same cotyledon, and this anastomosis may even be seen Avithout the aid
of an injection.  Again, if a coarse injection be thrown into  one of the
arteries, it will shortly  return by the other;  though, if the pressure be con-
tinued, it Avill  pass  from the arteries into the umbilical vein; but  if Ave
commence by filling the vein, the injection reaches the  arteries Avith more
difficulty.  If a very penetrating mixture be used, the Avhole uterine surface
of the placenta will be converted into a  very delicate  plexus, which never
affords  an outlet to the injected liquid;  patulous orifices do not exist, there-
fore, at the extremities of the vessels.
   When a placenta has been  thus injected, and  is then  macerated, it soon
appears to resolve itself into  a substance resembling Avoolly flakes covered
by numerous particles  of a soft pulpy tissue, that  is  detached from them
Avith  much  difficulty.  These flakes present under the microscope a large
number of granulations, composed of small, convoluted, tAvisted vessels, like
those  in the chorial villi of the coav or  the sheep.  These small  granules
have  been described as acini, or little grains.   The vessels  become  longer
as the maceration is continued, and finally lose flexuosity almost entirely.
   On the Avhole, therefore, the placenta  is formed by vessels  belonging to
tlie mother  as  well  as by those appertaining to the child, and each of its
cotyledons is constituted  in the folloAving manner:  the maternal, or utero-
placental vessels penetrate at all points of its uterine surface, forming in its
hubstance a net-Avork of exceedingly delicate  meshes,  Avhile  the umbilical
vessels that penetrate on the foetal surface  present those infinite ramifica-
tions  just described, and these twist around and embrace  the  contracted 
200
PREGNANCY.
meshes of the maternal plexus in all  directions.  Further, the connection
existing between these two orders of vessels appears to result from the mem-
branous sheath that  envelops them both, even into the substance of the
placenta.
  This sheath is furnished to one  set  by the chorion, to  the  other by the
extremely delicate prolongations of the  maternal vessels.   In other Avords,
being compressed and united with each other through the intervention of a
common substance, these divisions and subdivisions form a cotyledon of the
placenta.
  Again, all the minute  vascular ramuscles are so intimately connected
that it is impossible  to separate the vessels  belonging  to the  mother from
those peculiar to the foetus, and they  can only  be distinguished from each
other by the different colored injections.   But, although the two series thus
interlace,  the maternal branches  never communicate by their  terminal
extremities Avith those of the foetus ; since the finest injections, Avhen  most
carefully made,  have  never established a direct communication  between
these two orders of vessels, — unless by rupture  of the walls.
  The description of  Eschricht is  very  analogous to that of M. Bonami;
thus, the former concludes that tAvo orders of capillary plexuses are in con-
tact in the human placenta, and that the uterine arteries are continuous
with the veins of the same  name through a  capillary plexus, equally deli-
cate with the one existing between the umbilical arteries and veins.
  But the researches  of Weber have  led to different conclusions as to the
mode in which the uterine arteries run into the  veins of a similar  name in
the placenta, and these curious  results  deserve some notice,  inasmuch as
they seem to form a natural transition to the arrangement which we  shall
describe hereafter.
  He states that the uterine arteries enter the after-birth without giving off
any arborescent  ramifications ; and, on  the other hand,  that  the  veins do
not arise by delicate ramuscles, but present, at their very origin, large trunks,
which by anastomosing with each other very frequently and at all points, seem
to form in this manner  a  system of cells, whence the blood then passes by
some venous trunks into the uterine  veins.   These latter are continuous
with the arterial tubes from their origin ; their walls  are excessively thin in
the placenta, being there reduced to the  internal coat, and collapse, so as to
be nearly invisible when they  contain but little blood.  The terminal rami-
fications  of  the umbilical vessels project into these  venous sinuses; more-
over, the thin tunic of the vein is pushed into the interior of  the vessel by
the fcetal villus resting against its outer surface, and  it thus furnishes a
sheath to the latter, Avhich seems to penetrate to the interior even of the
maternal vascular tube, though in reality it does not.
  Read, in August, 1840, easily verified, he says, the existence of the utero-
placental vessels, when examining the uterus of a pregnant woman, who died
at the seventh month.
  After having detached a portion of the placenta under Avater, my atten-
tion was drawn to a number of rounded  bands  passing between the uterus
and the  externa]  surface of the placenta.   When  the least  traction Avas
miade, their  walls  lecame thinner as their length  increased, and had a eel- 
DEVELOPMENT OF  THE  HUMAN  OVUM.          201
lular  appearance, though they were  easily lacerated;  whilst sometimes,
though more rarely, they seem to separate like the tufts of the uterine sin-
uses.  By cutting into one of the sinuses, these tufts could be traced, and
seen to ramify in its interior;  some seemed to penetrate the patulous open-
ing of the sinus only, while others sank in for about an inch, and appeared
to penetrate even the surrounding sinuses.  I could easily  satisfy myself by
injection and microscopical inspection, that these tufts were the ultimate
ramifications of the umbilical vessels.
   It is  scarcely necessary to add, that these tufts only penetrate  the open-
ings of  the sinuses situated near the internal surface of the uterus, and not
those  more deeply seated.   Their volume varies very much, some appearing
to fill the opening of the sinus entirely, whilst others only occupy it in part.
Again, although the tufts appeared loose, and floating in the interior of the
maternal vascular tube, yet they Avere  evidently surrounded by the internal
tunic  of the latter, Avhich was reflected on their external surface.
   I have assured myself that  some of the utero-placental veins contained
no prolongation of the foetal vessels, but in many others the villous tufts (the
terminations of the umbilical  vessels) could be recognized and folloAved into
the uterine sinuses.
   In tracing these utero-placental veins that contain no foetal vessels through
the decidua to the surface of  the  placenta, the internal  membrane of such
veins  is found prolonged on the neighboring placental tufts; and further,
by following a large utero-placental artery through the decidua, Ave may see
that as soon  as  it arrives on the face  of the placenta, its  internal tunic is
prolonged on certain tufts that are found plunged in its  orifice.
   The numerous branches of the fcetal tufts Avhich stop at the placental sur-
face of  the decidua, and neither penetrate into the uterine sinuses, nor yet
into the orifices  of the utero-placental vessels, are fixed by their extremities
to the placental surface  of this membrane.  Consequently, the placenta is
formed  interiorly by numerous trunks and branches (each containing an
artery and a vein), and  each  of these branches, both venous  and  arterial,
is surrounded by a prolongation of the  internal tunic belonging to the
maternal vascular system, or at least by a membrane continuous Avith  that
tunic.  Hence, in adopting such ideas of the placental structure, it becomes
evident that the internal tunic of the  mother's vessels is prolonged on each
placental tuft, in such a manner that  the maternal  blood, arriving by the
utero-placental  arteries,  passes  into a large sac formed from the internal
lamina of these  vessels, and the blood is thus divided into a thousand dif-
ferent directions by  the placental villi, Avhich project like fringes into these
vessels, pressing  in their thin, soft parietes before them, and forming sheaths
therefrom which  completely envelop  each trunk  and each  branch.   The
blood  returns from  this sac by the utero-placental veins  without any extra-
vasation or abandonment of the vascular system to which it  properly belongs.
Therefore, the foetal  blood, and that of the mother, can have no action upon
each other, excepting through  the spongy parietes of the fcetal vessels and
the thin sac that surrounds them.
   It will be seen, that but a single step  has noAv to be  taken in order  to
reach  the dei cription giA'en by M. Coste. 
202
PREGNANCY
  It is really impossible to obtain a correct idea of the structure and devel-
opment of the  placenta, Avithout  being acquainted  with the nature and
structure of the villi of the chorion, as also with the  changes undergone by
that portion  of the uterine  mucous membrane (utero-epichorial decidua;
upon AAdiich the  ovule is ingrafted.
  A. Villi of the Chorion. — We have already stated that before the allantoid
is developed, each villus of the chorion  contains a canal, which is  open at
its base, but terminates in  a cul-de-sac at its free extremity ;  after the allan-
toid is developed, the terminal  ramifications of the  umbilical vessels, both
arteries and veins, penetrate into this  canal as into  the finger of a glove.
The villi, after having been thus rendered vascular, become  atrophied, and

                                   Fig. 67.
  This figure represents the manner in which the villi of the chorion ramify. — o C. Trunk of the villus.
       e. Terminal ramification intact.  G. A terminal branch broken off. v. A lateral branch.

finally disappear from all that part of the chorion which is covered by the
reflected or epichorial decidua.  Those, on the contrary, Avhich are in imme-
diate  contact Avith  the utero-epichorial  mucous  membrane  (inter-utero-
placental  decidua of authors),  undergo  a considerable development, and
ramify ad  infinitum.   When vieAved  collectively at this period, they have
the appearance of a soft, hairy mass, very tufted and flaky, and of a semi-
transparent gray rose-color.
  If the villi which compose this hair-like mass of the chorion be separated
from  each other  and  examined,  the folloAving  characters  will  be  found
applicable to all: a common pedicle, forming  the base or  trunk  of  the
villus, about one-sixteenth of an  inch long, and one-half as  Avide, for an
ovum of six weeks, the dimensions varying,  however, Avith the  size of the
ovum.  From this pedicle are  put  forth numerous  branches, forming  a
bulky tuft.  The largest of these branches, after  dividing  tAvo  or  three
times, are again subdivided into innumerable minute branchlets. 
DEVELOPMENT  OF THE  HUMAN  OVUM.           208
   Again, some of the smaller branches  stand alone upon  the surface of
 the chorion, in the interspaces of the tufted pedicles just mentioned.
   The extremities of the subdivisions of the  third and fourth orders are
 here and there found to present a sort of  cylindric or flattened SAvelling.
   One of the principal subdivisionsgof the umbilical arteries and veins is
 distributed to each of these pedicles, and extends  into all of its branches,
 ramifying as it goes.
   Inasmuch as the branches of any one pedicle  have no communication
 with those of a neighboring one, it folloAvs that each tuft of the  chorion has
 a circulation of its OAvn.
   Although the terminal villi become longer, their thickness is not sensibly
 increased, for their diameter is nearly the same after, as before the develop-
 ment of the placenta.
   B. Utero-epichorial Mucous  Membrane.—These hypertrophied villi come
 in contact with  a very thick and  much softened portion  of  the uterine
 mucous membrane.  As they grow longer, they penetrate into the tissue of
 the mucous  membrane itself, excavating therein a species of cells or lacunae,
 which can be  seen  Avithout difficulty upon  the  bottom of  the  receptacle
 represented  in Plate III., Fig. 53.
   Since the arteries, but more especially the veins, are so developed at this
 point that the frequent dilatations of the latter form large cavities or sinuses,
 from one-eighth to one-quarter of an inch in diameter, the vascular villi of
 the chorion  necessarily come in contact Avith the Avails of the uterine vessels.
 According to M. Coste, the fatter are even Avorn through  by  the villi of
 the chorion, which having  thus gamed entrance into their cavities, are sus-
 pended freely in the blood  which fills them.
   Soon these infinitely numerous and elongated villi become  united to each
 other by means of an amorphous substance, which  is deposited in small
 quantity amongst them, so as to give to each  tuft of the same  pedicle  the
 compactness Avhich each placental  cotyledon presents at a more advanced
 period of pregnancy.
   The villi  taken from the placenta immediately after  labor,  differ from
 those described only in  the greater number of their  ramifications, and the
 larger size of the pedicles and of the principal branches Avhich they put forth.
   The foetal portion of the  placental tissue is formed, in short, of interlaced
 filaments, which  are simply the chief branches of the villi of the chorion,
 whose ramifications can be folloAved to their termination only by the use of
 a lens, so inextricably entangled are  they, and agglutinated by the amor-
 phous matter of Avhich Ave have spoken.   They thus form, by their agglom-
 eration, a tissue of a reddish-gray color, soft, elastic, giving way to pressure
 of the finger, and yielding  a filamentous fragment by tearing.
  The structure of all the villi is not, however, identical at the termination
of pregnancy.  Although the greater number preserve until the end  the
double vascular canal Avhich  they presented at the beginning,  the vessels
of a feAV become atrophied, and like the non-placental villi, finally constitute
a very slender filament devoid of a canal.  Fig. 68,  for which  I am indebted
to the kindness of M. Robin, exhibits these  diflferences,  besides  showing 
204
PREGNANCY.
 very clearly the admirable disposition of the foetal vessel within the villus
 itself.1
   Thus  H and T represent a  terminal prolongation of  the  branches of a
 placental villus, ovoid- in shape, with a contracted pedicle  and  obliterated
 cavity; at B is another terminal prolongation of the same villus, having the
 structure Avhich  almost all of them retain in the placenta.   It is composed
 of an external envelope B, or wall of the villus, of a structure  identical with
 that of the chorion.   Its thickness, and consequently that of  the substance
 separating the blood of the foetus from that of the mother, may be estimated
 approximatively.  It is about "0004 of an inch.
  This villus  presents internally a partition,  a, dividing its cavity into two
vascular tubes.   The tubes are situated  beside each other, like the barrels
of a double-barrelled gun ;  they bend toward  each other at a", so as to form
a single canal at the extremity of the villus, which is arterial at D e, but
venous at g' g.  This partition A has only  half the thickness of the external
wall B.   It has a spur-like termination at a", and adheres by its base at a'
to the wall of the villus.
  When this  disposition of the terminal  ramifications is once understood,
all  discussion, as M. Robin remarks,  respecting a direct  communication
between the maternal and foetal vascular systems, is ended.
  Each of the capillary vessels of this double  canal empties  into a corre-
sponding  one  of  larger size, at the point of junction or of separation of a
ramification with a larger branch;  for example (Fig. 68), the arterial tube
                                  Fig. 68.
   The figure represents a fragment of the villi of the chorion obtained from the placenta.  It exhibits
               prolongations of various appearance. Magnified 360 diameters.

D e empties at a' into the trunk of the same nature of the principal branch
D v, and the venous tube g' g discharges at the point c.

  1 The minute details into which I am about to enter, are the analysis of the researches
uf my learned colleague and friend, M. Robin.   They are for the most part recorded in
in excellent nemoir publish&l by him, and also in  the thesis of M. Cayla, one of his
pupils. 
               DEVELOPMENT  OF  THE  HUMAN  O TUM.           205

  The placenta is therefore composed of two parts, which are very distinct,
in a physiological point of vieAV, although they are  confounded in a single
mass at the end of gestation.   One of these is the foetal portion, and is more
especially adherent to the chorion, from which it takes its origin; the other,
the  maternal  portion,  is  a greatly thickened part of the  uterine mucous
membrane.
  It is very difficult  to  say Avhat is  the real  mode of connection between
these two elements of the placenta, since such different  results have followed
the dissections of the most skilful anatomists.
  Their continuity, or direct communication, is at present,  however, out of
the question, for all are united in regarding  their  relation as one of simple
contact, a greater or  less extent of adhesion.

  [The foregoing represents Avhat AAras known until Avithin a few years past, of the
structure of the placenta.  More recently, Professor  Robin, who at first accepted
the ideas of M.  Coste, has changed his opinion on the subject, and we have now to
Btate his present views.  (Various memoirs and oral communications.)
  A close examination of the external surface of the placenta, will soon show that
the entire surface of the  cotyledons is covered by a grayish, semi-transparent, and
soft membrane,  from the tfs to the ^ of an inch in thickness in different specimens.
This membrane, whose existence we  have already asserted, is sometimes  smooth,
sometimes  rough,  quite elastic  and adhesive, and of a peculiar appearance.   It
passes Avithout interruption from one cotyledon to another, being only rather thicker
in the interstices.   It is formed by the epithelium of the inter-utero-placental mucous
membrane in its thickened  and hypertrophied condition.  A few other elements,
derived from the most superficial portion of the same mucous membrane,  are also
found in it, such as laminated fibres, amorphous matter, and molecular granules of
various  kinds.
  This layer represents the  maternal  placenta, and is traversed  by a profusion of
maternal  capillary vessels Avhich  pass  into the  body  of  the placenta.  If these
vessels be folloAved into the soft, grayish, and glutinous  layer, just described, we
find that they become  gradually flatter  and  more irregular;  they are distributed
over the conA^ex surface of the cotyledons and in their interstices, and at all these
points enter deeply in an oblique direction toward the foetal  surface of the placenta.
In pursuing this course, their walls become so extremely thin that they are often
discerned Avith great difficulty.   (Robin.  Communications  orales.)
  Having entered  the  placental tissue, they dilate and communicate so largely as
to form throughout the entire mass of the  placenta a pool  of blood, Avhich bathes
the entire placental surface of the chorion at the point of attachment of the pedicle
of each villus.
  This expanse of blood penetrates the fine sponge-like interstices between the
reticulated ramifications of the villi, but nowhere is there any direct communication
between the maternal and foetal blood.
  Beneath  the preceding layer is found  the  foetal  placenta, which constitutes the
greater bulk of the organ and is formed by the expansion of the villi of the chorion
agglutinated by amorphous  matter.   Amongst  these  villi  are distributed the
numerous maternal vessels.
  The glutinous layer, formed by the epithelium of the serotina at the surface of the
placenta, is always present, unless accidentally removed:  thus  proving  the very
important fact that the placental villi are not plunged  freely  by  means of floating
extremities in the sinuses of the  serotina.  The  cotyledons, it is true, project toward
the utero-placental mucous membrane Avhich, in its turn, penetrates  somewhat into
the furrows which  separate the cotyledons:  still, their convex surfaces are merely 
206
PREGNANCY.
applied against the sinuses of the serotina, which glide  between  the villi in ordei
to open into the aboA'e-mentioned pool of blood resulting from the enormous dilata-
tion and the destruction here and there of the walls of the capillaries of the super-
ficial net-Avork of this part of the mucous membrane.
  The adhesion betAveen the cotyledons and the mucous membrane is molecular
and so intimate, that, instead of merely separating from the latter, it brings away
with it the superficial layer of the serotina.
  Notwithstanding this, it is true that, in an anatomical point of view, the cotyle-
dons, in fact  the  placenta,  are merely applied by  the surface, against the inter-
mediate mucous  membrane.   The  foetal villi  are not plunged in the form of
arborescent or radical branches in the tissue of the serotina, as all the descriptions
would seem to indicate, but it were more correct to regard the maternal blood as
seeking them at a certain depth in the mass of the cotyledons.]
  The placenta appears to be destitute of nerves and lymphatic vessels.
  All  the cotyledons composing the placental mass are, as Ave have said,
united by the interlobular membrane.  Occasionally, hoAvever, one or several
of these lobes are  separated from  the  others, and seem to  form  another
placenta by  their  isolation; in  this way" it has  happened that  several
placentas have  been attributed  to a single  foetus,  and, perhaps, the- facts
mentioned at the beginning of this  article are to  be accounted  for  in the
same way.
  The placenta  may be inserted  upon  any part of the  uterine cavity, and
even upon its orifice, though most usually it is  fixed near the fundus of the
organ.  It has been customary to account for these varieties of insertion, by
saying that the latter is determined by the most  vascular portion of the
organ;  overlooking  the  fact, that, although the  point of attachment be
indeed more  vascular than any other  part of the uterine  parietes, it  is
simply because of the insertion,  thus confounding the cause Avith the effect.
According to  some authors, the weight of the ovule determines the point of
insertion of the placenta, which, if true, should most frequently  take place
upon the neck.  Observation, however, refutes this opinion.   Finally, accord-
ing to MM. Moreau and Velpeau, when the ovule enters  the Avomb, it is
obliged to separate the decidua  from the Avail  of the uterus, and therefore
naturally tends towards the points of least resistance.
  The details Avhich Ave have given respecting the mode of formation of the
decidua, shoAV that the latter opinion is Avithout foundation.   The folloAving
seems to us  to be the most probable explanation:  Generally, by the time
the ovule enters the uterine cavity, the latter is filled to repletion  by the
folded and  SAVollen mucous membrane.   This state of things  renders it
almost impossible that- it  should  progress very  far,  and  the consequence is,
that in the vast majority of cases  it lodges in one of the  numerous folds
near the fundus, and becomes attached in the vicinity of the orifice of the
tube by Avhich it entered.   The  placenta is, in fact, generallv found in this
neighborhood.  Why, in  some cases, it should be  situated  in the  inferior
segment of the womb, is of more difficult explanation, except upon the sup-
position that fecundation was effected after the arrival of  the ovule in the
uterine cavity;  in"which  case, in consequence of the less swollen condition
of the mucous membrane, it may have been able to obey the laAvs of gravity
immediately upon entering the cavity, and thus descend tOAvards the lowest
ooints. 
DEVELOPMENT  OF  THE HUMAN  OVUM.           207
   Sometimes the insertion of the placenta upon the lower segment of the
 uterus occurs in several successive pregnancies.  Ingleby relates one case in
 which it happened three times, and says he knew the same thing to occur
 ten times in another.  M. Dunal, from whom I quote the  above, gives an
 observation of M. Menard, in Avhich the Avoman had this unfavorable inser-
 tion twice consecutively.  Whether this sort of habit can depend upon a
 peculiar disposition  of the  Fallopian tube or of the uterus, is a question
 which anatomical research only is competent to decide.

   § 2. The Umbilical Cord.
   The umbilical  cord  is the  flexible trunk, Avhich unites  the  abdomen of
 the child to the placenta; it does not exist during the#early weeks of preg-
 nancy, and its formation only commences Avhen  the embryo is completely
 separated from the blastodermic vesicle, Avhich thereby becomes the umbili-
 cal vesicle; Avhen the allantois, by  being confounded Avith the external
 lamina of  the blastoderm, no longer constitutes a  distinct vesicle, but is
 merely a simple cord upon which the two  umbilical arteries and the vein
 ramify ;  and when all  these parts have received an enveloping  sheath from
 the amnios.  Now it scarcely appears thus formed until towards the end of
 the first month, being composed at this  period, in all normal embryos of  the
 age of the  one Avhich we shall describe (page 210), of three distinct parts:
 1, of an  enveloping  canal, Avhose walls are formed by a reflection of  the
 amnios, and Avhich is continuous at the  umbilicus with  the  skin of  the
 embryo; 2, of tAvo pedicles proceeding from the foetal appendages, around
 which this  amniotic canal forms a sheath, and Avhich communicate, the one
 under the name of the pedicle of the umbilical vesicle, with the  ileo-ccecal
 fold of intestine, and  the other,  under the  name of urachus, or the pedicle
 of the allantois, with the bladder.
   But soon after, as the  development  progresses, and  the pedicle of  the
 umbilical vesicle  is absorbed, the cord becomes simplified, and  is reduced
 to the amniotic sheath  and the urachus, accompanied by the umbilical ves-
 sels, with which this sheath is confounded by the obliteration of the canal
 that constitutes  it.   The effacement of this canal, along which only  the
 urachus  and its  accompanying  Aressels  pass,  progresses from  the chorial
 extremity of the cord  tOAvards the umbilicus, or abdomen  of the embryo;
 and, as the progressive obliteration approaches the latter, it encounters  the
 intestine Avhich advances beyond the  umbilicus, and forms arhernia in  the
 cord itself; but  this rupture is  naturally reduced,  in consequence of  the
 pressure exercised on the boAvel  by the  progress of effacement, Avhich ulti-
 mately reaches the navel, and presses back into the abdomen everything
 met Avith outside of its cavity.  HoAvever, in some instances this  process is
 not completed  in so  efficacious  a manner, and the  intestine in such cases
 remaining beyond the  umbilicus, produces  the malformation knoAvn as con-
 genital hernia; a hernia that is nothing more than the persistence of an
 inatomical disposition, Avhich always exists temporarily at a certain  period
 of the embryonic life.
  The cord, at the end of the first month, is still thin, cylindrical, and verv
uniall; but from  the  fourth  to  the eighth, and even the  ninth Aveek, it 
208
PREGNANCY.
acquires a considerable  proportional volume;  and it exhibits either som«
enlargements, vesicles, or swellings,  two, three, or four in number, which
are separated from each  other by a corresponding, number of bands, or con-
tractions.
  During the third month it diminishes in size, in consequence of a retrac-
tion of these tuberosities; but  again, commencing from this  latter  period,
it continues to groAV proportionally to the other parts of the foetus until the
end  of gestation.
  The cord varies greatly in length at  term : generally, it is from tAventy-
one  to twenty-three inches;  some  have been observed, however, from six
inches to five feet (one  metre fifty-three  centimetres) ; others,  still  more
rare, have reached  five feet nine inches in  length (one metre seventy-five
centimetres).  I delivered a Avoman with the forceps, June 23, 1841, in
whom the head had been retained above the superior strait, and where the
cord Avas only nine inches long.  These  extremes are very rare; neverthe-
less, they are  not the  utmost varieties the  cord  may offer in its extreme
limits, for it has been  knoAvn not to exceed  five inches, and has even been
as short as two inches.
  In a case reported by Mende, it was so short that the placenta  absolutely
seemed  fixed  to the child's abdomen.   Its size likewise varies in different
subjects, being generally about that  of  the  little finger, sometimes  much
smaller, and at others very large; but in all these cases its volume depends
much less on that of the  vessels than on  the quantity of fluids accumulated
in the surrounding tissue.
  The nerves  and lymphatic vessels, which certain authors have described
as belonging to the cord, are still a subject of research; admitted by some
and  denied by others, their existence is at least problematical.
  The arteries are tAvo in number,  and, following the course  of the blood,
they, arise from  the bifurcation of the abdominal aorta in the foetus, and
reach the umbilicus, Avhence they traverse  the entire  length of the  cord,
describing numerous flexuosities as far as the placenta, in the tissue of which
we have already followed their ramifications.
  The vein, still following the route of the blood, arises from the numerous
ramuscules studied in the placenta; the venous radicles of each  lobe  unite
to form branches, Avhich  in  their turn  aggregate on the fcetal surface  of
the after-birth, to form  there the trunk of the umbilical vein ; and the latter,
having arrived at the umbilical ring, abandons the  two arteries, and runs
tOAvards the fiver.  (See Circulation of the fcehls.)  The vein is nearly equal
in size to the two arteries united; but it is  much less flexuous, and  conse-
quently its course is shorter.
  These vessels  are Avound upon  each other  in a Avay nearly similar to the
twigs of osier forming the handle of a basket; they give off no branches in
the  cord, and  it  has been remarked that the twisting of the vessels  which
only begins after the second month, takes place, nine times in ten, from left
to right.   The vein usually occupies the axis of the cord, and the arteries
wind uniformly around it.  Of course, this enrolling must depend somewhat
on the torsions of the embryo itself, and then the entire cord,  together with
its sheath, is involved, as not unfrequently happens; but Avhen the cord  ia 
DEVELOPMENT OF  THE  HUMAN  OVUM.           209
etraight, and the arteries are tAvisted at least more than it is, these contortions
seem to result from a more rapid  groAvth  of the vessels Avithin the sheath,
than of the sheath itself (Haller).  Now, the  embryo and placenta being
immovable, the turns starting from these  tAvo points will  necessarily meet
each other, and  this indeed frequently takes place.   Two, and even three
umbilical veins have been met Avith in some cases ; in others, instead of two
arteries there is  but  one.  Osiander once found three of the latter.  It is
worthy of remark, that  neither the arteries nor  the veins have valves at
any part of their course.
  These vessels are surrounded by a gelatinous substance called  Wharton's
gelatine, Avhich is variable in its quantity, thereby giving rise to the division
made by accoucheurs into the thin and fat cords.   This substance is con-
tinuous on one part with the sub-peritoneal cellular tissue of the foetus, and;
on the other, accompanies the vessels into the placenta.  Being spongy in
character, it is constituted by a  clear, tenacious  liquid, contained  in  the
cellular areola?, that communicate so freely Avith  each other.  The cord
frequently has one or more knots when it is very long, some of Avhich are
formed during pregnancy, and often even  at an early stage; but  others are
only produced at the period of labor:  they never become  so  tightened (in
gestation) as to compromise the life of the child, to whose  movements they
are certainly due; but we can understand  that the cord may become tightly
draAvn  during labor, from being  shortened by circular turns around  the
trunk or neck ; the knots, in such cases, may be so hardened  as to intercept
the circulation completely, and the death of the foetus will necessarily result
if the  labor be prolonged.  In one case, figured in the Avork of M. Baude-
locque, the cord was knotted three times at the same place, and Avas inter-
laced like a mat.1
  M. Soete, an accoucheur at  GheluAve, has described a very singular case
of double  pregnancy, in Avhich the tAvo
foetuses Avere inclosed  in the  same bag,
and the tAvo cords formed a perfect knot
with each other.
  Besides  these knots,  true  nodosities
likeAvise exist at times in the  cord, pro-
duced  either by the  duplicature  or  the
varicose state of one of its vessels.
  We have already stated that the cord
is  attached  by  one  extremity  to  the
umbilicus of the  child, and by the other
to some point of the foetal surface of  the
placenta;  but this, however, is not  ahvays
the case, for  the facts are too numerous
which  go  to prove  that the  cord may
indeed  be  inserted on  the head,  neck, shoulders, and  other parts  of the

  i The ancients thought they could determine the fecundity of the female by these
knots: thus, according to Avicenna. the more knots the more will be the future  con-
ceptions; and if they occur at some distance apart, the pregnancies will also be more
distant from each other. — (Israelis Spachii gynseceorum libri.)
       14
Fig. 69.
 
210
PREGNANCY.
fcetal trunk, not to admit some of them, at least; such, for example, as the
one observed by M. Jules  Cloquet, at Brussels.  The placental extremity
of the cord also presents some anomalies; it is usually fixed very near the
centre, but sometimes is found attached to a part of the periphery, bearing
then the title of the battledoor-plaeenta.  Nor is it always attached to a point
of the foetal surface of the placenta.  For instance, Benckiser has collected
in his thesis numerous cases in which the cord was inserted at some point
on the periphery of the membranes;  and having arrived there, the vessels
of the cord then divide into five or six large trunks, the branches of which,
by ramifying between the  membranes, reach the placental  circumference,
and plunge into the parenchyma of this body.  (See Fig. 69.) ^
  All such modifications, however, merely depend on the way in which the
allantois contracts its adhesions with the point of the ovum in contact with
the womb.  In fact,  the placenta is always  developed there, and if the
allantois happens to strike" the chorion  at a point someAvhat removed from
that which is in apposition with the internal  uterine surface, the umbilical
vessels must evidently have a tendency towards the latter, just as the roots
of a plant always stretch towards the spot which will afford them the most
nourishment.
                         CHAPTER  Y.
                           OF THE FOETUS.
  We shall  not attempt to study the  foetus  by describing the different
organs, and the various tissues  successively, that enter into its structure at
the moment of birth, nor by tracing each of them through the modifications
it undergoes at the divers periods of the intra-uterine life; for such a course
would evidently compel us to overstep the limits imposed by the nature and
character of this work.   Therefore, laying aside all embryological researches,
we shall  content ourselves with mentioning a few interesting particulars of
organogeny;  and while considering the foetus in a general manner, we shall
point out succinctly the successive development of its form and its external
parts.  But  before entering upon this subject, we believe  it will prove
profitable to  present, in a figure, the various details  already furnished, as
such  an exposition  will  complete the  description previously made, and
facilitate a knowledge  of the facts we have yet to speak of.

       EXPLANATION OF THE FIGURES IN PLATE IV.
  Fig. 1.  The  human ovum, of its  natural size, at about, the thirtieth or thirty-sixth
day.
  Fig. 2.  The  same ovum (of its natural size) laid open to show its constituent parts
  a a. The chorion.
  b. The amnion.
  c. The foetus.
  n. The umbilical vessel.
  Fig. 3. The same ovum highly  magnified, and opened in  such a way as to exhibit
 the principal  relations existing between the embryo and its appendages.   The walls 
PI. IV.
"Kg.l    ■

& A
K 3  '\^
K^. 3
4  K 6 M 5
' SyTu>l{*si+- 'Lvtri 
 
OF THE F(ETUS.
211
 of the abdomen and chest have been cut away so as to bring the viscera into view, and
 the umbilical cord has also been split up, for the purpose of showing how the appen-
 dages of the foetus are brought into relation with this latter.
  a a.  The chorion, consisting  of two layers, placed back to back, and confounded
 with each other, but which have been  dissected apart for a limited extent at a' k''.
  b b.  The amnion, laid open,  so as to show how it is continuous with the umbilical
 cord, along which it is reflected, thereby forming a sheath, which, under  the form of
 the canal b' b/, is directly continuous  with the umbilicus or the  abdominal walls c 0
 of the  embryo.
  ». The umbilical vesicle, and d' its  pedicle.
  D//.  The point where this pedicle communicates with the intestine e.
  e. The loop of intestine prolonged into the cord.
  r. The urachus, continuous by one extremity, g, with the chorion, and by the other
 with the rectum at the point h.
  i i. The umbilical arteries.
  /.  The umbilical vein.
  j'. The part of the right auricle from which the umbilical vein comes off.
  K. The vena cava inferior.
  m. The inferior surface of the liver.
  n. The omphalo-mesenteric vein.
  o. The point where this vein empties into the umbilical vein.
  p. Tlie omphalo-mesenteric artery.
  1. The heart.
  2. The arch of the aorta.
  3. The pulmonary artery.
  4. The lung of the right side.
  6. The Wolffian body.
  6. The branchial fissure, which is converted into the external ear.
  7. The lower jaw.
  8. The upper jaw.
  9. The nostril of the right side.
  10. The nasal canal still  forming a kind of fissure, which extends from the eye to
 ■he nostril.
  11. The caudal extremity, or coccyx, projecting like a tail.
  12. The upper extremity.
  13. The lower extremity.

                              ARTICLE  I.

 DIMENSIONS AND WEIGHT  OF THE  FOETUS AT THE DIFFERENT PERIODS
                         OF INTRA-UTERINE LIFE.
  At the time Avhen the  embryo  first begins to be distinct, that is, about
 the third week, it is oblong, sAVollen in the middle, obtuse  at one  extremity,
 though draAvn to  a blunt point at the other, and straight, or nearly so, being
 somewhat curved fonvards.   It is therefore vermiform in shape, of a grayish-
 Avhite color, semi-opaque, almost Avithout consistence, and  gelatinous, vary-
 ing from two to four lines in  length, and weighing one or two grains.   At
 this period, the only trace of the head is a small tubercle separated from the
 rest of the  body by a notch, but no  rudiments of the extremities are observed,
nor is there a cord at first.
  The embryo is clearly surrounded  by the amnion, Avhich lies quite near
it, in the form of a delicate membrane, leaving it, hoAvever, ahvays free.
The  abdominal  cavity is opened for a  very considerable extent in front.
The embryi becomes more  consistent tOAvards the fifth week:  its  head then 
212
PREGNANCY.
increases  greatly, in proportion to the remainder of the body,  and tho
rudimentary eyes are indicated by tAvo black spots turned tOAvards the sides;
the development of the thoracic extremities is announced by two small,
obtuse nipples, situated on the sides of the trunk; it is nearly two-thirds of
an inch long, and weighs about fifteen grains; the cord exists in a rudi-
mentary condition, and the abdominal members are likeAvise present, in the
form of two rounded pimples.  The vertebral divisions are quite apparent,
all along the back, although the caudal vertebrae closely approach the front
part of the head, in consequence of the anterior  curvature of the  embryo.
  Already does the  heart exhibit, in its external form, a tolerably close
resemblance to that in the adult; for we may even noAV observe  the fissure
that will afterwards  separate  the auricles, as also one corresponding to the
inter-ventricular partition; but there is, in reality, only one ventricle, from
which  both the aorta and the pulmonary artery arise.  And, further, there
is but one auricle; or, rather, the two communicate so freely that the inter-
mediary contraction*Avhich should  divide them is still very imperfect; for
the partition is formed by the progressive contraction of the orifice of com-
munication, and this incomplete opening, Avhich  sometimes persists in the
septum until birth, is known under  the name of  the foramen of Botal.  But,
after birth, the opening becomes obliterated, and the two auricles are thence-
forth isolated by a complete partition.
  The single ventricle will be converted into two  cavities, by the interven-
tion  of a septum, which will be  gradually  developed from  the  summit
tOAvards the base, being placed between the  two arteries (the pulmonary
and aorta), and so disposed that one of them shall open into the right and
the other into  the left cavity.
  The lungs at this period are constituted of five or six lobules, in which
we can readily distinguish the  bronchial extremities, terminating in slightly
swollen cul-de-sacs.  Moreover, two large glandular structures lie along the
vertebral column at this period, extending longitudinally on each side, from
the lung to the bottom of the pelvis.  These are  the Wolffian bodies.  They
are constituted by an excretory canal, which runs throughout  their whole
length, being  placed  on their external margin, and terminating below in
the transitory  cloaca.  The canal  puts  forth,  on one of its  sides only, a
series of more or less elongated cceca, which roll or curl up, so  as to form a
considerable mass by their agglomeration.   These coeca secrete a liquid,
Avhich is subsequently emptied into  the cloaca by means of the canal.
  The Wolffian bodies  anticipate the function  of the  kidneys  until  the
latter are  developed, and hence they have  been denominated the false
kidneys; but they disappear as soon as the true  organs can replace them,
leaving no trace of their  past existence.  Just  alongside of the excretory
canal, in the Wolffian body, a second one is seen to accompany it through-
out, and even in like manner to  empty into  the cloaca.  But this second
canal is perfectly distinct from  the other,  and will become, in the adult,
either  the oviduct or the vas  deferens, according as the new being  shall be
of the male or female sex.
  In the early stages of embryonic life, there likewise exists on each side
of the  neck in the human foetus, as also in  the  mammalia, four  transverse 
OF  THE  F03TUS.
213
fissures Avhich open into the pharynx.  These are separated from one another
by certain  bands, or fleshy partitions, that  correspond Avith  the  branchial
arcs of fishes; for the vascular apparatus distributed there affects, to a cer-
tain extent, the same form temporarily, that it has permanently in the inferior
vertebratse.  We, therefore, see that the bulb of the aorta, instead of curv-
ing immediately in a  single arch, divides,  on  the contrary, into three or
four branches, on each side of the neck; and after these branches  have each
accompanied a branchial arch, they reunite, at a common point, to form the
descending aorta; however, they are soon effaced, along with  the corre-
sponding fissures, and but  two remain on the left side, one of which is con-
verted into the arcus aorta?, Avhile  the other, after  having existed as  an
arterial canal, will form the common trunk of  the pulmonary arteries.
  The branchial fissures just under  consideration  also disappear, with the
exception of a single one (the first on each side), which is converted into the
external ear, as  may be seen in the figure.  (See Plate IV.)
  At this period, the upper jaw is still composed of two- papula? one for each
side.   These pimples, or isolated  mandibles, gradually approach the median
line, and there unite in a single body, which forms the jaAV such  as we find
it in the adult.
  The nostrils are separated by the incisive papulae, Avhich keep them apart
for  some time; then, as the latter diminish in size, they approach each other
and assume their definitive form ; but, in the meamvhile, they are  separately
split doAvn to the mouth, and it  is the permanence of this  transitory state
that constitutes the double  hare-lip.  All  of  the  branchial fissures have
disappeared by the sixth Aveek, leaving only a slight cicatrix behind.
  The first centres of ossification  appear during the  seventh Aveek, first on
the clavicle and then on the lower jaAV.  The intestine still extends for a
considerable  distance along the  interior of the  umbilical  cord, but  the
omphalo-mesenteric canal  is  nearly obliterated, although  it  may  yet  be
traced as far as the umbilical vesicle, Avhere it is reduced to a very delicate
thread.  The anus remains closed ; and the  bodies of Wolff alone  exist near
the vertebral column.   It is only then that the  kidneys and capsular renales
begin  to appear,  and  soon after them  the sexual organs.  The  urinary
bladder is first  manifested under the form of  a tumor that is continuous
with the urachus.  At this time,  the embryo is nearly an inch in  length.
  At two months, the tubercles of the extremities become more prominent.
The fore-arm and  hand can be distinguished, but not the arm; the hand is
larger  than the forearm, but it is not supplied Avith fingers.  The cord  has
not  as yet assumed a spiral arrangement, but it is infundibuliform in shape,
the  base corresponding to the abdomen, being  continuous with it, and con-
taining a large quantity  of intestine; it is four to five lines in  length, and
is inserted near  the loAvest point of the abdomen.  A small tubercle, fur-
nished with one  or more very contracted openings, may be distinguished
between  it  and  the termination of the spine, Avhich  are  the rudimentary
external  organs of generation ; but the extreme length of the clitoris renders
the  distinction of the sexes difficult at this period.
  The embryo is from one and a  half to tAvo inches long, and weighs fiom
three to five drachms, the head forming more than one-third of the whole. 
214
PREGNANCY.
The eyes are prominent, but the lids, from being itill  rudimentary, do not
sover the eyeball;  the nose forms an  obtuse  eminence;  the  nostrils are
rounded  and separated; the mouth is  gaping, and the epidermis can ha
distinguished from the true skin.
  At ten weeks, the  embryo is from one and a half to tAvo and a half inches
in length, and  weighs an ounce or an ounce  and a half.  The palpebrse,
having become more apparent,  descend in front of the eye, and the puncta
lachrymalia are now visible; the buccal fissure, which  has  increased in size,
begins to be obliterated by the commencing development of the lips.
  The thoracic parietes are apparent; hence the heart's movements cease to
be visible.   The fingers are distinct, and the toes look like little tubercles
held together by a soft substance.  The cord is longer than  the embryo, and
begins to assume the spiral arrangement; it is less infundibuliform  than
previously, and is not inserted so Ioav  doAvn on the  abdomen, but its  base
always contains a portion of intestine.
  At the end of the third month, the embryo weighs three to  four ounces, and
measures from five to six inches; the  eyeball is seen through the lids; the
membrana pupillaris is more manifest;  the forehead and  nose are clearly
traceable, and the lips Avell  marked and not turned outAvards.   The  neck
now establishes a visible separation between the head and thorax; the latter
cavity is closed at all points, but is still very slightly  developed relatively
to the other cavities.  The  cord  contains no intestine, and its spiral turns
are more numerous and  evident.  The  nails begin to  appear as thin mem-
branous plates;  the sex is distinct, and the integuments, which  heretofore
were  only a soft, viscous  covering, acquire more  consistence, but are still
very thin, transparent, of a roseate hue, and without  an apparent  fibrous
texture.
  At the fourth month, the embryo takes  the name of foetus; its groAvth is
not so rapid in the commencement as at the end of this month.   The  body
is six to eight inches in length, and weighs from seven  to eight ounces.
The fontanelles  are very large,  as are also  the sutures;  and  some short,
Avhitish, silvery hairs may be observed on the head.  The face still remains
but little developed, although more elongated  than it has  previously been.
The eyes, nostrils, and mouth are closed, and Avhen the occlusion of the lids
happens to be incomplete, it is  generally at the internal  part.  The tongue
may be distinguished behind the buccal fissure, and the  projection of the
chin is observable.   The cord is inserted higher up on the abdomen, Avhence
the centre of the body is an inch or tAvo above the umbilicus.  The skin has
a rosy color, and begins to be covered by down;  and some fat, tinged  Avith
red, is deposited in  the areola? of the  subcutaneous cellular tissue, and the
muscles noAV produce a sensible motion.  A foetus born at this period might
live for several hours.   Whilst I Avas Interne at the Hotel  Dieu, I received
one that had scarcely reached  the fourth  month.  It lived,  hoAvever, from
half-past seven to half-past eleven o'clock.
  At five vxonihs, the length of the body is eight to ten inches, and it weighs
from eight to eleven ounces.  The skin is more  consistent, and many patches
of sebaceous matter may already be seen, but the pupils cannot be dis-
tinguished. 
OF  THE  FOSTUS.
215
   At six months, the length  is eleven to twelve and a half inches, and the
 weight about one pound (avoir.).  The hair is both longer and thicker, the
 eyes closed, the eyelids someAvhat thicker, and their margins, as well as the
 eyebrows, are studded with very delicate hairs.  Agreeably to most authors,
 the membrana pupillaris always exists; on the contrary, the pupil at this
 period has seemed very large, both to M. Velpeau and myself.  The  skin
 is better organized, for the dermis and the epidermis may be distinguished,
 though its surface is wrinkled  and puckered, OAving to the  small  quantity
 of subcutaneous fat.   The nails  are  solid  already.  The scrotum is  very
 small, quite  red, and empty.
   At seven months, the foetus  acquires a length of tAvelve  and a half to
 fourteen inches ; all its parts have become firmer and more voluminous, and
 their respective dimensions  better proportioned.   The bones  belonging to
 the vault of the cranium  exhibit  near their  centres a considerable promi-
 nence at the point  where the first rudiments of ossification occur, Avhence it
 folloAvs they  are less  uniformly arched than at the succeeding periods, and
 more curved than in the former months, Avhen  they Avere  in reality nearly
 flat.  The pupillary membrane disappears completely; indeed, according
 to M. Velpeau, this  membrane does  not exist at any period of the intra-
 uterine life.   The iris commences as a simple  ring, Avhich then groAvs in a
 concentric manner, leaving at last only the opening called the pupil.   The
 eyelids are partly open, and the testicles begin to descend  into the  scrotum.
   At eight months, the foetus seems to groAV, as Desormeaux remarks, rather
 in thickness  than in length; it is only  sixteen to  eighteen inches long, and
 yet Aveighs  from  four  to  five pounds.   The  skin is very  red, and covered
 with  long doAvn, and a considerable quantity  of sebaceous matter.1   The
 lower jaAV, which Avas at first very short, is noAV as long as the upper  one.
 The scrotum usually contains one testicle, generally that on  the left side.
   Finally at term, the foetus is about nineteen to twenty-three inches  long,
 and Aveighs  from six to seven  pounds.  Although, in consequence of the
 development  at the inferior part of the trunk, the umbilical  ring is now
 considerably removed from the  hypogastric region, yet the insertion of the
 cord does not correspond, as has been  stated, Avith the centre of the body.
 Thus, in a foetus Avhose total  length  is twenty inches, we shall generally
 find ten and  a half to eleven inches from the crown to the umbilicus.
   Indeed, from the researches of M. Moreau, communicated to the Academy
 of Medicine, it appears  that  in  ninety-four children born at nine months,
 four only had the  umbilical  insertion in the  middle of the  body,  Avhile in

  1 About the middle term of the intra-uterine life, the skin is covered by a constantly
 increasing mass of a fat, slippery, viscous  substance, yellowish-white in color, called
 the sebaceous coat.  This substance is more abundant on some embryos than on others,
 and is in greater  quantity  on certain places, as, for  example, the head, axilla, and
 groins; it is insoluble in Avater, alcohol, and oil, and only partially soluble in potash.
 It  is not  a  precipitate furnished by the  amniotic liquors, as some  persons  have
imagined,  for there is none of it on the external surface of the amnios, nor on the
 umbilical cord; it is a secretion of the foetal skin, and, so far as we  can judge by its
com position, is a mixture of effete epidermis and matters furnished  by the sebaceous
glands, which  assist perhaps in the hour of labor by facilitating the expulsion of the.
chill. 
216
PREGNANCY.
ninety others it was below this.  The mean of the variations Avas nearly an
inch.   M. Ollivier, of Angers, has also observed the same thing in thirty
children, examined by him.
  The Aveight and length of children at birth have been Avonderfully exag-
gerated in many cases; thus, some are recorded of a yard or more in length,
and others that weighed eighteen, tAventy, tAventy-four, and even  thirty
pounds.  These  statements must certainly be great exaggerations;  for the
most voluminous of three thousand children, born under my charge, either
in the Hotel Dieu or  at La Clinique, Aveighed ten pounds, and it Avas an
enormous one.
  Of  four thousand  children  delivered at La Maternite, one only weighed
twelve pounds.   (Lachapelle.)
  Baudelocque asserts, that he superintended the delivery of one of tAvelve
pounds and  three-quarters;   and M. Merriman,  one  weighing  fourteen
pounds; Richard Crofts, another of fifteen pounds;  lastly, Mr. J. D. Owens,
a surgeon at Haymoor, near LudloAV, has  seen  a still-born  infant that
weighed seventeen pounds twelve ounces, and had the folloAving dimensions:
   Occipito-frontal diameter,      .       .     .      .          1\ inches.
   Occipito-mental,   "      .....       8J   "
   Bi-parietal        "         .....     6    "
   Total length,         .     .     .     .      .      .      24
  In the month of May, 1849, I was called in  consultation by Dr. Riem-
bault in a case of shoulder presentation.  Several attempts at version had
been made by himself and another physician, and it was Avith the greatest
difficulty'that I succeeded in accomplishing it.   The child, which was born
dead, appeared to me a very large one, and I estimated its weight at from
ten to tw-elve pounds.  After my departure, M. Riembault, who, like myself,
had been struck Avith  its size, Aveighed it carefully, once Avith a steelyard,
and tAvice in different balances,  and  ascertained its weight, by the three
trials, to be eighteen pounds.  Its extreme length Avas two feet one and a
half inches, the bi-acromial diameter nine inches, the greater circumference
of the head sixteen and one-eighth inches, and the lesser circumference nine
inches.  M.  Riembault has assured me repeatedly, that he  could guarantee
the accuracy of these statements, since being himself astonished at the results
of the measurements, he had  taken the precaution to repeat them several
times.
  The mother stated that her last menstrual period occurred July 12,1848,
and that she expected to be confined  about the  12th of April, 1849.  The
size of the abdomen had been so great since March, as to lead her to suppose
that she was pregnant with twins.  The first pains Avere experienced on the
evening of the  6th of May, that  is to say, nearly a month later than she
had anticipated.   Whether the  pregnancy had really run over its  usual
term,  and Avhether the extraordinary size of  the  child was attributable
thereto, are questions which it  is impossible to decide.
  On the Avhole, therefore, Ave  may conclude that the foetal growth is rapid
for the first three months, then slackens off about the middle of pregnancy,
ind again becomes greatly accelerated during the last three months.
  Chaussier has given  the folloAving as the proportions exhibited by the 
OF  THE  FGETUS.
217
different parts of the foetus at birth (taken from a child nineteen and a half
inches long), namely:
    From the top of the head to the pubis,.     ..... 12£ inches.
       '  the pubis to the feet,   ........  7}   "
      "  the clavicle to the bottom of the sternum, .    .     .    .2    "
      "  the latter to the pubis,.......6£   "
  With regard to the  transverse measurement, he found as follows: —
    From the top of one  shoulder to the other (bis-acromial or trans-
      verse diameter of the thorax), .......  4| inches.
    From the sternum  to the spine (antero-posterior diameter),    .  3f   "
      "  ilium to ilium (transverse diameter of the pelvis), . .    .3    "
      "  one femoral tuberosity to the other,  .    .   .    .    .  3£   "
  We shall examine hereafter the dimensions of the head.
  Fortunately, these diameters are reducible; thus,  the bis-acromial in' par-
ticular, which presents  four and three-quarter  inches, may be reduced  to
three and three-quarter  inches,  by compression.

                           ARTICLE   II.
                    HEAD  OF  THE  FCETUS AT TERM.
  The head of the foetus merits the particular attention of the accoucheur,
as  being really the most voluminous and  least compressible part  of the
child.  It is, therefore,  highly  important to ascertain Avhether its  several
diameters are proportional to those we  have heretofore studied in the pelvis.
The head is likewise, in the  majority of cases, the part Avhich presents dur-
ing labor; consequently, it is very  necessary  that  Ave  should be fully
acquainted Avith  all its characters, in order to recognize them at this period.
  The fcetal head, considered  as  a  Avhole,  is ovoidal  in form, the  larger
extremity being  posterior, and the smaller anterior;  as, in the adult, it is
composed of the cranium and face;  but as  the latter does not claim a par-
ticular notice, avc refer, for  a knoAvledge of its different parts, to the works
on  anatomy.  Several bones enter into the formation of the cranium; they
are —
  The frontal.—A symmetrical bone,  forming the forehead, as w7ell as the
superior-anterior part of the face.  It is divided in the foetus into two por-
tions.
  The two parietal.—One upon the right, the other on the left side, meet-
ing at the median line;  they are situated upon the superior lateral parts  of
the head, and concur  to form the vault of the cranium.
  The occipital. — A symmetrical  bone, constituting the posterior part  of
the skull, as also a portion of its base.
  The temporal. — Two  bones placed, one on the right, and the other on the
left side, beloAV and beneath  the parietal, completing the lateral portions  of
the cranium, and contributing to the  formation  of  its  base;  lastly, the
sphenoid and the ethmoid, which  belong exclusively  to the  base.   These
bones are not united to each other  at birth by serrated articulations, as they
are in the  adult {immovable synarthrosis),  but  are  separated, those of the
vault especially, by membranous intervals, of greater or less extent, accord- 
218
PREGNANCY.
ing to the degree of ossification.  The intervals have received the name of
sutures, or fontanelles.
  This arrangement of the vault of the cranium have several advantages.
It facilitates  the development of the brain, and Avhat is hardly less impor-
tant in  the vieAv of the accoucheur, it allows of a  certain reduction of the
diameters of  the head.  When the latter is  compressed forcibly, the  mar-
gins of the bones approach each other and may even overlap.
  The extent of  this overlapping is  liable to be thought greater than it
really is, for, as M. Malgaigne  remarks, if Ave  examine the matter closely,
Ave shall find that the membrane interposed  betAveen the parietal  bones is
too firm to  be drawn out, and too narrow to permit  a  notable overriding;
and further, that it usually maintains these two bones so close together, that
the superior  margin of one laps over the other, leaving even on the dried
skull a true normal  crossing.   Some of those sutures, or fontanelles, are
highly important in an obstetrical sense, and we shall next proceed to  their
consideration.
  The Sagittal Suture. — This great or antero-posterior suture extends  from
the root of the nose to the superior angle of the occipital bone;  being
formed  in  front  by  the ^interval  that divides the  frontal  bone into tAvo
halves, and in the middle, and posteriorly, by that between the parietals.
At  the superior and internal angle, formed by the two portions of the frontal
bone, this suture  is joined  at the sides by the tAvo fronto-parietal or trans-
verse  (coronal) sutures, which are formed by  the space existing betwixt the
superior border of the frontal and the anterior margin of the parietal bones,
and crossing the former suture nearly at right angles.
  Having arrived at the superior angle of the os occipitis, it seems to bifur-
cate,  and give rise to  tAvo oblique lateral sutures formed  by the posterior
borders of  the parietal bones, and the superior one  of the occipital.  These
latter are called the lambdoidal sutures, probably from their resemblance to
the Greek capital A (lambda).  Just at the points where the fronto-parietal
and the  lambdoid sutures  join the sagittal  one, two membranous  spaces,
much larger  than those just described,  are found  to  exist,  which  have
received the name of the fontanelles.
  The great or anterior fontanelle is the one formed by the junction of the
two transverse sutures with the sagittal.   It  is also  called, from the fact of
its  corresponding with the bregma, the bregmatic fontanelle; in  general, it
presents an extensive surface, bounded by four bony angles, produced by the
lateral sutures leaving it nearly at right angles.  It is  lozenge-shaped, and
is usually much more prolonged into the frontal  than betAveen  the parietal
bones.  Sometimes even, according to M. Gerdy, Juri., it scarcely ceases
short of the nose, the margins of the coronal suture being parted through-
out their Avhole extent by an interval which gradually  diminishes  from
above downwards, being only about one or two lines wide toAvard the root
of the nose.   It is not at all uncommon to find  at the loAver  part of this
suture a rounded or oval membranous space, varying from three to seven
lines  in its diameter.
  The posterior or occipital fontanelle is formed by the union of the two
lambdoid suture' with the termination of the sagittal suture;  it is smaller 
OF  THE FffiTUS.
219
than the preceding, and of a triangular form, being bounded by three bony
angles.   The lateral sutures leave it  at an acute angle.   The bony angles
are generally found in contact, no membranous interval being left betAveen
them.   Sometimes the two portions of the os occipitis are not fused into
each other at birth, and in such cases a median suture exists, AA'hich sepa-
rates them, and terminates in the posterior fontanelle.  The latter has then
a lozenge shape, and is subtended  by four osseous angles, and can only be
distinguished from the anterior by the obliquity of the lambdoidal sutures.
The opposite condition is observed at times, the triangular space knoAvn as
the posterior fontanelle not existing at all, because the projecting angle of
the occiput then fits in and fills up the entering one formed by the parietal
bones ;  still the convergence of the three sutures, and the  prominence of
the bony margins Avhich overlap each other, will  aid the diagnosis (Mal-
gaigne) ;  for Avhen the head  is engaged in the excavation, and  has become
strongly compressed, the superior angle of the occipital bones is completely
concealed by the internal  or supero-posterior angles of the  parietals;  and
if the touch is  resorted to under  such circumstances, the finger can only
recognize the position by detecting the little holloAV formed by the depressed
occipital angle.   Of course, particular attention must be given in this case
to the oblique direction of the lambdoidal sutures.
   The  not unfrequent existence of spaces  upon  the cranium, Avhere the
ossification is less advanced than usual, is  another source of  error.  For
this defective ossification  is substituted  a membranous expansion,  which
might be  mistaken  for a  fontanelle.
   Such an error might the more readily have occurred in the four cases of
this kind which I have had an opportunity of observing, from the fact of
the accidental fontanelle being situated just  in the course  of the sagittal
suture,  about equidistant from the anterior and  the  posterior ones; and as
this point is precisely Avhere the finger first falls, in  practising  the  touch,
Ave might mistake it  for  a fontanelle.  But, by a little  attention, it  Avill
always  be easy to avoid this error, by ascertaining that no lateral sutures
pass off from this membranous interval.
   There yet remain some other sutures, and some other fontanelles on the
inferior lateral parts of the cranium;  but as they are devoid of interest Ave
shall not describe them.
   Diameters of the Head.—The term  diameter  has been applied to certain
fictitious lines, Avhich  traverse  the  head in a  determinate direction.   To
avoid over-loading  the  memories of students, Ave shall not multiply their
number as some have done ;  but, folloAving the example of M. Velpeau, shall
describe only seven at first, as it will  be very easy to supply the deficiency
hereafter in treating of the mechanism of labor.
   Seven diameters, then, may be distinguished for the foetal  head, which we
divide,  in order to facilitate their study, into the antero-posterior, the trans-
verse, and the vertical.
   1st. The antero-posterior diameters are: the occipito-mental, a b (Fig. 70),
extending from the posterior  fontanelle to the chin ; this is the longest of
all, being five and a quarter inches.  The occipito-frontal, d e, Avhich extends
from the occipital protuberance to the frontal  boss (also called the antero- 
220
PREGNANCY.
posterior diameter) : it measures four and a quarter to four and a  half
inches.  The sub-occipito-bregmatic, cf, extends  from the middle of the'
space betAveen the foramen magnum and the occipital  protuberance (to the
anterior fontanelle—Transl.), and is three and three-quarter inches.
  2d. The transverse diameters are two in number: one,the bi-parietal, ab
(Fig. 71), goes from one parietal protuberance to the other; it is from three
and a half to three and  three-quarter inches  long.  The other, the bi-tero-
Fig. 70.                              Fig. 71.
poral, c d, passes from  the root of the zygomatic process on one side to the
same point opposite.  It is two and three-quarters to three inches long.
  3d. Lastly, there are tAvo  vertical diameters:  first, the vertical diameter,
properly so called, or the trachelo-bregmatic, i g, traverses the head perpen-
dicularly, passing from the most elevated point of the vertex to the anterior
part of the occipital foramen.  It  is three  and three-quarter  inches long.
Professor Moreau points out another  diameter, which he calls the cervico-
bregmatic, c h (Fig. 70) ; this leaves the preceding someAvhat obliquely,  and
runs from the anterior part of the  occipital foramen to the anterior fonta-
nelle;  it is three and three-quarter  inches in length ; the second, the fronto-
mental, or the facial, da, extends from the  frontal boss to the point of the
chin.   This is three inches.
   Circumferences. — A circumference has been assigned to each  of the above-
mentioned diameters, since  it  is very easy to describe  from the middle of
every one of  them,  as a centre, a circle whose radius is equal to one-half of
the diameter, and whose circumference shall pass through  the  two extremi-
ties of the latter.
  As a matter of course, the greatest circumference of the head corresponds
Avith the occipito-mental diameter,  and  passing at the same time obliquely
over the sides of the face and through the extremities of the diameter, has
a nearly horizontal direction.
  Most authors describe  it  as dividing  the head  into two  equal  lateral
halves, — a  mode  of regarding  it, Avhich, as  M. Jacquemier judiciously
remarks, is devoid of meaning as applied to obstetrical practice.
  The occipito-frontal periphery, agreeing Avith the diameter of the  same
name, runs,,  horizontally, a little  beloAV  the  extremities of the transverse
diameter, and separates the vault from  the  base.  The sub-occipito-breg-
matic  circumference passes through  the extremities of both  the occipito-
bregmatic and the bi-parietal diameters, being thus common to both.
  The two latter are the most important of all, because they successively come
into relation Avith the parietes of the pelvis  in the progress of natural labor. 
OF  THE  FOETUS.
221
  The  circumferences  belonging to the other diameters scarcely offer any
interest, and Ave shall therefore merely mention them in passing; in number
they equal the diameters.
  The  fronto-mental circumference, however, should be noticed as passing
over the forehead, cheeks, and chin: being also called, on that account, the
facial circumference.
  The  diameters just  described, although but  slightly reducible in their
dimensions,  are  not absolutely  invariable.  Thus  it  is only necessary to
witness a  feAV difficult labors to become satisfied, that in such  cases the
head is most  frequently elongated in the  direction of  the occipito-mental
diameter, and flattened in its transverse one.  And Ave further learn, from
the experiments of Baudelocque, that the  bi-parietal  diameter  (see art.
Forceps) may be reduced one-fourth, or one-third of an inch, by the aid of
instruments; indeed, we have even  known this diameter to be diminished
much more than that  under the efforts of  the womb alone, without any
accident occurring to the child.
  Independently of those variations in  length of the diameters of the head
in individual cases, Avhich  it is impossible to foresee, there  is one Avhich is
almost uniform for  each sex, and of importance to be acquainted Avith. The
head of the male  foetus is generally larger  than  that  of the female;  the
difference, according to Clark, being about  the one-tAventy-eighth or the one-
thirtieth.  This difference exerts a notable influence upon the duration  of
labor even in Avell-formed Avomen,  and may consequently have an  injurious
effect upon the health of the mother, and upon both the life and  health  of
the foetus.
  Thus it is shoAvn  by the researches of Dr. Simpson : 1. That the majority
of the children which die during labor are males:  the proportion of still-
born boys to  still-born girls being as 151 : 100.   2. That of children born
living, there are more boys than girls presenting some morbid condition, or
some lesion produced  during labor, and consequently more likely to suc-
cumb Avithin the first  weeks of their existence. 3.  That of the mothers
who die during labor, or in consequence of it, the majority have given birth
to boys.
  It Avill be readily understood that the sex of the child "will have a still
greater influence upon the result of the labor where the pelvis  is slightly
contracted ;  and that Avith the  same diameters, the life of a male  foetus
would be often compromised Avhen a girl might pass with little difficulty and
no danger.
  We present, in the  folloAving table,  the diameters of the foetal head, as
also those of  the pelvis, before described; hoping that, Avhen thus collected,
their study Avill be rendered more easy: —
Diameters of the pelvis. (In inches.)	Antero-Posterior.	Transverse.	Oblique.	Sacro-cotyloid.
Superior strait, . . . Inferior strait, . Excavation, ....	4* 4£ to 4f 4| to 5£	5* 4|	4a 4$ to 4£ 4J	4 to4| (( »< (« ii
 
222
PREGNANCY.
FCETAL HEAD.

         (Occipito-mental,    .    5J    inches.
         Occipito-frontal,    .    4}      "
         Sub-occipito-bregmatic,  3£      "
         Bi-parietal,    .    .    3£ to 3J  "
           temporal,    .    .    3       "
Transverse

Vertical
rBi-
\Bi-
r
If
Trachelo-bregmatic, .    3£ to 3£
 ronto-mental, .    .    3
  The fundamental principles of midAvifery are  deduced  from the corre-
spondence betAveen the fcetal dimensions and  those of the  pelvis.   It hap-
pens, in fact, that the child at term  can only clear the  pelvic canal by
presenting one end of its long diameter ; that, Avhichever extremity this may
be, the delivery will still remain impossible if the head should present  in
such a manner as  to have its occipito-mental diameter parallel to those at
the inferior strait;  that, consequently, the  occiput must  ahvays engage
before the chin, or vice versa; and, lastly, that the most favorable position
of the head requires the latter to be strongly flexed upon the trunk, so that
its smallest  diameter (the sub-occipito-bregmatic) shall be parallel  to  the
plane of the strait; and that to be in its most favorable relation  Avith  the
pelvis, the occiput must correspond Avith one of the extremities of an oblique
diameter.
  The articulation of the head with  the vertebral column, and the move-
ments it permits, should also be carefully studied: thus, the occiput is con-
nected to the atlas by a close  union, which only admits the motions  of
flexion and  extension, which in the foetus are far more extensive than in the
adult; the  atloido-axoid  articulation, on the contrary, being ginglymoid,
only permits a rotation, Avhich is limited to  the fourth of a circle.  Whence
the conclusion is manifest, that whenever the head is caused to rotate—the
body being  fixed—great care must be exercised not to pass the limits indi-
cated; for generally the foetus Avould thereby suffer  a  mortal  lesion.  We
say generally, not always, because two cases cited  by Prof. Paul Dubois
evidently prove that children may not only survive this accident,  but even
seem to experience no bad effects Avhatever  from it.
  The great laxity of the articular ligaments in the infant can alone explain
the little danger attending  an occurrence Avhich Avould  prove so disastrous
in the adult.  Finally, the  natural situation of the head is  such in the neAv-
born child,  that the chin descends much loAver  than the  occiput, and the
axis of the  trunk  traverses the cranium obliquely from base to summit, and
from before backAvards, passing a little in front of the posterior fontanelle.
                          ARTICLE  III.

                POSITION AND ATTITUDE OF THE FOETUS.

  The foetus lies curved on its anterior plane within the bag formed by the
membranes; usually, the head is someAvhat flexed, the chin resting on the
anterior superior part of the breast;  the neck is  so short that a slight degree 
                           £>F  THE  FOETUS.                        223

 of flexion will, says M. Dubois, produce this effect; the feet are bent up in
 front of the legs—the latter strongly flexed
 on the thighs, and these again are applied               fig. 72.
 to the anterior surface of the abdomen; the
 knees are separated from  each other, but
 the heels lie close together on the back part
 of the thighs ; the arms are placed on the
 sides  of  the  thorax;  the  fore-arms  are
 flexed and throAvn across the sternum, so
 as to receive, as it Avere, the chin betAveen
 the hands.  The foetus, thus  folded on
 itself, constitutes a nearly ovoidal mass;
 the longest  diameter  of Avhich  is about
 eleven inches, having  its larger extremity
 represented 'by the breech, Avhich is turned
 tOAvards the fundus uteri, while the smaller,
 formed by the head, is directed doAvmvards.
 Noav,  it is evident  that this constrained
 position could not have been produced by
 the mere pressure of the uterine Avails on
 the child, since the latter  is in  a cavity
 much  larger  than its  Avhole   volume; The "sual p°sition of the chiid in the womb.
 hence, it  must be referred  to the  individual itself.
   The pendent position of the  head at term is so common, that we are
 naturally led to inquire Avhy such should  be the case?  Formerly, it Avas
 supposed that, after having reached the uterus, the head occupied the fundus
 for the first seven months of gestation, and the pelvic extremity its inferior
 part;  but that towards the expiration of this period, the foetus reversed its
 position ; the head approaching  the orifice, and the breech going above.
   This Avas the received doctrine until the arguments of Delamotte, Smellie,
 and more especially of Baudelocque, completely subverted it; and since
 then, it has been generally  admitted  that the foetus, suspended, so  to speak,
 in the amniotic fluid, by the umbilical cord, Avould naturally observe the
 laAV of gravity: that is, the head being the heaviest part Avould  descend.
 This  explanation Avas  almost universally adopted, Avhen M. Dubois, after
 re-examining the question, proposed  another theory.  He urged the follow-
 ing objections (Avhose value Ave fully  acknoAvledge) against the influence of
 specific gravity, to Avhich the great frequency of vertex presentations had
 been  so uniformly attributed, viz.: 1. If a child be plunged into  a  con-
 siderable  quantity of any liquid, contained in a bathing-tub, for instance, so
 that its descent Avill be very sIoav, in  order to afford the head sufficient time
 to exert  its superiority in Aveight, Ave shall find  all parts of the  foetus to
 descend Avith an equal rapidity, and, consequently, either  the back or one
shoulder will first reach the bottom of the tub.   This result, Avhich  is con-
 trary  to tlie general belief, is more in accordance Avith what is learned from
an attentive examination of the foetal structure ;  indeed, Avhen a comparison
is made, between the volume of the cephalic and the pelvic halves of the
foetus, it Avould  naturally appear that  their weight must be nearly balanced ;
 
224
PREGNANCY.
 the cranial cavity, it is true, contains a well-developed brain, but the abdo-
 men incloses the liver, which is no less so, as also the intestines and bladder,
 together with  the meconium  and the urine accumulated therein during
 pregnancy; 2.  It is really impossible to believe that the foetus is suspended
 by the  cord alone, except during the early stages, for even at  the third
 month the cord is longer than the greatest diameter of the uterine cavity,
 and therefore  its insertion near  the pelvic extremity can in no wise  con-
 tribute to the more frequent presentation of the head; 3. Besides, those women
 who maintain  the horizontal  position during  gestation on  account of ill
 health, are not the less liable to exhibit the same phenomenon ; 4.  If the
 laws  of gravity  alone  determined  the position, the  head being  more
 voluminous relatively  to  the  trunk, during the early months,  the foetus
 should  present, in cases of abortion, by the  cephalic extremity still more
 frequently than at term; but observation establishes the contrary;  5. Lastly,
 in animals the  lowest part of the  organ does not correspond with the neck,
 but rather to  the fundus, of the Avomb;  nevertheless, the foetus is much
 oftener delivered by the head than the pelvic extremity.
   After having tried to combat the generally  received opinion by the objec-
 tions just given, M. Dubois endeavors to prove that the vertex presentation
 is a consequence  of the instinctive  will of the foetus itself......The
 child, in its mother's womb, has the faculties of perception and motion; for
 the regular and nearly constant succession of the perception of impressions,
 and the movements which  folloAV,  sufficiently indicate  the same connection
 in the foetus, betAveen these tAvo functions, that should exist after birth.
   Now, the object of these foetal movements are partly certain, partly pre-
 sumptive ;  consequently, they may be regarded as really instinctive deter-
 minations ;  again,  it is  in consequence of  such a determination that the
 head in the mammalia is usually found at that part of the uterus nearest to
 the pelvic outlet.
   We frankly confess that M. Dubois seems to us more skilful in destroying
 than  in  building up; and though the  reasons  by which he combats the
 doctrine hitherto received  appear very strong, yet those whereon he founds
 his opinion are not fully convincing.   He is entitled to credit, however, for
 having sought,  in a higher  order of ideas, the explanation of a singular fact,
 which does not  seem, in the present state of our science, capable of elucida-
 tion by the material reasons heretofore given.
   If we might  be permitted to hazard an opinion, after so many others, Ave
 should unhesitatingly say they have erred by seeking  only in the foetus, its
 form and structure, for the cause of the various  positions which it assumes
 in the uterine cavity.
   Already have several authors endeavored  to account for  the  rarity of
trunk presentations, by the vertical, or the nearly vertical direction  of the
long diameter of  the uterus, which Avould naturally force the  greatest foetal
 diameter in the same line: for instance, the cause of  trunk  presentations,
says Wigand, must be referred less to the foetus  itself than to a change in
 the ordinary elliptic form of the uterus.  Now, by advancing  a step further
in the path they have marked  out, may we not find a  satisfactory explana-
 tion of the  great frequency of vertex presentations in the form of the uterus, 
OF  THE FOETUS.
225
 and especially in its mode of development at the different periods of preg-
 nancy?  For, Avhen Ave reflect that the uterus, being developed during the
 first six months at the expense of its fundus, is spread out superiorly, but,
 on the contrary, is much  contracted below, does it not become evident that
 the pelvic extremity, which, from the folded  condition of the loAver  limbs,
 is much more voluminous than the head, must naturally lie in the largest
 cavity, that is,  towards the fundus; and, consequently,  that the  cranium
 will descend to the cervix?  There can be no doubt that the inferior part
 spreads out  in  the  last three months  nearly as much as the fundus; but.
 then, the  foetal  vertical diameter is too long to  permit it to traverse the
 transverse diameter of the uterus;  and hence, with some  few exceptions,
 the child is forcibly retained in the position it first assumed.
  Finally, can we not explain by this circumstance the position of tAvins, in
 cases of double  pregnancy, where it frequently happens that one foetus pre-
 sents by the pelvic extremity, and one by the head?   In  a word, the child.
 shut up in its close sac, and constantly subjected to movement, must assume.
 not instinctively but mechanically, such a position as will bring its largest
 parts into correspondence with the most spacious portions of the organ.

                           ARTICLE   IV.
                       FUNCTIONS  OF THE FCETUS.
  The functions of  the child, while it remains in the uterine cavity, that
 require our particular attention, are its nutrition, respiration, and circulation.

  § 1. Of  Nutrition.
  Few questions in physiology have given rise to more discussion than this
 of foetal nutrition.   However, it is universally admitted  that the nuiitive
 materials  are furnished  by the mother's body;  but authors  are not  as
 unanimous in regard to the mode of their  introduction into the in'.vior of
 the product of conception.  For instance, some think that the liq uius sr.tveted
 by the internal  uterine surface transude through the membranes, s-„ as to
 reach the amniotic cavity, to be there taken up by the foetus.  Others regard
 the maternal placenta as designed to supply the child Avith nutritive matter,
 and find in the umbilical  cord the only  means of conveying it.
  It is necessary to admit at the  outset, that there  can be no discussion of
 the question until after the placenta is developed, or at least, until after
 connection is established  betAveen the  mother and  child by means of the
 allantois.   Noav, as nothing of the kind exists in the early periods  of preg-
 nancy, it must be acknoAvledged that during this time, at least, the maternal
 fluids must  reach the foetus by endosmosis through  the membranes of the
 ovum.
  The nutritive matters cannot all be derived from the same source  at the
 various periods of gestation.  Thus, Avhen the ovule quits the ovarian vesicle,
it carries Avith it a portion of the granules Avhich  formed the proligerous-
disk;  and it is probable that  these may subserve its nutrition during its
progress through the first half of the Fallopian tube.   In its passage  through
the  other  half, an albuminous matter  secreted by  the walls of the tube
        15 
226
PREGNANCY.
 envelops  the ovule,  and probably also  penetrates through the vitelline
 membrane.
   Arrived in the uterine cavity, the ovule  comes in contact, at all points,
 with the mucous membrane of the uterus.   The villi of the chorion undergo
 a considerable development, and until the placenta is formed, are all capable
 of imbibing the fluids secreted by the internal surface of the organ.  As the
 canal Avith which each is provided opens into the cavity of the chorion, the;,
 are Avonderfully adapted to this purpose; and notAvithstanding the  closure
 of their extremities, the uterine  secretions pass by endosmosis through their
 thin walls; like the roots of a tree, they serve to  convey the nutritive fluids
 into the space separating the chorion from  the amnion.   From thence, the
 nutritive  juices transude through  the Avails of the  amnion  into its cavity.
 A certain portion of  them is conveyed  into the body of the foetus through
 the canal of  the umbilical vesicle.
   But as soon as the  vascular connections,  which, as we have learned, are
 established betAveen the maternal and foetal placentas, begin to be formed,
 the non-placental villi of the chorion tend gradually to waste aAvay; the
 development of the amnios obliterates the cavity which separated it from
 the  3horion,  and along with it  also disappear the vitriform body and the
 umbilical vesicle.   It now becomes a question, whether the nutritive matters
 supplied by the mother can  penetrate into the amniotic cavity through the
 two membranes of the ovum, Avithout  collecting  to an appreciable amount
 during the passage?  Or, on the other  hand, are they absorbed  by the
 vascular radicles of the fcetal placenta, and introduced into the body of the
 embryo by means of  the umbilical cord ?
   The partisans of the former  opinion have endeavored to prove: 1, that
 the amniotic fluid is  derived from the mother; 2, that it contains nutritive
 matter;  3, that it may enter the embryo in several ways.
   A.  It is almost certain that the fluid is supplied  by the mother, for it is
 the more abundant as the child is less developed, and its quantity diminishes
 relatively  to  the  foetus, in  proportion to  the  advancement of  gestation.
 Noav, the contrary should  be true, were it a product of the foetus itself.
 Besides, foreign matters introduced into the stomach of the mother, or
 injected into her veins, have been discovered in the amniotic cavity.  It is
 also true, that they have nearly always been found at the same time in the
 blood of the  embryo and in the placenta.   So that, strictly speaking, it is
 difficult to say into Avhat part they Avere first distributed.  Verv  dissimilar
 observations  having  reference  to this subject  are  on  record.   Thus,  for
 example, in the case  of an embryo of five months, the mother of which had
 been poisoned  by sulphuric acid, Otto found that Avherever the skin had
 come in contact with the amniotic fluid, it Avas of a reddish-brown color,
 and as hard  as parchment.  On the other hand, in the case of a Avoman
 four  months  pregnant, Avho had been  poisoned by arsenic, MM. Mareska
 and Lados found, by analysis, traces of the poison in the body of the foetus,
' in the uterus, and in  the placenta, whilst  it could not be detected in the waters
 of the amnion.  Mayer, however, injected  cyanide of  potassium into  the
 trachea of a rabbit, and afterwards discovered it in the amniotic fluid, 1hc
 placenta, and the-organs of the foetus. 
OF  THE  FOETUS.
227
  B. The amniotic fluid must be nutritive, for it contains albumen, osmazome,
and some salts; in fact, young calves have been sustained two weeks on fresh
amniotic liquor.  Finally, the quantity of this fluid, and more especially
that of the animal and nutritive substances found in it, is much diminished
towards the end of pregnancy.
  c. Supposing it to be furnished by the mother, and to possess nutritive
properties, it  remains to be  shoAvn  hoAV it is enabled  to enter the body of
the foetus.  There are numerous hypotheses in reference to this point.
  The liquor amnii may reach the body of the foetus in various ways.
  1st. By cutaneous absorption.  When the umbilical vesicle ceases to fur-
nish nourishment to  the embryo, the skin  becomes  developed,  and, very
probably,  absorbs the surrounding amniotic liquid ; it is even possible that
the lymphatic vessels, Avhich are highly developed in  the foetus, are formed
as a consequence of this absorption, just as blood-vessels  are called into
existence by the circulation.
  Brugmans  proved this absorption by an experiment: thus, after having
extracted  several living embryos of animals from the  Avaters of the amnios,
he noticed that the cutaneous lymphatics Avere filled,  and  that those of the
intestines  Avere not  so;  then plunging the limbs, previously  tied, into this
liquid, he found, after the lapse of some time,  the lymphatics below the
ligature Avere filled Avith lymph.
  The epidermis is  so excessively thin, that it can offer no obstacle to the
imbibition, and the liquor amnii itself contains a large proportion of water.
Again, the sebaceous matter Avhich covers the foetus at birth, only becomes
manifest at an advanced stage  of pregnancy; and, lastly, this  absorption
has been directly proved in animals both by experiments and dissection.
  2d. By the intestinal canal. Though the cutaneous absorption may suffice
for the nutrition of the embryo, as is sufficiently proved  by the birth of
monsters and  anencephalous foetuses Avith closed mouths, neA'ertheless, it  is
highly probable that the child makes some efforts at deglutition, at  least
towards the termination of pregnancy, thereby determining the introduction
of fluids  into the intestinal canal.  Thus, embryos  may occasionally be
observed executing motions of respiration Avith their jaws, during Avhich the
waters Avould necessarily be SAvalloAved;  indeed,  in  ova, that  have been
frozen after their extraction from the  coav, an uninterrupted band of ice has
been found extending from the mouth to the stomach.  And  when the me-
conium is mixed with the amniotic liquid, it is  sometimes detected in the
throat, pharynx, and stomach.   Lastly, hair  is occasionally found  there,
which could only happen  as a  result of deglutition.
  Besides these two  modes of absorption, by the skin and  the  intestinal
mucous membrane, some physiologists have supposed this fluid  might be
taken up in other avuvs :  thus,  according to some, the  mammary glands are
provided  Avith conduits  that  act  the part of lymphatics,  absorbing the
Avaters, and carrying them  to  the thymus  gland, to be there elaborated.
Others suppose that the liquor amnii may enter the trachea and  bronchia,
and there  undergo some modification Avhich may render it suitable for nutri-
tion.  Lastly, Lobstein seems to think it might possibly enter through the
genital organs.  But all these  opinions are merely hypothetical. 
228
PREGNANCY.
  With all deference to their ingenuity, these hypotheses are still  far from
being satisfactory.  The introduction of the liquor amnii into the intestinal
canal as a regular and normal occurrence, is by no means proved  by the
facts cited in its support.   It is, indeed, more  than probable, that the move-
ments of deglution which the child has been seen to make, were really respi-
ratory efforts determined by the suspension  of the placental  respiration;
also that the icicles, the  hairs, and the meconium, found  in the  stomach,
had entered it  but a short time before the  death  of the  child;  in short,
where the antecedent death of the  mother, the compression of the cord, or
the separation of  the placenta had begun to produce asphyxia.
  Supposing the cutaneous absorption of the  liquor amnii to be proved by
the experiment of Brugmans, it would still  seem unequal to the develop-
ment of the foetus, which must have some additional source of nutrition.
  Looking beyond the membranes, there evidently can be no other  source
of supply than the maternal  placenta, and,  in fact, many  modern authors
regard the placental circulation as the principal agent in  the nutrition of
the foetus.   It  is  unnecessary  to suppose a direct communication between
the maternal and fcetal vessels, in order to  understand how that, by means
of the extensive contact existing betAveen the  vascular apparatus of the two
placentas, a transudation may take place  of the more fluid  parts  of the
maternal blood, which are absorbed and mingled Avith the foetal blood; also
that  this transuded  fluid being  charged with oxygen is subservient to the
hsematosis of the foetal blood, at the same time that it supplies it with nutri-
tive material.  (Van Huevel.)  It may, perhaps, be allowed, that  all of
the villi of the chorion, in  the midst of which  the placenta is developed,
may not be applied to the formation of the  radicles of the umbilical vessels,
but that some of  them may continue to exercise their primitive functions,
and still absorb the fluids secreted by the utricular glands of the utero-epi-
chorial mucous membrane.
  What we have  already said regarding the structure  of  the chorial villi
of the placenta lends countenance to  this supposition; for we have seen
(Fig. 68), that  beside the vascular villi, some  are  found to be solid, and
destitute of  any ramification of the umbilical vessels, although still  adher-
ing by their pedicle,  and communicating with a larger branch of the villus.
This fact seems, indeed, to  have been  anticipated by some authors: thus,
although Eschricht  regarded  the  placenta proper as being in reality the
respiratory organ of the foetus, he supposed that the utricular glands of the
womb secrete a fluid designed for the nourishment of the embryo, which
fluid is taken up by other  branches of the umbilical vessels than those by
which the placental respiration is  effected; MM. Prevost and Morin also
regard the placenta as the organ in which the absorption of the plastic mat-
ters supplied by the mother is  accomplished by the vessels  of the foetus.
According  to them, this fluid, which is deposited upon the  internal surface
of the Avomb, is taken up by the vessels of  the  cotyledons.  Thus, in  the
ruminantia, if the ovum Avith  its cotyledons  be extracted  from the Avomb
tOAvards the end of gestation, by which, consequently, the fcetal and mater-
nal placentas are separated from each other,  the separation being easily
effected  without laceration, a whitish fluid  is  discovered in the uterine 
OF  THE  FOETUS.
229
caruncles, and a similar one can be expressed from the vascular brushes of the
cotyledons.   HoAvever  this may be, it  is very probable  that  the nutritive
fluids reach the foetus through the umbilical vessels properly so called.
  When mixed Avith the fcetal blood, the nutritive elements supplied by the
mother, are, like the chyle in the adult, devoted to the development of the
organs.  Lee supposes, however, that they undergo certain changes, first in
the liver, and aftenvard in the intestine. When thus brought by the umbi-
lical vein into the large liver of the foetus, these elements  experience changes
which result in the formation of a new albuminous and nutritive compound
which is poured along with the bile into the duodenum; there the mixture
is separated into  a recrementitial part, Avhich is taken  up by the absorbents,
as in  the adult, and  an excrementitial part, charged with  carbon, which
forms the meconium.
  In fine, until the placenta is formed, the  nutritive elements reach  the
interior of the ovum by means of endosmosis ; at a later period the groAvth
of the foetus is maintained by an absorption through  the  skin of some  of
the nutritive matters contained in  the liquor amnii, and  by the assimilation
of those which the radicles of the umbilical vessels take up in the placenta.
  [It should be  added, in reference to this subject, that in the foetus, as well as  in
the adult, glucogenesis  is one of the essential  conditions of nutrition.  After a
fruitless search for glucogenous matter in the fcetal liver, M. Bernard  found  it in
the placentas of the mammalia, being especially present in the epithelial  layer of
the inter-utero-placental  mucous membrane.  To the already determined functions
of the placenta Ave haAe, therefore, to add this of glucogenesis, which would  seem
to replace the hepatic function in this respect during the earlier periods of embry-
onic life.
  In the ruminantia, the glucogenic matter having become  separated from the pla-
centa,  is found spread over the free surface of the amnion and chorion in the form
of epithelium-like  scales, which are easily seen, but which  have not hitherto been
understood.  (CI. Bernard.  Lecoiis de Physiologie, 1855.— Memoires de la Societe de
Biologie, I860.)]
  §  2. Respiration.
  Does the foetus respire in the amniotic cavity?
  If something analogous to respiration in the adult be  sought for in the
functions of the foetus, this question will doubtless be  answered negatively;
because the atmospheric air having no access to it whatever, the fcetal blood
could  not possibly  obtain any  elements from it.  But does it, therefore,
folloAV that the sanguineous fluid will experience no similar modification at
any part of the circuit ?  Most physiologists think otherwise, and I share
their opinion.
  According to some, the liquor amnii is the modifying agent for the blood,
and Beclard  supposes that the lungs  are  the seat  of such changes, the
amniotic liquid reaching them  through the air-passages.  Agreeably to M.
(Jeoffroy St. Hilaire, the Avhole  surface of the child's body absorbs air, or a
vivifying gas,  like  insects, by a species of air-tubes, or  by minute  fissures
which exist on the lateral parts of the neck in young embryos.  The resem-
blance betAveen those fissures and the  branchial  apparatus in the fish has
given  rise to the belief of an   analogous  function;  hence, \hey are called
the branchial fissures. 
230
PREGNANCY.
  But, says Bischoff, in the mammalia and man, these arcs never have an
organization justifying in the least the supposition of tneir  being intended
for  respiration ;  they never have  internal nor external branches; nor do
we ever see, as in the branchia, vessels distributed either on  their surface or
in their interior.
  Latterly, M. Serres has attempted anew to explain how respiration may
take place  in the embryo  before the placenta is fully formed.   He says the
breathing apparatus of the human ovule consists of the chorion, the tAvo
layers of the decidua, the liquid contained betAveen the latter,  and of  a
particular  class of villi, called by him the branchial, Avhich, after having
traversed the reflected decidua, come into contact with this  liquid.  On the
one  hand,  the reflected decidua  is perforated by multitudes of foramina,
which  may be aptly compared  to those on the cribriform plate  of the
ethmoid bone;  and on the other,  the chorial villosities, the branchial villi,
entering the substance of this membrane, lodge in those openings, and thus
are brought into immediate apposition Avith the liquid.  M. Serres believes
that this arrangement presents all the conditions of a branchial respiratory
apparatus; but this mode of respiration only lasts during the first fifteen or
tAventy days of the intra-uterine  life;  because, as the embryo  is developed
and  grows, one  part of the  villi of the chorion is  transformed into the
placenta, and the foetal respiration in the uterus then commences the second
time, as the placental respiration.   Then "the  branchial function decreases,
the apparatus atrophies and disappears:  at first, the branchial villi of the
chorion wither aAvay; the cavity of the  decidua is  contracted; the liquid
diminishes; and, finally, the  tAvo laminae of the decidua being brought into
apposition, unite and become confounded with each other.
  This hypothesis, though ingenious, is evidently based upon badly observed
facts, and cannot be sustained after the description of the  decidua which we
have given.
  After the allantois is developed, the villi of the chorion, Avhich have then
become vascular, are in immediate contact  Avith the hypertrophied vessels
of the mucous membrane, and from this  moment the foetal blood derives
therefrom  the elements necessary to haematosis.  In  proportion as the con-
tact becomes more intimate and extensive, the organization  of  the placenta
progresses,  and soon forms a compact mass, which is the seat  of the placental
respiration.
  In fact, this body is formed throughout in such a manner as to establish
the greatest possible approximation betAveen the maternal  blood  and that
of the  embryo;  and this mediate union,  in Avhich the tAvo  liquids are
separated  by  fixed membranes,  establishes between the  foetal and the
maternal blood the same relation that is known  to exist in the lungs of the
adult, betwixt the venous blood  and the  atmospheric air: thus, in the pul-
monary organs, the blood is brought Avithin  the influence of the inspired
air; true, there is none of the latter  in  the after-birth,  but  the maternal
vessels  are found there in great abundance, whose exceedingly delicate
walls remain for a long time in  contact with  the  umbilical  radicles, the
parietes of which are also thin and transparent.
  Therefore, if nothing but  thin, transparent membranes  divide the foetal 
3F the  foetus.
231
 olood from that of its mother, is it not possible for the first to communicate
 some of its elements to the second?  for, does not the air act thrjugh the
 walls of the pulmonary vessels  of the blood  contained therein?  And
 further, is not such a modification of the foetal blood in  the placenta suffi-
 ciently proved: 1st.  By the early death of the  child, Avhen the  umbilical
 cord becomes flattened from compression, and its circulation thereby arrested.
 2d.  By the pathological phenomena of asphyxia, which are always revealed
 by the autopsy in such cases.  3d. By the  antagonism  knoAvn to exist
 betAveen the after-birth and the lungs; in fact, the new-born  infant may
 dispense Avith the pulmonary respiration, so long as its connection Avith the
 placenta remains uninterrupted,  and this communication may be  broken
 without danger as soon as it respires through the lungs ; if it breathe freely,
 the  blood no longer passes  along the cord, and, should respiration cease, it
 shortly flows anew.  And 4th. By  the  difference in the blood circulating
 in the  umbilical vein, and  that  in the arteries, — a distinction not very
 manifest upon simple inspection, but which has been detected by physical
 and chemical experiments.  Now, in the adult  pulmonary respiration, the
 blood not only absorbs a certain portion of oxygen  from  the air, but it also
 gives off some carbonic acid.  Thus far, Ave have only learned  that the fcetal
 blood derives from  the  placenta a vivifying principle; but we have not
 observed the separation of  those  materials from it, Avhich may be unsuited
 to the nutrition of the child.  We may state, hoAvever, that most physiolo-
 gists believe the liver is destined to  the performance of this last elaboration,
i and to the  removal of its superabundant carbon and hydrogen, which latter
 are  employed in the  formation of the bile, and  contribute to the complete
 development of the organ.  We  know, in fact, that the growth of the liver
 folloAvs  that of the placenta, that both  have a  perfect  organization at the
 same periods, that the bile  is a highly carbonized fluid, and that the liver
 has a similar chemical composition.

   § 3.  Circulation.
   a. The foetal vascular apparatus exhibits certain  anatomical peculiarities
 that do not exist  in the  adult, and Avhich must be noticed, in order to render
 the account of the circulation comprehensible.  Noav, these characteristics
 evidently depend on the absence of the pulmonary respiration, for they dis-
 appear as soon as it is established ;  thus : —
   1. It is Avell known that the heart in the adult is composed of four cavi-
 ties : namely, a right and  left  auricle, and a right  and  left ventricle, each
 auricle communicating freely with the corresponding ventricle, but not Avith
 its fellow, being separated from  it  by  a complete partition.  In  the foetus
 this dividing Avail exhibits  an  opening, called  the foramen of Botal, Avhich
 becomes smaller as the pregnancy advances, and is  avholly obliterated after
 birth, in consequence of a  vah'e being developed on its inferior  margin
 Avhich gradually diminishes the freedom of the passage, and is large enough
 at term to obliterate the orifice entirely.
   2. In the adult, the  pulmonary  artery divides into tAvo large branches,
 one for each lung: these ramify throughout its ultimate  tissue, distributing
 therein the venous blood derived from the right ventricle; the blood is next 
232
PREGNANCY.
taken up by the radicles of the pulmonary veins and carried back by them
to the left auricle.  This vascular circle is interrupted in the foetus, in Avhich
the two pulmonary arteries  are very small, although their common trunk
gives origin to a voluminous canal which opens directly into the arcus aortre,
and is called the  arterial canal or the ductus arteriosus.
  3. The  abdominal aorta  bifurcates, so  as to form  the primitive iliac
arteries, and each of these again divides into tAvo branches, the hypogastric
and the external  iliac.  In the foetus, the hypogastric seems to be continuous
Avith a large vascular trunk called  the umbilical artery, but  this is nearly
obliterated in  after-life.   The two  umbilical  arteries run forwards  and
inwards along the lateral and superior parts of the bladder, and soon curve
forwards so as to reach the inner surface of the anterior abdominal Avail,
along which  they ascend to the umbilicus, then pass along the  cord, and
ultimately ramify in the placenta.
  4. Lastly, the foetus further differs from the adult in having an  umbilical
vein, which, commencing by numerous ramifications in the placental tissue,
traverses the whole length of the cord, and reaches the abdomen by passing
through the umbilical ring; then, running upAvards and to the right in the
substance of the  suspensory ligament of the liver immediately behind the
peritoneum, it gains the horizontal or umbilical fissure of this organ at its an-
terior part, where it gives off a few branches that ramify in the right and left
lobes.  Just at the point where the two fissures of this viscus intersect each
other, the umbilical vein becomes  enlarged, and  then  divides  into tAvo
branches: the posterior of which, called the venous canal, or ductus venosus,
is a continuation of the primitive trunk, and goes  sometimes to the vena
cava inferior above the  diaphragm, though at others it joins one of the
hepatic veins, and the common  trunk thus  formed  empties  into the vena
cava; the other branch is much larger, and runs to the right; it leaves the
principal  trunk lower  doAvn and more in front than the venous canal; then
it unites with the vena portse, producing a canal whose diameter is double
its own.   This is called the canal of reunion, or the confluence of the portal
and umbilical veins.   After a short course, this vessel subdivides  and rami-
fies in the substance of the liver, anastomosing Avith the hepatic veins, Avhich
(as in the adult) finally reach the vena cava a little above the ductus venosus.
  Plate V., together  with the accompanyfng  explanation, illustrates the
whole vascular apparatus of the foetus, and to it the reader is referred.

                  EXPLANATION  OF  PLATE V.
  WHICH  EXHIBITS THE WHOLE VASCULAR  APPARATUS  OF THE FOETUS.
  a. The heart,  b b. The lungs,   c. The spleen,  d. The liver,  n. The lobulus
spigelii.  e e.  The kidneys,   f. The thymus gland,  g. The upper extremity of tbo
rectum,  i. The* bladder.  K. The ureters,  h.  The womb.  o.  The umbilical cord.
1. The aorta.  2  The brachio-cephalic trunk.  3. The left primitive carotid artery.
4. The left subclavian artery.  5.  The  pulmonary artery.  6. The ductus arteriosus
7. The vena cava superior.  8.  The right internal jugular and  the right subclavian
veins.  9.  The left subclavian vein.  10. The  abdominal  aorta.  11. The  primitive
iliac arteries.  12.  The umbilical arteries, coming off from the bifurcation of the primi-
tive iliac.   13. The external iliac artery.  14.  The umbilical vein.  15.  The ductus
venosus.  lfi   Vena cava inferior.  17. The vena portarum.  18. The renal arterj
and veins.   1). The splenic artery.  20  The ovarian vessels. 
PI.  V.
T Sv~.-ia-.T<S-£Hh. 
 
OF  THE  FOETUS.
233
    B. Noav, having acquired  these anatomical views, let us see what is the
 course of the blood  in the foetus.  A part of this fluid, circulating in the
 umbilical vein, is, therefore,  discharged  by the venous canal directly into
 the vena  cava;  another part is  distributed to the liver, Avhere it probably
 undergoes, as before stated, some purification, and thence is  brought  back
 by the hepatic veins to the vena cava.  Consequently, all the  blood  from
 the umbilical vein reaches the vena cava inferior either directly or indirectly.
 The blood contained in the latter is therefore a mixture of that Avhich returns
 from the inferior extremities of the foetus and of that poured into the liver
 by the vena porta?,  with  the  addition of the portion contributed by the
 umbilical vein.   This  compound reaches the  right auricle  through the
 ascending vena cava, Avhere  it only mixes partially  Avith the blood of the
 upper extremities, which has been  brought back by the  descending vena
 cava;  because, in passing into the  auricle, the ascending or inferior vena
 cava is directed  towards the foramen of Botal, and  hence its blood passes
 in a great measure through  this opening into the left  auricle, and thence
 into the left ventricle.   By the contractions of this latter the fluid is then
 forced into the aorta, its impetus being broken against the great curvature
 of this artery; and the blood then passes into the vessels which arise from
 the arch, and is distributed through them to the head and superior extremi-
 ties, a very small portion of it  only reaching  the  descending  aorta and the
 lower parts of the body.
   The blood, after having thus supplied the upper half of the body, is  col-
 lected by the veins, which, by their  successive union, form  the superior or
 the descending vena cava;  the latter empties into the right auricle, where a
 small quantity of its blood mixes with that brought by the ascending cava ;
 but much the largest  part passes  directly into the  right ventricle, which
 forces it into the pulmonary artery.
   This vessel sends but a trifling portion  to the lungs; the rest being thrust
 into the ductus arteriosus, which discharges its contents into the aorta: that
 is to say, the blood that has contributed to the nutrition of the superior parts
 of the body, and has traversed the descending vena cava, the right auricle,
 the right ventricle, and pulmonary artery, and then has passed through the
 ductus arteriosus, finally mingles Avith the remnant of blood still existing in
 the descending aorta.  The whole noAV descends to the inferior part of the
 latter vessel, Avhere a small  portion of it is sent through the arterial trunk
 to supply the inferior  extremities, whilst much the largest quantity is driven
 into the umbilical arteries, and is carried by them back to the placenta:
 Avhere, after having undergone the modifications  produced by the placental
 respiration, it is again taken up  by the radicles of the umbilical vein to once
 more traverse the same circuit.
   c Of the Changes in the Circulation after Birth.—It is difficult to  explain
 the cause of the first  inspiration ; by some, it has been attributed to an
 instinctive movement  of the foetus, from the '' besoin de respirer"  (necessity
 of respiring) experienced by it, after a separation  from the placenta; but
 these  reasons  are not satisfactory to  me,  for the air is only introduced into
 the lung as a consequence of the enlargement of the cavity of the chest, and
nrt, as some imagine, to fill  a vacuum  which never existed.  Noav  this 
234
PREGNANCY.
expansion of the chest has for its sole cause the violent, jerking, spasmodic
contraction of the diaphragm, Avhich is ahvays the result of a suffering con-
dition of the foetus, caused by the suspension of the utero-placental circula«
tion, the sudden impression  of cold, or the different characters of the media
to Avhich the child is successively and rapidly subjected.  Finally, also, by
the artificial excitations (friction on the surface, irritation of the mucous
membranes, &c.) resorted to when the infant is feeble.
   As soon as the respiration becomes established,  the sanguineous current
takes another direction; because, on the one  hand, the fluid  Aoavs tOAvards
the lungs in greater quantity; and, on the other, the placental circulation
is  forcibly interrupted.  Below, I subjoin the results of the labors of Billard,
who has devoted particular attention to the modifications  then observed in
the organs of circulation, as  they are  interesting  alike to the accoucheur
and the medical jurist.
   The foetal openings are generally obliterated in the course of a week after
birth, still, they may remain  patulous  at that  age; and, I may add, that
either the foramen of Botal or the arterial canal may continue pervious at
two or  even  three Aveeks, without the  child's experiencing any particular
disadvantage therefrom during after-life.
   The  umbilical arteries are  usually closed  on the second  day ; even  at
tAventy-four hours they have already become  smaller in the vicinity  of the
ring, and they are  obliterated by the third or fourth  day as far as their
junction Avith the hypogastrics, by gradually changing  into a fibrous cord;
the whole process being completed in three weeks.
   The umbilical vein is never obliterated until after the arteries have become
impervious, and the same is true of the ductus venosus; however, both are
quite empty, and considerably contracted on  the fourth day, and  they are
generally closed up by the sixth or seventh.
   The arterial canal and the  foramen of  Botal are the last to undergo this
process; but they rarely persist beyond the eighth or ninth day, although
the foramen sometimes remains open  much longer, being only effaced com-
pletely tOAvards the end of the first year.
   If the ductus arteriosus and the umbilical arteries be examined during
the progress of obliteration, their parietes Avill be found to grow gradually
thicker; this hypertrophy is particularly observable in the arteries near the
navel, as may be easily verified by making sections of them  at this  point;
but the  thickness gradually  diminishes  towards their origin from the iliacs,
and their canal is likeAvise  obliterated  precisely in the same order of pro-
gression. Of course, the contractility of its walls Avill also contribute towards
effecting the occlusion.
   The arterial canal undergoes a similar  hypertrophy and  parietal retrac-
tion, which takes place in such a manner that, whilst the absolute size of
the vessel does  not appear  diminished,  its  orifice is greatly contracted,
resembling a pipe whose fracture is quite thick, and opening at its  centre
of very moderate calibre.   The obliteration is therefore  the immediate
result of the retraction and  concentric hypertrophy of the walls;  neverthe-
less, it  should not  be regarded as   the  primitive cause,  for if  the same
quantity < f blood flowed into those vessels, such a retraction evidently could 
OF  THE  FOETUS.
235
 not take place; but  from the very first inspiration, this  fluid is driTen by
 the contraction of the right ventricle (see hereafter) almost entirely into the
 pulmonary arteries,  scarcely  any of it  passing  by the ductus arteriosus;
 and,  on the other hand, the  very oblique  angle at Avhich  the umbilical
 arteries pass off, satisfactorily  explains Avhy the blood, that flows into them
 in such great abundance Avhen it has  no  other outlet, no longer enters them
 at all, or at least only very feebly, when  the establishment of respiration
 has completed  the vascular circle of the neAv-born child.
   But the umbilical vein and the ductus venosus are not obliterated in this
 way,  and their walls exhibit no remarkable increase of thickness;  for,  after
 the cord  has been  cut, these  vessels receive no more blood, excepting in
 those cases where it regurgitates from the vena cava, and then the Avails fall
 in and become contiguous, just like any other canal, when the liquids that
 habitually traverse it are cut off; nevertheless, the umbilical vein and the
 ductus venosus retain  their cavities  free for a long time, for a large probe
 may easily be introduced into them ; but this cannot be done in the arteries
 nor in the ductus arteriosus.1
   The foramen of  Botal is  the last to disappear,  although  an effort at
 obliteration  may  be  observed  there sooner than  in  any other of  the foetal
 openings:  thus, the tAvo auricles are  nearly confounded in one in  the early
 stages of intra-uterine  life, and  the diminution of the foramen ovale only
 begins to take  place  about the third month by the development of a semi-
 lunar valve on its inferior border.   This valve, composed  of a double mem-
 branous layer, containing fleshy  fibres in  its  substance, gradually  rises
 along the margins of the opening towards the  left auricle, by contracting
 adhesions  with the  circumference  of the  foramen, and it ultimately forms
 the fundus of the fossa ovalis, as also, the  little  semilunar fold  seen in the
 auricle.   In this  Avay the partition is completed, being  merely perforated
 by an oblique  canal occasionally found  in young subjects, which  also  dis-
 appears  after a time.2
   The folloAving summary will enable the reader to appreciate the  influence
 of these vascular  changes upon the circulation.
   Immediately after the first inspiration, and from the sole fact of the  dis-
 tention of the  pulmonary cells, the branches of the  pulmonary artery,
 ramifying in the mucous  membrane, and  contributing to  the  formation of
 their  Avails, are suddenly rendered permeable throughout their Avhole extent,
 and a vacuum  is therefore produced,  into Avhich  the  blood is sent from the
 right  ventricle; consequently, from that period,  the route travelled by this

  1 A  case of persistence of the umbilical  vein in the adult, which communicated at
 one extremity with the vena porta;, and at the other with the crural vein through the
 superficial abdominal veins, is reported by M. Cruveilhier, in the  16th number of his
 Pathological Anatomy.
  2 According to  Dr. Tyler S*nith, the expansion of the lungs produces a compression
 of the  ductus arteriosus by the left bronchus, and thus assists in its obliteration.   The
 cliango effected in the position of the heart also aids mechanically  the occlusion of the
 foramen  ovale; and finally, the depression of the liver by the respiratory act, closes
the umbilical vein by flattening its walls.   (The Lancet, Sept., 1848.)  None of these
assertions appear to us sufficiently well proved, and therefore demand further investi-
gation. 
236
PREGNANCY.
fluid, from the right ventricle to the aorta, is much longer than heretofore,
and the ductus arteriosus, being thus emptied, will retract at once, and have
its calibre very much diminished.
  The right auricle, Avhich could scarcely force all the blood that it received
from the venae cava?, through the  foramen of Botal, now sends the most of
it into the right ventricle.
  Prior to birth, the  left auricle only received  the blood by the foramen
ovale,  but it  is henceforth filled with  that brought through  the  four  pul-
monary veins.   Moreover, the relation that  existed, in the quantity of the
blood deposited in each auricle, is changed from that  time; for the right,
which was distended beyond measure,  now relieves itself Avith facility, Avhile
the left, that scarcely received any before, is  filled with  the blood brought
by the pulmonary veins;  so that it would Aoav from  the left  to  the right
auricle, through the foramen ovale, if the semilunar partition, Avhich acts as
a valve, did not prevent such  a  movement.
                                                »
  [g  4. Innervation.
  Most of  the encephalic functions remain,  according to M. Jacquemier,  entirely
dormant during intra-uterine life.  Sensibility, however, becomes highly deA'eloped
in the foetus at quite an early period ; in proof of  Avhich it is only necessary to press
upon the Avomb through  the walls of  the  abdomen, Avhen the foetus  will be found
to move for the purpose of avoiding compression.
  A  more direct   experiment may  be made as follows.   If the  abdomen  of a
pregnant  rabbit be opened, the fetus will be visible through the transparent
walls of the womb, and  a foot may be readily caught and compressed by a pair of
forceps.  When this is done, the foetus moves in such a manner as to leaAre no
doubt that it feels a certain  degree of pain:  for its action could not be regarded a
merely reflex phenomenon.  Spontaneous motions are caused by instinct or a vague
and obscure exercise of volition.
  During  intra-uterine  life, therefore, and  especially near the end of gestation,
innervation is almost as perfect as  in  the new-born child.
  The  functions of the  fcetal nervous system present, like those of the adult, an
intermittent action or periodicity, resembling the waking and sleeping states.
  When a new-born child is asleep, if it be awakened and  excited  briskly several
times with the tip of the finger, it will, at  the moment of awakening, almost always
make some abrupt motions.  The same thing takes place, no doubt, during intra-
uterine life, so that when we try to produce active movements by compressing the
uterus, it is probably aroused from the sleeping to the waking state, and just then
the hand on the abdomen becomes conscious of the actions elicited.]

  § 5. Secretion.
  As it is not our intention to  treat of  all the  various secretions which occur
in the foetus, we shall confine  our remarks to those of the bile, meconium,
and  urine.
  1. Secretion of Bile. — The  liver is the most voluminous of  all the foetal
organs.  At .three months its texture is soft and pulpy, not yet having the
granular character visible at term  ; the gall-bladder at that period resembles
a white  thread,  its inferior extremity  being the largest, and its  cavity
exceedingly contracted.   At five  months the volume of the  liver is much
greater, the texture more condensed,  and the gall-bladder more apparent;
the secretion of  bile  then  begins,  and  continues to  augment  thereafter 
DIAGNOSIS  OF  PREGNANCY.                 237
throughout pregnancy.   We have just stated Avhat appear to us to bt the
principal elements of the bile.  At the seventh month, the  gall-bladder is
filled  Avith a yellow  secretion, and a considerable quantity of this is also
found in the intestinal canal.
  2.  Meconium. — During the early periods of the intra-uterine  life, the
digestive canal is merely moistened by a little  fluid, but a more abundant
secretion begins to take place tOAvards the third month.  According to Lee,
the stomach then contains a clear, acid, and non-albuminous fluid; whilst
at the upper part of the  small  intestine a substance similar to chyme  is
found, consisting of pure albumen,  and there is an analogous albuminous
liquid in the biliary duct.  The meconium exists in the small intestine only,
prior to the fifth  month, and is of  a greenish-brown color, but  after that
period it reaches the large intestine, becomes of a  darker hue, and finally
accumulates in the rectum.   This fluid is a mixture of bile with  the pro-
ducts secreted by the intestinal mucous membrane.
  3.  Urine. — The urine never  fills the  bladder  entirely  in the human
embryo; now, as the kidneys are developed  early, and their secretion com-
mences at  once, the urine must certainly be evacuated by some outlet.  On
this account, certain  embryologists  have supposed  that the bladder  com-
municated originally with the allantois by means of the urachus, and that
the cavity of this  membrane Avas the  ultimate reservoir of the urine.
HoAvever,  this is not the  generally received opinion, for, as Ave  have else-
where proved, the allantois ceases to exist in the human species as a distinct
vesicle long before the development of the  kidneys; and  the urine must
therefore be expelled through the urethra into the amniotic cavity.
  That its evacuation is necessary is proved  by the facts  already  cited, in
Avhich the  existence of an imperforate urethra led to extreme distention and
even rupture of the bladder.
                        CHAPTER  VI.

                      DIAGNOSIS OF PREGNANCY.

  The signs of pregnancy are divided into the rational and the sensible.
  The first comprise all those characters pointed out by authors as existing
in the earliest periods, by which they  assert a conception may be justly
suspected ;  then in the subsequent stages, — the suppression of  the menses,
the enlargement of  the abdomen, the pouting of the navel, the  phenomena
just studied in the breasts, the  symptoms, or rather the functional disturb-
ances in the digestive organs, the condition of the pulse, the modifications
in the urine, and lastly, certain changes that occur in the woman's habits,
as Avell as in her moral and intellectual  faculties.

  § 1. Rational Signs.
  According to Aristotle, there  is some ground for believing the Avoman has
conceived, if no  fluid oozes out from the vagina after coition, and  if the 
238                         PREGNANCY.
penis is unusually dry when Avithdrawn;  and the opinion  seems to be uni-
versally received by shepherds, that the retention of the semen  is an evi-
dence of impregnation.  Agreeably to Hippocrates, the eyes become more
sunken, more languishing, and are surrounded by a bluish circle, and spots
of different sizes appear on the face.  Again, since the days of Democritus,
a swelling of the neck is also enumerated as a sign of conception.  Hoav-
ever, all these symptoms have but little, if any value, and I accord far
greater  importance  to the more voluptuous sensation, the more general
erethism experienced by some females during a prolific coition, by which a
feAV of them can recognize Avith a degree of certainty that they have become
pregnant.
  1. Suppression of the Menses.—Females cease to be regular during preg-
nancy;  and this is a law of such general truth, that Avhenever it occurs in
a healthy woman, without a knoAvn cause, and not attended Avith, or followed
by any morbid symptom, it is justly regarded as a probable sign of  gesta-
tion ; but as  this suppression might  be  produced  by a number  of other
causes, Avhenever a physician is consulted about it, he ought carefully to
inquire  into all the  circumstances,  past  or present, Avhich may have pro-
duced such an effect.   It would be out of place noAV to enter into this diag-
nosis, but Ave may reiterate an observation, already made by several  authors,
and  which our  experience has frequently verified, namely, that  in some
yqung married'women, Avho had hitherto been quite regular, the menses be-
come at once  suppressed, and continue so for several months, without any
known cause; and this suppression, resulting probably from the irritation
or derangement  produced in  the  genital organs by  the  first conjugal
approaches, is frequently accompanied by an augmented volume of the ab-
domen, and a  more exalted sensibility of the mammary glands ; and,  as the
mind so readily believes what  it most ardently desires, nothing more than
this is Avanted to found a hope of a commencing  pregnancy.   Hence  the
physician must exercise great discretion in his diagnosis, Avhen consulted  on
so delicate  a subject.
  The menses may continue during pregnancy;  thus they frequently appear
in the earlier months, more rarely during  the first five or  six months, and
Avhat is still more unusual by far, they may exist during the whole period of
gestation.
  Numberless observations of this  kind,  recorded by authors,  prove  the
truth of these assertions, and we also can bear testimony to the same point;
thus, Ave saAv some females in 1837-38, Avho Avere evidently  pregnant, and in
whom the menses floAved at the usual periods, and lasted for the same num-
ber of days;  one of them  assured us that she menstruated during  the first
five months, and that her courses appeared on the second of each month,
and  lasted for two  days, just  as she  had  them previously.   Again, tAvo
females came under my observation at the  Hotel  Dieu, Avhose cases have
been already published in my  thesis, Avho Avere regular throughout  the
whole term of  pregnancy.  Dunal (of Montpellier), Haller, and Mauriceau
likeAvise cite similar cases; but notAvithstanding all this, some accoucheur?
still deny that Avomen can be regular Avhilst pregnant.
  M. Moreau, who professes this belief, has, however, often knoAvn females 
DIAGNOSIS OF  PREGNANCY.                 239
 to have sanguineous discharges at variable periods during  gestation, but
 the  irregularity of their appearance, the qualities  of the  blood itself, and
 the  greatness or smallness of its amount, serve  to distinguish these, in his
 estimation, from a true menstrual discharge.  The remark of M. Moreau is
 certainly applicable to many cases, but the instances above cited, and num-
 bers of others that might be quoted from various Avriters, do not permit me
 to entertain a doubt that a Avoman may menstruate during pregnancy.
   On the other hand, females  may become pregnant Avithout ever having
 had their menses;1 and the same  is true of some others in Avhom  they are
 suppressed  either by accident, from the  progress of age, or in consequence
 of nursing.2
   All those  anomalies will be understood Avithout difficulty, if we do but
 recollect that, although the appearance of  the menses is always connected
 with the ovarian evolution,  the  latter may take  place Avithout being accom-
 panied by the menstrual Aoav.   (See Menstruation.)
   Deventer, Baudelocque, and  Chambon furnish  accounts  of women Avho
 were regular only during gestation ; the case cited by Deventer is  particu-
 larly curious, from the opportunity he had of  observing  this  fact in four
 successive pregnancies of the same Avoman.   Finally, Desormeaux  believes
 from his observations, that in certain years, and often Avithout any apparent
 cause, a greater number of Avomen  have their menses during gestation, even
 Avhere they Avere completely suppressed during  former pregnancies.   Does
 this result,  as he appears to think, from atmospheric influence, or is it pure
 chance ?  For my part, I am unable to decide the question.
   Though it is important to be aware of these exceptional cases, it is equally
 necessary to guard against the  general  tendency to a belief of  the  marvel-
 lous. It should not be forgotten, that the continuance of the menses during

  1 A young  woman presented all the signs of pregnancy, and although she had never
 menstruated  previous to that period, her courses then appeared and continued during
 the whole of  gestation.  (Perfect, Cases of Midwifery, vol. ii. p. 71.)
  A  lady, aged twenty-four years, during eight of which she had been married, was
 never regular except during pregnancy, and  each appearance of  her menses proved
 to be a certain  sign of that condition.
  A woman,  who married  at twenty-one, had never been regular; two years  after-
 wards she experienced  some gastric distress, and the flow appeared.  Nine months
 subsequently, she was delivered of  U healthy child, notwithstanding the menses did
 not. fail to appear every month.  (Churchill, Observ. on  the Diseases of Pregnancy, p. 36.)
  2 Dr. Flechner, of Vienna, relates that a young woman of twenty-two, had always
 been regular, but the menses never reappeared  after the first accouchement,  being
 replaced  each month^by an intense headache, accompanied with a feeling of oppres-
 sion and heat in the forehead and parietal regions.  During the  succeeding thirteen
 years, she gave birth to six healthy children.  (Gaz. Med., p. 91, 1841.)
  Dewees states,  that a  woman who had been  married for several months, suffered
 some gastric  distress.  She had never been regular but three times, and for a number
 of years there was a complete suppression.   He directed rhubarb pills, which purged
 her slightly, but did not  relieve  her; six months afterwards, the abdomen being some-
 what enlarged, he was enabled to ascertain that she was six months advanced in preg-
 nancy ;  and soon after the menses returned, and continued regularly until term.  Dur-
ing  lactation, which  lasted a year,  the courses did not appear;  she then weaned the
child, and in  a short period again became regular, and this, like the former, was the
announcement of a new pregnancy. 
240                         PREGNANCY.
pregnancy is of rare occurrence, and that, although theii suppression is of
gieat value as a point of diagnosis, it may nevertheless be the  result of a
variety of causes.
  2. Enlargement of the Abdomen.—An increase in the  size of the abdo-
men may be produced by so many different causes that  its  slight value as
a sign will  be readily foreseen.  There  is, however, something  peculiar in
its shape and mode of development in gestation.   Thus the abdomen swells
someAvhat in the first month, but this is owing to a collection of gas in the
intestinal cavity, Avhich, after remaining a few weeks, diminishes and  dis-
appears, whence the Avoman often seems  smaller at the  end of the second
month  than during the first;  but Avhenever this slight  tympanitis  is  not
manifested, the abdomen is flatter the first month than before, probably be-
cause the uterus settles down in the excavation.   At the beginning  of the
third month, or at three months and a half, the hypogastric region evidently
becomes  more  salient, and the enlargement  is thenceforth regular and
always increasing  until  term.  Consequently, the tumefaction begins to
show itself just above the symphysis pubis, being more considerable at first
on the  median  line than elseAvhere, while the sides appear flattened; after
the fourth month, the upper extremity of the uterine tumor may be clearly
perceived through the abdominal wall, especially  in thin subjects, by placing
the woman on her back and the abdominal muscles in a state of relaxation ;
but  if  the  parietes be thick and tense, palpation,  practised  in the manner
hereafter described, will become necessary to ascertain this point.
  The  modifications in the size of the abdomen,  at different  periods of  ges-
tation, have already been described; but its development  is  not ahvays
regular, being, for instance, much more  rapid  in tAvin  pregnancies, and in
dropsies of the amnios than in other cases.   Besides, the relation  betAveer
the volume of the abdomen and the stage of pregnancy, is not ahvays main-
tained ; thus, some women are no larger at seven or eight months than
others are at five, owing either to their high stature, their breadth of pelvis,
or the small degree of projection in the vertebral column  and upper part
of the sacrum.  On the contrary, in small Avomen, more especially in those
having a contracted pelvis, and in Avhom the womb is therefore necessarily
raised, during the early months, above  the superior strait,  the abdominal
protuberance  is premature, if I may so express  it, and is much  better
marked at quite an early period than ordinary.
  The  umbilical depression at first appears deeper, its bottom seeming to be
draAvn  doAvmvard and backward in consequence of a tension of the urachus,
occasioned by the fundus of the bladder folloAving the descent of the uterus
in the excavation.   The circumference of the ring becomes at the same time
the seat of a distressing dragging sensation, and  is more sensitive to pres-
sure; and this sensibility is sometimes extended  over a considerable portion
of the  abdominal Avail.   But about  the end of the third month, that is, as
soon as the uterus gets above the  superior strait, the umbilicus resumes its
normal condition ;  at the fourth month, it is less hollow than before concep-
tion— then its bottom becomes more and more superficial during the fifth
and the sixth, and the Avhole depression  is effaced, and is  found  on  the same
level as the skin by the  seventh month, and  in  some  cases, the umbilical 
DIAGNOSIS  OF  PREGNANCY.
241
 ring is sufficiently dilated to receive the end of a finger; finally, in tie last
 two months, the navel forms a protuberance.  Not unfrequently, small por-
 tions of  the epiploon become engaged in the ring during the exertions  of
 the female and project externally.
   These changes in  the umbilicus  afford a rational sign of great value,
 because they are almost constant.  I say almost, for in a case observed  by
 M. Blot, there existed a depression  three-eighths of an inch in depth, the
 woman being at term and of ordinary embonpoint.  Though these altera-
 tions of the umbilical depression may be produced by a pathological tumoi
 of considerable size, or by  an accumulation of fluid  in the peritoneum, it is
 equally true, that  they almost always  exist in advanced pregnancy, and
 that their absence is, in a majority of cases, conclusive against the existence
 of a foetus of seven or eight months.
   3. The presence  of the streaks, and especially of the brown line, Avhich
 extends,  as we have stated, between the pubis and umbilicus, is very impor-
 tant to the diagnosis, especially in a primiparous female.  The streaks, how-
 ever, may be present whenever the abdomen has suffered great distention
 from  any cause whatever.
   4. The phenomena presented by the mammse afford, in the opinion of Mr.
 Montgomery, a certain sign of pregnancy.  Smellie  and  Hunter also con-
 sidered the  changes in the areola as a positive evidence of this condition.
 The latter surgeon, indeed, did not hesitate on one occasion, when  examin-
 ing a dead  body, to declare from this sole indication,  the  uterus to  be
 enlarged by the product of conception; as the examination proceeded the
 hymen was  found intact, but  even  this did not change  his  opinion, and
 when the womb was opened its correctness was fully confirmed.  This fact,
 with many others which might be cited, prove the value of these signs when
 they exist, which unfortunately is  not ahvays the case; any one of them,
 indeed, may be wanting,  and sometimes they are totally absent.  Thus, in
 1837, I saAv  a strong and vigorous young brunette at La Cliieique, Avho had
 advanced to the end of gestation, without any of the indicated marks appear-
 ing around  the nipple; and I have since made  the same observation on
 several different occasions.  Their absence is not therefore an absolute proof
 of the non-existence of pregnancy, so that their importance in this respect
 has been  exaggerated by  some English surgeons.  These cases, however, are
 rare, and I should diagnosticate as  almost certain the existence  of preg-
 nancy in  a voung woman avIio had never borne children, and Avhose breasts
 presented  both a broAvnish-colored  areola, the tubercles, and  the freckled
 characters before described.  But in those Avho have had children, it is very
 difficult to determine Avhether these  signs  result from the modifications of
 ihe breast in former pregnancies, or from a neAV conception.  In such cases
 we have only the  testimony of the Avomen  themselves to  rely on, and  this
 more especially, if but a short  time has elapsed  between  the last and the
present gestation.
  [Wo  have examined a young Avoman  in Avhom both vagina and uterus wero
absent, although the external  genital parts were well formed.   Pregnancy in such
a case is evidently impossible, yet here the  true areola Avas of a very dark color,
B.nd the dotted one very decided.  Still,  the deepened color of the  breasts, when
       16 
242
PREGNANCY.
 well marked, is a good rational sign, though its absence is far from disproving'the
 existence of pregnancy.  In brunettes, the true areola  almost always darkens as
 the dotted  one  forms.   Such, however, is not the  case with blondes, in whom the
 color of the breasts is far less decided, and in women of a ruddy complexion it is
 generally absent even at the end of gestation.]
   5. I have never been able to appreciate the reputed value of the signs
 founded on  the state of the pulse of pregnant women, for although it has
 always seemed more developed, fuller, and harder, I could discover nothing
 further concerning it.
   6. The disorders of digestion, as well as of the  moral and intellectual
 faculties, are of but secondary diagnostic importance; they can do little more
 than direct the attention of the possibility of a doubtful pregnancy, but as
 they belong more properly to the pathology of gestation, they  will be
 studied hereafter.
   7. Alterations of the Urine. — Having treated at length of the production
 of Kyesteine in the urine of pregnant women,  we merely state here that its
 presence is not as certainly diagnostic  as some authors have supposed.  Yet
 its existence in the urine of an otherwise healthy woman is an important
 rational sign.
  Finally, it will be perceived that no one of the rational signs whose diag-
 nostic value has just been  discussed is  conclusive,  when taken singly;
 excepting,  hoAvever, the changes undergone by the breasts, which, if  Avell
 marked in a primiparous female, may of themselves remove all  doubts as
 to pregnancy.
  But although, singly, these various signs may only give rise  to doubts,
 their union furnishes a sum of probabilities nearly equivalent to certainty,
 a certainty which, however, could never be complete until after a determina-
 tion of the sensible signs, Avhich Ave shall next proceed to examine.

  § 2. Sensible Signs.
  All the sensible signs of pregnancy are  derived  either from auscultation
 or the touch.   Hence, we must carefully study these two means of explora-
 tion, as Avell as the results which they  furnish.
  A. Of the Touch.—The touch, considered in an obstetrical sense, is the art
 of ascertaining the condition of the various hard and soft parts in the female,
 which contribute to the great act of reproduction ; and it consists in the
 exploration of  those parts by aid of the finger and hand  applied to the
 vulva, vagina,  and rectum, or upon the abdomen.
  The  touch is practised  under various circumstances, for  the purpose of
ascertaining the existence and stage of the gestation;  the imminence of an
approaching accouchement;  the progress of the travail;  the presentation
and position of the foetus;  the  nature and  energy, or the feebleness of the
contractions;  and the character, volume, and situation of obstacles  pre-
sented  by  the  hard or soft  parts, which  might  prevent  the spontaneous
termination of labor, and demand the resources of art.   The fact that any
moment in the life of the accoucheur may call  for its exercise, is of itself an
evidence of  its great importance,  and of the necessity for practising it.
 W'th some experience, any one, whatever be the shape or size of his finger, 
DIAGNOSIS  OF  PREGNANCY.
243
 may acquire such a degree of skill in the touch as Avill bear him tniough
 the most difficult cases in practice.
   Let no  student, therefore,  be disheartened by the difficulties met at the
 commencement,  or  by the groundless fears of too  short a finger, for  this
 becomes  longer by exercising the touch; and those pedants are  unworthy of
 credence, avIio seize a hand, and after  examining it gravely, reject it with
 disdain, exclaiming, " You will never  be an accoucheur with such a hand
 as that."  Women,  generally, have shorter fingers  than ourselves, yet they
 become  very perfect in the touch;  and I repeat, that, unless there is a mal-
 formation  of the hand or  fingers, anybody may learn by practice to touch,
 and to touch well.
   1.  Vaginal Touch. — The index-finger is usually employed for this purpose;
 after being extended, it is entered horizontally in the fissure betAveen  the
 nates, until arrested by the soft parts, and the index is then draAvn fonvards,
 as far as  the  opening of the vulva.   I  prefer this  method to the  one in
 Avhich the  finger is carried  from before backwards, in such a manner as to
 pass  over  the clitoris and the meatus urinarius, because friction  against
 these parts should  ahvays be avoided Avith the greatest care.   In bringing
 the finger  from behind  fonvards, it Avould not be  possible, except through
 gross negligence, to  confound the anal orifice with the vaginal opening, and
 this being  once found, the index is first pressed almost directly backAvards.
 until one-third of it has penetrated  into the vagina, and then by strongly
 depressing the Avrist, the operator gives his finger a nearly vertical direction,
 so that  the thumb may be applied against the anterior face of the symphysis,
 the radial  border of the  index be directed in front, and its cubital border be
 placed  against  the  anterior  perineal commissure, Avhich it serves to push
 backAvards.  The other three fingers vary in position, according to the case,
 and more  especially  to the object in  view;  for example, if desirable to
 explore  the parts situated on  the posterior plane of the excavation with  the
 index, it is better, in my opinion, to extend them on  the perineum, pressing
 the latter up by the radial border of the medius; but if, on the other hand,
 we Avish to perform the ballottement, or to explore the parts on  the anterior
 plane, it will  be more convenient to flex  the  thumb and  the  other  three
 fingers  into  the palm,  the index  alone being extended, Avith its palmar
 portion  directed  in front.  Stein directs  the medius to be joined with  the
 forefinger,  but this is generally useless, and often inconvenient, for although
 the two fingers may possibly penetrate a little deeper, the sensation is  not
 so clear  as that obtained by one.            \
  Physicians should accustom themselves to touching Avith both hands,  for
 there are some diseases of Avomen, and some positions of the foetus, Avhich
 compel  the accoucheur to use the  left hand.   Or, it  may also happen that
 a wound upon the  right will necessarily require the left to be substituted,
 though for all ordinary purposes the right is sufficient.
  The Avoman should  be placed either in the erect, or the recumbent posi-
 tion during the examination, according to circumstances.  In the commence-
 ment of pregnancy, it is  better, as a general rule, to have her lying down;
 because,  in this  position, the head  being propped  up,  and  the inferior
extremities flexed and separated, the abdominal muscles are throAvn into a 
244
PREGNANCY.
 state of relaxation, and thus the development of the uterus cai. more easily
 be determined.  Again, such diseases as prevent the female from standing
 erect, may also require the same posture.  But at a more advanced period,
 either position may be used  indifferently, though most frequently the bal-
 lottement can be accomplished better while the woman is standing.   In
 this latter case, her loins should lean against a wall or some piece of furni-
 ture ; a chair must be placed at each  side for her hands to rest upon, and
 the upper part of her body is to be slightly flexed forward.
  Where any difficulties are encountered in the exploration, it is advisable
 to touch in both positions.
  Before operating, the accoucheur should  anoint his finger with some
 unctuous substance, fat, butter, oil, mucilage, &c, for the double object  of
 rendering the introduction  easier and less  painful to the woman, and  to
 protect himself from the contagion of any disease she may be affected Avith.
  When the female is standing, he should place himself before her, resting
 on one knee—in my opinion, it is not wholly immaterial which—for, as a
 general rule, the knee opposite  to the operating  hand is preferable, because
 the  other one will then  furnish a point of support for the elbow to lean
 upon ; though, if the woman be very short, it would be better to flex the
 right knee, if the right hand is used.
  When the patient is recumbent, the accoucheur places himself at her side,
 the right one, if he intends  using the right hand, and on  the left, if the
 other is to be employed.  One hand is then placed upon the abdomen, while
 the  other is  engaged  in the vaginal  exploration; and  this precaution is
 especially advisable, when the  ballottement is practised, in order to fix the
 fundus uteri, and keep it steady.  In passing the finger over the perineum,
 and before entering the vagina, we ascertain  the presence or absence of the
 fourchette, or the inequalities  that supply its place after a labor;  and  as
 the index enters the vagina, it should examine the condition of the external
 labia, the length and  width of the vagina, its mucous membrane, whether
 smooth or rugous, the  various  diseases, tumors,  or degenerations that may
 exist on the surface or in the substance of its walls, and the condition of the
 rectum, whether full  or  otherwise.   Hereafter, we shall  have occasion to
 speak of this  process as a means of  diagnosis in the various  vices of con-
 formation.
  All these explorations being  made, the next step is to examine the neck
 of the uterus, and  learn  its modifications in form, consistence, situation,
 direction, and in the dimensions of its cavity; all which have been carefully
 described.  (See page 130, et seq.)  The finger may detect the development
 of the body of the  uterus, by ascertaining the spreading out of its  inferior
 part. Until  toAvard the third month, the organ is almost wholly within the
 excavation, it having at  that early period increased so much in size as to
 occupy almost all the true pelvis.   Its mobility is, however, very slight, in
 consequence of its restrained position, Avhilst in the ordinary  unimpregnated
 state, it may  be carried to the right or left, forward or backAvard, by simply
pressing with the finger on the side of  the neck.   The restraint of the body
 during pregnancy renders the neck immovable, so that it  becomes impos-
 sible, or at least very difficult, to produce such motions ; the uterus Avill also
 be found much heavier if any attempt be made to raise it. 
DIAGNOSIS  OF  PREGNANCY.
246
  2. The Anal Examination.—The accoucheur is very seldom obliged  to
introduce  his  finger into the rectum, but still a partial obliteration of the
vagina may render such an exploration necessary; it might also be useful
where there Avere reasons  for supposing a young girl to be pregnant, avho
insisted  upon her virginity.  For the necessity of sparing the hymen, Avhich
may possibly be intact, renders  the  vaginal  touch very difficult.   In cases
where a tumor exists at the posterior  part of the vagina, it is sometimes
difficult to decide Avhether the  enlargement is located in the recto-vaginal
septum, or  is  attached to the bony structure.   Here the diagnosis is very
important, for the course to be pursued in  the  tAvo cases would be widely
different, and  all doubt may be removed at once by introducing the index
into the rectum, and the thumb into the vagina.
  I can recall but a few other circumstances Avhere an accoucheur would
feel obliged to resort to the anal  examination, although I am well aAvare
that it is frequently recommended for certain cases of doubtful diagnosis in
the earlier months; but most Avomen are so shocked by this mode of exami-
nation, that, in truth, they are unwilling to submit to it, unless from motives
of strong interest or necessity.
  B. The  J'assive Movements,  or Ballottement.—This, according to most
authors, is a  sensation analogous  to that produced by placing a ball  of
marble  in a bladder full of Avater, and  then striking the bladder Avith the
finger just under the spot Avhere the ball rests, Avhen the latter is throAvn up,
and falls back from its oavii Aveight upon the finger Avhich displaced it.  This
comparison, hoAvever, only holds  good at a certain period of gestation, and
we  shall again take occasion to refer more particularly to this point.  To
perform the ballottement, M. Velpeau directs the index finger of one hand
to be placed under the cervix, and  the  palmar face of the  other hand over
the fundus uteri; then, by a sudden movement of the finger in the vagina,
the uterus is to be pushed upwards; being movable, free, and the only solid
body in the amniotic liquid, the  foetus ascends, strikes the point diametrically
opposite, and falls back upon the finger Avhich gave it the impulse.
  But as this  mode will not, I believe, afford any  satisfactory results in the
majority of cases, I  recommend  students to pursue the folloAving plan  in
performing  the  operation: the vaginal  finger should not be placed under
the cervix, because it will then be  separated from the  foetus by the Avhole
length of the neck, and of course the finger cannot recognize so clearly the
descent of the displaced body; but rather in front of, or behind  the  neck
(according to the woman's position), upon the walls of the body itself, for then
the index is only removed from the substance to  be examined by the very
thin walls at  the  inferior region of the uterus, and it detects very readily
the least motion of the inclosed foetus.
  If the Avoman  is standing, the  index  should be introduced  in a vertical
position, Avith its palmar face  turned fonvard, and the other three fingers
flexed  into the palm, and as the symphysis pubis scarcely exceeds an inch
and a half in  length, the digital extremity of the forefinger easily  passes  its
superior part, and reaches the body of the organ, where it almost  ahvays
encounters a hard globular tumor formed by the head of the foetus; then a
light, quick blow is to be given by it, after Avhich the finger must remain 
246
PREGNANCY.
immovable on the part struck.  This shock should be  made in a direction
from  below upwards and from behind fonvards, by suddenly flexing the
first phalanx.  This  last recommendation  I  deem very important;  for in
the great majority of cases, the uterus is inclined forwards, its long diameter,
like that of the foetus, corresponding very nearly to the axis of the superior
Btrait.   Now if, under  these circumstances,  the shock be communicated to
the presenting part of the child from below  upAvards, and from before back-
wards, as generally done, it is evident  that  the motion given to it will, at
furthest, be but a slight movement, of displacement or jolting, but never one
of ascension, Avhich in fact Avould be  impossible, because  by the  direction
of the bloAv the foetus is pushed against the posterior uterine wall, and not
along the axis of its cavity.
  The ballottement may also be effected when the woman is recumbent, by
acting in the manner I have just indicated, but it is then generally necessary
to place the  finger upon a point  someAvhat  nearer to the  neck, sometimes
before, but at others behind it.  The erect position, hoAvever, is usually the
more  favorable for the perception of the ballottement, and therefore pre-
ferable.
  It sometimes  happens, about the fifth month of gestation, that  if the
AAroman be standing, the vaginal  touch does  not afford  the  sensation of
ballottement;  but if she be directed  to lie doAvn, and  the vaginal  finger be
applied upon the uterine wall, Avhilst the  body of the Avomb  is forcibly
depressed by the other hand placed  near  the  umbilicus, the vaginal finger
is struck by some part or other of the  foetus, which is displaced by the ex-
ternal pressure.
  At an early period of pregnancy, it is sometimes possible to perceive the
ballottement  by simply feeling the abdomen.   If the Avoman be placed on
her side, in a horizontal position, the  foetus, in obedience to gravity, descends
to the lowest  points.  If the hand be then glided  beneath the side  of the
abdomen which touches the bed, some part of the foetus will  be distinguished
and may be readily displaced, but soon returns to its original situation.
  This  sign usually becomes valuable  about  the fourth month, for before
that period the foetus is generally too small,  and, possibly, the uterine Avails
are too thick.  Again, it \Taries much  after that time : for instance, our
search is not always successful in  the fifth month, the small size of the child
permitting it to change position very easily; on one day it  is found without
difficulty, and on the folloAving it defies all efforts at detection.
  ToAvards the seventh  month, the ballottement is  in general the most
clearly recognized, since it is at this  period, especially, that the finger per-
ceives  the solid  mass, inclosed and  swimming in a liquid, to rise up and
shortly  afterwards to fall back  upon  it; but the sensation is no  longer
perceptible at the end of the eighth  or the beginning of the ninth month,
unless there happens to be an unusual  amount of Avater, for then the foetus
has become too large.   The' finger can  indeed  raise  it,  but the friction
against the  walls  of the  uterus  almost destroys  the  tendency to ascend.
The mobility of  the tumor is readily detected, but it now leaves the finger
which  impels it;  it is a displacement  in  mass rather  than ballottement.
Finally, in the latter  periods of  gestation,  the head pushing  the  uterine 
DIAGNOSIS  OF  PREGNANCY.
247
wall before it, engages in the superior strait, sometimes even gets low down
in the excavation, thus becoming jammed in, as it Avere, and of course the
ballottement is then altogether impossible.
   Writers declare this sign to be a certain indication of pregnancy ; but the
proposition is, perhaps, someAvhat too absolute : for example, it is possible
for a stone resting in the bas-fond of the bladder to lead to an error, and I
once  met with a case  Avhich might readily cause  a mistake of  this kind.
During the  time I acted  at the obstetrical clinic,  as  chef de  elinique, a
Avoman  Avas  subjected to the touch, Avho  declared herself pregnant, and
advanced three or four months; at first, I examined her in the recumbent
position, and found all the negative  signs of gestation, but  one of my
advanced pupils  then  performed the same manipulation in  the standing
posture, and  declared  that he perceived the ballottement, Avhen I re-exam-
ined her, and found the folloAving condition of things : The neck Avas strongly
pushed  backwards and a  little  to the  left;  it Avas slightly softened, and
sufficiently patulous to admit the  extremity of the finger.  (This Avoman
afterwards acknoAvledged she Avas  delivered only  four months  previously.)
As the finger left the cervix, and advanced just behind the symphysis pubis,
it encountered a large resisting  surface, which Avas evidently the body of
the organ, and then, by giving a slight blow, a moArable bodyAvas felt there,
Avhich immediately fell back upon the finger,  exactly as the foetus Avould in
the fourth month.   I  confess that  at first I believed her  pregnant, and  re-
touching  her in the recumbent  state, I once more remarked  the negative
signs, but my finger could  not noAV detect  the substance  that  had been su
easily moved  Avhen  she Avas standing.   At  the third examination, I dis-
covered an anteversion of the Avomb, so complete that its anterior face had
become inferior or horizontal, and  it was over  nearly the Avhole extent of
this face the  finger had passed in examining;  and  further, I found that the
fundus uteri, situated behind  the symphysis pubis, was  the light movable
body Avhich had produced the sensation of ballottement.
   If a similar case should occur again,  it might give rise to uncertainty in
diagnosis, and on that  account I concluded to make it public through this
Avork.
   There are also some particular positions of the foetus in Avhich the ballotte-
ment Avould be of little service: for instance, in  those of the breech it is
generally very difficult, and nearly impossible in  those of the trunk.   In
two cases, hoAvever, I succeeded  in  detecting a small  part, which, from  its
diminished size, must have been an  elbow, Avrist, or heel; and this, together
with the other signs, satisfied  me that  it Avas a  position of the trunk.  M.
Ifatin, Avho attended one of these  Avomen  in her  accouchement, found a
presentation of the left shoulder; the other Avas delivered at the Clinique,
and like the first, verified my diagnosis.
   2. Palpation of the  Abdomen. — An  exploration of the abdomen, says
Schmitt, is of great importance in diagnosis, and should ahvays be resorted
to Avhen it is  desirable  to ascertain  Avhether -pregnancy exists.   It is often,
indeed,  more  instructive,  and furnishes surer  results, than  the internal
examination.
  Some obstacles are, hoAvever, met Avith in this mode of  research.   Thus: 
248
PREGNANCY.
 1, the walls of the abdomen may be too thick;  2, its muscles may be very
 tense; 3, the bladder may be greatly distended with urine, and the intes-
 tines with  gas  or fecal matter; 4, lastly, a fixed  pain in the hypogastric
 region, rendering any pressure there often insupportable to the patient.
   The too great  thickness of the walls of the abdomen is the only one of
 these difficulties  which  is  permanent, but which, nevertheless,  frequently
 renders the palpation of the abdomen  entirely  fruitless ; for as the tension
 and sensibility of the walls are  but temporary, the exploration  may be
 deferred to a more favorable opportunity, and the bladder and rectum may
 always be  evacuated beforehand.
   These obstacles are of rare occurrence, the examination being generally
 quite easy, owing to the flexibility of the Avails of the abdomen.
   In order to practise it, the female must  lie  doAvn in such a way that her
 hips shall  be elevated, the head flexed on the chest, and the thighs on the
 abdomen;  in  a word, so as to  relax the abdominal muscles completely.
 Whilst in this position, the abdomen should be first  examined  Avith  both
 hands, so as  to ascertain  its form, size, tension, resistance,  and hardness,
 especially in the  sub-umbilical region.  In the earlier months of gestation,
 if the parietes are not too thick, a round tumor, of fleshy consistence, can
 be detected rising out of the pelvis, sometimes in the middle, and at others
 a little tOAvards the right or the  left side; during the first tAvo  months it
 seems to rise higher above  the pubis than in the course of the third, which
 fact is readily accounted for by the sinking down  of the  organ, occasioned
 by its increasing weight and volume.   This  tumor, which is the Avomb,
 rises gradually toward the  epigastrium as gestation progresses, and it often
 becomes  necessary, in order to form some idea of the  time at which labor
 will probably occur, to ascertain the  exact amount of its elevation.  The
 following is,  I think, the  best mode of accomplishing this object: Place
 the ends of the eight fingers immediately above the symphysis, and  then
 continue to ascend gradually so long as they feel any resistance, for Avhen
 the fundus uteri  is gained, the resistance suddenly ceases, and the  fingers
 sink deeper as they glide over the convexity, which is thus recognized with-
 out difficulty.
   The uterine tumor,  which is at  first  quite resisting, becomes  less so as
 gestation advances; sometimes, however, it is so  soft as to be barely dis-
 tinguishable.    An attentive examination will enable us  to  detect  the
 following characters:  1.  It ahvays remains circumscribed and retains  its
 oval form; 2.  It  presents a certain  amount of elasticity,  similar to that of
 a cyst filled Avith  serum;  3. If this manual exploration be continued in the
 same direction, the examiner will detect greater or lesser  parts of  a single
 irregular mass, which are  movable and  easily displaced like bodies  sus-
pended in  Avater.   Often, indeed, these movable parts may be recognized
as belonging to the foetus.
   As a part of the abdominal  exploration should also be reckoned the
sign furnished by percussion, namely, a dull sound over  every part of the
 abdomen occupied by the developed uterus, instead of the resonance per-
 ceived at other  points.
   Some care is  necessary in percussing, during the first four or five months 
DIAGNOSIS OF PREGNANCY.
249
not to be misled by the  dulness which  a distended  bladder, or a patho-
logical tumor of considerable size might  produce.   It should also be borne
in mind, that although the uterus may have risen to near the umbilicus, a
clear sound will be yielded on percussion throughout the  greater part of
the sub-umbilical region, provided a few folds  of intestine  be  interposed
between the walls of the abdomen and the womb.
   Sometimes the uterus is above the superior strait in the  earliest months.
I had an opportunity of observing a case of the kind at  the Clinic, with
Professor Dubois, in a woman who Avas advanced six Aveeks or tAvo months;
the uterus Avas so elevated, being found in the right iliac fossa, that at first
we doubted the  existence of pregnancy, which hoAvever was real, as Avas
proved more positively several Aveeks after, and fully justified by the event
of the case.
   The palpation of the abdomen and the vaginal touch  are  in  most cases
practised simultaneously; we shall, therefore, point  out  the signs  Avhich
this joint investigation furnishes at the different periods of pregnancy.
   In the first three or four months the uterus either remains wholly  Avithin
the lesser pelvis, or  else its fundus projects someAvhat above the superior
strait.   In the first case, it w ill  he easily discovered  by the vaginal touch
that the entire excavation is occupied by a slightly movable tumor,  with a
smooth and regular  external surface.  In the  second  case, the lower half
of the lesser pelvis is empty, but the  examination of the abdomen, con-
ducted according to  the rules above mentioned, discovers the tumor formed
by the Avomb in the hypogastrium.  The first point  to  be  ascertained  is
the exact size of the uterus, and this can only be determined by  the double
exploration spoken of: the finger having been  introduced  into the vagina,
is applied directly on the  neck, or, still better, against the  anterior or pos-
terior portion of the inferior segment of the uterus, while the other hand
placed above the pubis, presses down the muscular Avails, and searches for
the tumor formed by the fundus uteri; the Avomb  is thus included betAveen
the finger in the vagina and the hand on the hypogastrium, and, of course,
the volume of the organ may be thus ascertained, and a comparison made
betAveen  it and the  unimpregnated  uterus.  Moreover, its displacement in
mass can be very easily recognized in this position.   To accomplish  this,
the  finger  should remain  applied  as above stated,  and  when the hand
slightly depresses the fundus, the  finger in the vagina recognizes the de-
pression ; and the counter-proof may be  made by endeavoring to raise the
uterus from beloAV, by pressing strongly on the inferior part, which is found
deep in the exca\ration.
   But the tumor which is felt in  the lesser pelvis, or in  the hypogastric
region, may be either formed by the uterus, or developed  in  the  adjacent
parts.  In the latter case, the Avomb will generally found  to be displaced,
and  pressed by the  tumor  against one of the sides of the pelvis; and if
the  neck be traced from below upwards, the  finger Avill  detect a line of
demarcation between the  Avail of the uterus and the pathological tumor;
sometimes,  it can even be  insinuated betA\reen them.  The motions to which
the neck is subje  ted are not usually communicated to the tumor, and vice
versa.  Finally. th° neck  will exhibit none  of the  changes peculiar to
pregnancy. 
250                          PREGNANCY.
  Hitherto Ave have only demonstrated that the uterus-is developed, but
the question arises, what is the cause of  that development ?   The solution
is  nearly ahvays  difficult; Ave  may state, however, that Avhen the Avomb ia
enlarged by a product of conception, its walls are generally more flexible
than if the enlargement Avere dependent upon some  chronic  disease; and
that, after a little practice, this suppleness can be detected by carrying  the
finger to the posterior surface of the body, Avhich  may be done in conse-
quence of the depression and retroversion of the fundus.  The uterine Avail
then, offers about  the same  resistance  as an cedematous limb,  or perhaps
still nearer, that of caoutchouc Avhen slightly softened in hot water.
  The tumor detected either by the vaginal touch, or by depressing the ven-
tral parietes, is rounded and smooth  throughout, and does not present any
of those irregularities observed in cancerous or fibrous degenerations  of its
walls; and this fact, together with the preceding observation, will serve  to
distinguish a morbid state from a true gestation.
   It certainly will not prove quite so easy to determine whether the enlarge-
ment is caused  by a foetus, or the presence of a mole in the cavity; in fact,
I do not believe this diagnosis is possible, except at a very advanced stage,
and then  the absence of the foetal  inequalities, the non-appearance  of its
movements, auscultation, &c, might suffice to remove the doubts on the
subject.
   In some women, the womb becomes congested and  considerably tumefied
at the menstrual  periods.  Noav this state may readily be confounded Avith
a commencing  pregnancy, the  more particularly,  because at  those epochs
the neck usually becomes softer and  dilates a little; and I know no way of
escaping this error, if the woman insists that she is pregnant, and experiences
the various rational  signs of that condition.  In  tAvo cases of  the kind I
have met with,  I only succeeded in detecting the falsity of my diagnosis by
examining the  woman a second  time, tAvo or three Aveeks after;  for these
females, who Avere used as subj ects for practising the touch at the  Clinique,
Avished  to  be considered pregnant;  but, unhappily for them, the fortune
Avhich aided in  the first examination, deserted them at the second ; for, being
ignorant of the cause of my mistake, they returned at a time still more dis-
tant from their menstrual period.
   On the Avhole, then, there is'no certain sign of pregnancy during the first
three or four months; yet it becomes almost certain, Avhen the sensible signs
above indicated coincide Avith the presence of the rational  ones, in a healthy
woman Avho can have no intention of deceiving us  as to her condition; still,
in a medico-legal case, the physician should express his doubts, and demand
a new examination at a more advanced period. But if it is not  ahvays pos-
sible at the beginning of a gestation to prove that it does exist, Ave can, at
least in the great majority of cases, satisfy ourselves positively that it does
not; for most  frequently the  unimpregnated  state  of  the organ can  be
readily made out.
   3. Active Movements of the Foetus. — The  existence of pregnancy is  an-
nounced during the  last five  months by certain  signs that  are  far more
reliable than any of those hitherto mentioned; these are the foetal  move-
ments, AA'hich have improperly been called the active and passive, but better 
DIAGNOSIS  OF  PREGNANCY.                251
designated  by M. Stoltz as the movements proper  and the communicated
ones.   We  have already studied the communicated ones in treating of bal-
lottement and palpation of the abdomen; so that it only remains to describe
the active movements.
  The Avoman generally perceives the foetal movements at about four months
and a half,  although the muscles of the infant had contracted long ere this,
unconsciously to her; for  every  accoucheur  must have detected these
motions by  placing his hand upon the abdomen, at a time Avhen the mother
herself still doubted her OAvn pregnancy.   Noav these movements are exces-
sively feeble at first, and produce a kind of  tickling, or rather a sensation
analogous to that of  the craAvling of a spider; they gradually become more
characteristic, and may then be classified in tAvo  species.  One of these is
produced by the movements of the whole trunk, or some of its parts, the
first of Avhich are recognized  by a quivering that is perceptible to the female,
Avhile the partial motions give rise to quite large projections, Avhich are even
visible through the abdominal Avails;  the other, on the contrary, are blows,
certain small, short strokes, Avhich at times are violent enough to elicit cries
from the sufferer, and these shocks are evidently produced by the  action of
the thoracic or inferior extremities  of the child.  Such movements, so dis-
tinct and clear to the mother, would seem to  be an infallible sign of gesta-
tion, and yet such is by no means the case, since  it is not at all uncommon
to find women, whose veraoity is beyond  question, asserting that they  have
felt them for a long period, and sometimes the motions have even  been per-
ceived by the husband or other persons, yet Avithout their being pregnant.
  The history of one of the English queens  is Avell  knoAvn, Avho, believing
she had felt, the motions of a child, dispatched couriers Avith the happy news
to all the foreign courts, but  proved  to be  only the commencement  of a
dropsy!  Such errors are frequent,  and  there are but feAV accoucheurs Avho
have not met Avith many of  them in practice.   Consequently, the physician
should not  rely in this matter upon the statement of the woman, but should
perceive them  for himself before  hazarding  an  opinion.   It Avould seem,
indeed, that in some cases, the  intestinal movements, the rapid passage of
gas in the  intestines, certain partial and irregular contractions of  the ab-
dominal muscles, and the pulsation of a large artery, especially Avhen situated
behind  any tumor Avhich  it raises  at every beat, have often deceived not
only the patient, but even her medical attendant.
  Some females, from  the desire  of simulating pregnancy, have acquired
the power of contracting their abdominal muscles in so singular a manner,
that many  able accoucheurs have been deceived, and  believing that they
felt the  foetal  movements, have consequently pronounced them pregnant.
(Montgomery, p. 84.)
  These motions may be detected by the vaginal  touch in certain positions
of the breech, or even of the trunk, but Ave must rely chiefly on the abdo-
minal palpation for their detection.  In general, it is only necessary to place
the hand flat on the abdomen, or to make use of slight pressure, to perceive
them ; though if they are feeble and infrequent, it is better to dip the  hand
in some very cold liquid, and then  place it suddenly upon the skin.  This
rapid change in the temperature of the abdomen probably reacts upon the 
252
PREGNANCY.
infant, for it  generally  moves convulsively.   I believe, with  Dr. Tyler
Smith, that the sudden impression of cold is more likely to produce a rapid
contraction of the abdominal muscles or uterus, than  to act directly upon
the foetus, and that its use might readily deceive as to the nature of the
motions Avhich it occasions.
  I prefer placing a hand upon one of the sides of the  abdomen, and strik-
ing Avith  the other on a  point opposite;  for the foetus  then  rarely fails to
move briskly as though to resist the impulse.
  As before stated, the  movements begin to be felt about the  end of the
fourth month. To this laAV, however, there are  numerous exceptions; thus,
some Avomen perceive them as early as the latter half  of the third month,
others not before the fifth, sixth, seventh, or  eighth months of gestation.
One woman, who had advanced  to the  latter  period, Avas brought to the
Clinique, in consequence of a fall  in the street,  and she assured us that she
had never felt the movement prior to the accident.   We  have already
alluded to the person, seen by us at La Charite, under  the care of Professor
Fouquier, Avho was delivered at term of a very healthy child,  but  the
motions of Avhich were neither perceptible to the mother nor ourselves.
  Mauriceau,  Delamotte, and many  others, bring fonvard similar cases.
But the most remarkable of all is the one reported by Campbell.   I knew
a lady, he says, the mother  of nine children,  Avho, excepting in  her first
pregnancy, never perceived any motions of the foetus ;  but she Avas herself
very inanimate and passive, and Avhat was still  more singular, the children
were equally nonchalant  with herself.  Whenever  ascites complicates the
pregnancy, these  motions are very indistinct,  thus affording an  evidence
that it is the abdominal walls,  and  not the  uterus,  which perceive the
impulse.
  After the  movements have been distinctly felt, they sometimes diminish
without any appreciable  cause, both in frequency and intensity, and then
altogether disappear, Avhich circumstances demand the most  serious atten-
tion of the accoucheur, as it is in  general an unfortunate symptom.
  I believe this spontaneous cessation of the active movements may usually
be referred to a congested state of the uterus,  which reacts on the child's
health.  But whatever may be the value  of  this opinion, it is quite certain
that bleeding, under  such circumstances,  has always produced  a favorable
result; for when not delayed  too long,  the movements reappear soon after,
and hence I  cannot recommend the measure too highly.
  4. Of Auscultation as applied to Pregnancy. — M. Mayor, of Geneva, first
detected  the  pulsations of the foetal heart  by  auscultation; but  this dis-
covery, originally published by him in 1818, had been entirely forgotten,
when M. de  Kergaradec announced,  in  1823, that if the  abdomen of a
woman who has passed the first half of her  pregnancy be carefully auscul-
tated, two sounds, which are perfectly distinct in character,  will be recog-
nized : one of them, consisting of double  pulsations, or rather of xedoubled
ones, according to the expression of M. Stoltz, is evidently produced by the
movements of the foetal  heart, and has been compared, Avith some reason,
to the ticking of a watch enveloped  in  a napkin; the other is a kind of
rustling,  unattended by  shocks,  and  consequently without  beating, being 
DIAGNOSIS  OF PREGNANCY.
253
characterized by simple  pulsations, accompanied by the souffle, A\hich have
been successively compared to the sibilant murmur, or to the sound of an
erectile tumor,  or varicose aneurism; this is called  the belloAvs sound (bruit
de souffle).  Another belloAvs murmur, of more frequent occurrence than
the former, is termed the murmur of the cord, and will be studied after the
preceding.1
  [At the end of the third month the pulsations of the foetal heart may, therefore,
be heard, though not as a general rule.  Careful and long continued auscultation
at this period, however, often enables us to detect with the stethoscope sudden and
repeated blows,  which would seem  to be produced by rapid motions of the foetus.
The  sensation is sometimes so clear, and leaves so little doubt as to its cause, that
the sound occasioned by the displacement of the foetus in the amniotic fluid may be
accepted as a useful sign in the diagnosis of pregnancy, and one which, in a diffi-
cult case, ought  not to be neglected.  It cannot, however, be always detected, inas-
much as it is necessary  that the foetus should move  briskly at the moment of
observation.]
   1. Sound  of  the Heart.—The  pulsations of the  heart generally become
perceptible  in  the course of the fourth or fifth month, though  more fre-
quently during the  latter, and often then at an elevated part of the abdo-
men near the  umbilical region; in one case, however, I thought I heard
them a little  before the fourth month, but, unfortunately,  I  could not
re-examine  the female  until six Aveeks afterwards.  M. Depaul declares
that he has heard them  at the end of the third month and in the eleventh
Aveek.
   These pulsations are far more  frequent than those of the  mother's  heart;
ranging, as they do, from one hundred and thirty to one hundred  and sixty
per minute; and, moreover, they are  very often accelerated or diminished,
Avithout our being able to detect the cause of the changes.
   Like most  observers, I have  several  times remarked  that, if  the  foetus
exhibited any  violent  movements during the examination, the  pulsation
increased and  became very difficult to count; but  they are not  influenced
by any variations in the mother's pulse, whatever may be their cause.
   The dorsal region of  the child  seems to transmit the double  pulsations
most easily, and consequently they are more clearly perceived at that part
of  the  abdomen  which corresponds  to it.  This circumstance likeAvise
explains Avhy the  pulsations change position so easily priojr to the seventh
month;  in  fact, it  is only during the  last three  months, that  extensive
movements on  the part of the child become difficult, and its position  nearly
fixed.
   They may be heard most frequently^on the anterior inferior portion of the
abdominal Avail, just above the iliac fossa, or still more rarely on the median
line, and  not  merely at a very  limited  spot, but  over a radius of two or
three inches.   In  some cases they may even be heard over more  than half
of the abdomen;  but it is ahvays easy to perceive that  they are stronger

  1 The character of this work prevents our giving a detailed account of the  history
of this important subject.  I cannot, however, too strongly recommend all who wish
to be fully informed  upon  the matter, to consult the  excellent Monograph recently
published by M.  Depaul. (Traits de I'Auscultation Obstetricale, 1847.) 
254
PREGNANCY.
and  clearer at one point than  elsewhere, and from this point as a centre,
they become Aveaker  and weaker as the distance increases.  The intensity
of pulsation is of course less marked as the child is younger, although, in
some instances, they  exhibit as much force in the sixth month as at term,
but this is very unusual.
  As regards the number of pulsations, the  statement  made by  many
observers that it is much more considerable at an  earlier period  than at
term, is not absolutely true, for the fcetal  heart  ahvays beats with the same
quickness, saving some accidental variations, at whatever  period it may be
examined.   Labor produces no modification of the foetal  pulsations up to
the moment of rupturing the membranes; but  this rule fails  after the
amniotic liquid has  escaped, because  they are  then generally louder and
clearer, and may be  heard over a more considerable extent  of surface,  Avhich
can  readily be explained  by the fact that the  ear or instrument is then
nearer the foetus.
   When the contractions  become more energetic, the pulsations are  not so
regular, and they are more feeble and sloAver Avhile the contraction lasts.
   In those cases Avhere the labor is of moderate duration, the indistinctness
of the sound of the heart may be referred, I believe, to  the  difficulty of
ausculting during the pain; but if the  foetus has been too long  subjected
to uterine pressure — as Avhere the labor has been unusually prolonged—the
number, force, and regularity of  the pulsations sensibly decrease
   Most observers have asserted that the sounds are not ahvays perceptible,
and  M. Stoltz even declares that they cannot be heard Avhenever the  dorsal
region is directed backAvards, unless some part of the thorax be in contact
with a portion of the uterine Avails Avhich may be explored.   For my own
part, I have not failed, for several years past, to hear them in examinations
made  after the sixth month, in all cases Avhere the children were living;
and  as my researches have now extended  to at least seven  or eight hundred
Avomen, I feel convinced that Ave can always  distinguish  them after that
period, in any position of the foetus Avhatever.
   M. Dubois Avas the first to point out the fact, that the sound of the foetal
heart has sometimes a peculiar resonance, resembling the metallic tinkling,
a  singularity which  I have twice had the  opportunity of observing at the
Clinique.   This remarkable sonoriety is most frequently met Avith in Avomen
in Avhom the uterus is distended by a  great quantity of fluid.  There are
also some  circumstances  Avhich  render the pulsation a little  obscure and
someAvhat difficult to hear;  thus, for instance, a lumbo-posterior position of
the foetus, a large quantity of Avater, by which the uterine  Avails are greatly
distended, and a sufficient depression of them by the stethoscope -to approach
the child prevented; the interposition of  several folds of intestines between
the abdominal  Avails  and  the uterus, and  the existence of borborygmi, are
all so many circumstances calculated to render  the perception  of the pulsa-
tions more difficult,  although not absolutely impossible.
   The beatings of the foetal heart are composed of tAvo distinct sounds, the
second  being  stronger and more sonorous  than  the  first; but, in a great
majority of cases, both of  them may be heard  quite distinctly.
   M. Noegele, however, appears to  think  that only  a single sound is heard 
DIAGNOSIS  OF  PREGNANCY.
255
under certain circumstances, and I have sometimes made the same observa-
tion ; but it has always seemed to me that the perception of only one sound
might  either be referred to bad  manipulation on  my part, or else to some
one of  those circumstances just described having prevented the application
of the stethoscope over a point near enough to the back of the foetus.  Thus,
though I have  frequently heard  but a single  sound at first, after changing
the instrument, others became clearly perceptible.  I am happy to extract
the folloAving paragraph from the thesis of M. Carriere, a pupil of M. Stoltz,
Avhich  fully confirms my opinion.  He says: "I  have remarked  that the
single character of the foetal pulsations here described, is most likely to be
observed Avhen  the point examined approaches the fundus of the uterus."
  Like all useful discoveries, obstetrical auscultation has had its opponents
as Avell as  its  partisans; and though  the former are daily diminishing in
number,  the latter certainly have injured their cause by  exaggerating its
importance ; Ave shall, hoAvever, carefully endeavor to ascertain its practical
utility.
  a. It has been stated that a perception of the pulsations of the foetal  heart
Avas  a  certain sign of pregnancy, as also that the absence of this sound,
positively determined by several  examinations made after intervals of some
hours, subsequent to the sixth month, announces  with certainty the death
of the  foetus; supposing, of course, Ave have a satisfactory assurance of the
previous  existence of gestation.
  [It is a very rare  circumstance, says M. Depaul, for the pulsations of the foetal
heart to be inaudible during the three last months of gestation, unless  the child
be dead.  They failed to be detected in but eight cases  out of nine hundred and
six, examined at this period.]
  There  is, notAvithstanding, one  circumstance Avhich might lead  to a sus-
picion  of pregnancy even Avhen the uterus Avas really empty;  it is this: in
certain females the pulsation of the heart is felt and heard as Ioav down as
the sub-umbilical region, and we  can imagine that if, in such persons, under
the emotions naturally produced by  an unjust suspicion  of gestation, or,
from the influence of any febrile  movement, the circulation be accelerated,
the pulsations, from their number and  rapidity, might be mistaken for those
of a fcetus;  but in such cases, all errors of diagnosis may be easily avoided
by observing:  1st.  The perfect isochronism betAveen the pulse at the Avrist
and the abdominal beatings ; and 2d.  That the intensity of pulsation con-
stantly increases as the precordial region is approached; Avhich tAvo  pecu-
liarities are never  presented by the sound of the foetal heart.
  b. Can a twin pregnancy ahvays be recognized  by auscultation?   It  is
said  that, in most cases, the existence of two children in the uterine cavity
may be knoAvn  by the folloAving sounds:  1st. The sound of the heart will be
heard at tAvo distant parts of the abdomen; and 2d. The Avant of isochronism,
and of frequency, Avhich may sometimes be detected betAveen these tAvo series
of pulsations.
  These  characters are advanced by some Avriters as indicating a double
pregnancv  with certainty, but Ave shall point out several sources of error on
this point:  thus, it frequently happens that the pulsations of a single  heart
resound  in  very distant parts.   Now, can this be  referred, as M Dubois 
256
PREGNANCY.
thinks, to deficient thoracic  development, to the  unusual comparative siz<
of the heart's cavities, to the density of the lungs, or, lastly, to the position
of the foetus itself, the head and extremities of which, being applied against
the thorax, and there receiving the impulses from the heart's  contractions,
serve to transmit them to a greater distance?  I should be inclined to adopt
this view; for, Avhatever be the  explanation, the fact is certain, and the
foil OAving* appears to me the  best method of resolving the difficulty: When-
ever the pulsations are heard at tAvo  distant points, the line between  these
should be carefully folloAved Avith the instrument; for'if they are produced
by the presence of two foetuses, the pulsations will become feeble, or almost
disappear, tOAvards the centre of this line;  but if, on the contrary, they are
due to a single child,  they will be just as  strong at its middle part as at
either extremity.
  Again,  the absence of isochronism in the pulsation  does not positively
prove the existence of tAvo  children;  for  one series may be owing to the
foetal heart,  and the  other  belong to the  same  organ in the  mother, the
resonance being transmitted to the abdominal cavity.  Hence, it is evident
that the unusual distinctness of the mother's pulsations coinciding Avith the
presence of a single foetus may lead  to  the belief of a double  pregnancy
which  does  not  exist, and a comparative  examination of the  pulse  then
becomes  necessary.

  [After all, it must be  acknowledged that the pulsations of the  foetal heart may
vary from  one instant to another, without our being able to comprehend why such
should be the  case.  It may lead, also, to a wrong inference when the auscultation
is practised at two different points successively, inasmuch as a Avant of isochronism
might in this case give rise to the impression that there were two children, whilst,
in fact, there Avas heard the sound of but  a  single  heart beating with variable
rapidity.   To avoid all chance of error, two practised observers should place their
stethoscopes over the two points where the sounds are most clearly heard, and  then
count them together during the same time.  Should there be a notable difference
between the tAvo numbers thus  obtained, a twin pregnancy  may be  regarded  as
certain.]

  A double  gestation may  be easily recognized,  if the precautions just
indicated  are observed, because, the  twins  being habitually placed one on
the right the other at  the left part of the abdomen,  distinct beatings will be
clearly heard, if the stethoscope be successively applied to each side.   But
this happy state of affairs does not always  exist,  for sometimes  one foetus is
situated directly before  the  other; and  then it  is  nearly impossible,  even
with the  greatest attention, to hear  the  heart of the posterior child;  and,
consequently, when  the  other signs of a tAvin pregnancy are present, the
results derived from auscultation Avould  not prove its non-existence.   Is it
necessary  to add, that equal care should be  taken  to abstain from hasty deci-
sions in those  cases  in  which  there  is reason to believe  that one of the
children is dead ?
  c Can  we appreciate  the state of  the  child's health or disease, of its
debility or vigor, during labor, by means of auscultation ?
  This question, which was  brought before  the  Academy by a memoir of
M.  Bodson, and which gave rise  to a remarkable report by M. P. Dubois, 
DIAGNOSIS  OF PREGNANCY.
257
is certainly one of the most curious and  interesting  subjects of &iudy; for
if Ave could possibly judge from the signs furnished by auscultation, of the
integrity of the  fcetal life, no  uncertainty could  arise with regard to the
course to be pursued when the labor is too long delayed, after the rupture
of the membranes; for the feebleness and  relaxation, or the excessive fre-
quency of the foetal pulsations; the intermission  and irregularity of their
rhythm ; the absence  of the second stroke; or the complete cessation of this
phenomenon during the uterine contraction, and the sloAvness of  its return
after the pain has ceased, would sufficiently authorize a prompt termination ;
whilst the opposite phenomena would justify delay.
  These signs, and more especially the irregularity of the pulsations, which
appears the most important of all, indicate in the clearest manner that the
foetus  is in a state  of suffering; and hence  they should serve as a formal
indication to the accoucheur to remove the infant promptly from the danger
which threatens it, by an artificial termination of  the labor.  But, as M.
Dubois has very judiciously remarked, there is not then a sufficient integrity
of circulation to establish the  extra uterine life; for, although  the  foetal
pulsations  may be still  regular  and  sonorous at   the  moment of birth,
yet the child has suffered so much from the long pressure of labor, that the
respiration cannot be established ; and hence,  in this respect, the accoucheur
should not rely upon auscultation alone for judging of the opportune moment
for the intervention of art, because other considerations quite  as important
should influence his  decision;  still, however, this is a method of diagnosis
that is never to  be  neglected.
   2. Souffle of the  Cord. — M. Naegele, junior, has recently described a bel-
Ioavs murmur, which he attributes to the pulsations of the  umbilical cord,
and compares it with the sound produced by the beating of the carotids in
chlorosis, and the murmur consists, he states,  of a simple pulsation which is
caused, as  he thinks, by the Avinding of  the  cord around the neck of the
fetus, or by  its  compression between the child's back and the uterine walls;
the sound increases after the  escape of the  liquor  amnii, and its  force is
greater in proportion as  the arteries of the cord are the more developed, and
subjected to greater tension.
   In the positions of the head, it is situated below the umbilicus, but higher
up in  those of the  breech, and it  seems to descend during the expulsion of
the foetus.  Sometimes a belloAvs murmur is heard accompanying the cardiac
pulsations, especially at  the first sound, but it appears difficult to reconcile
this circumstance Avith  the interruption  in  the circulation caused by any
pressure on the  cord.  Since M. Nsegele, junior, pointed out this peculiarity,
severa-1 others have noticed it, and I also have metAvith it at different times,
where nothing Avould indicate even a slight compression of the cord, or any
winding around the neck.
   Does this belong to the foetal heart, as M. Dubois and M. Depaul believe?
Indeed, the latter states  that he has detected  this sound, which he had pre-
viously heard during the intra-uterine life, by  ausculting the  infant imme-
diately after birth.  But nine other cases, he says, turned  out differently,
and oblige  me  to state  the facts as sthey occurred.  The  foetal murmur
occupied a part of the uterus entirely removed from that where the beating
       17 
25S
PREGNANCY.
of the heart was  detected; the latter  being pure, and unmixed with any
murmur.  Five of these children  were  born Avith one or several turns of the
cord about the neck, Avhilst  in the sixth, it surrounded the  loAver part of
the thorax.  The remaining three Avere free from anything of the kind.  All
were born living, and on  none of them Avas it possible to detect a souffle in
the cardiac region immediately after birth.
  The question must therefore be decided by neAV observations; for, although
the sound may be produced by the compression of the cord, the compression
often exists Avithout the abnormal murmur.
  3. Uterine Souffle.—Numerous denominations, each of which is founded
on  its supposed nature, have been applied to this sound; for instance, M.
Kergaradec thought it Avas produced in the utero-placental circulation, and
hence gave it the name of the placental murmur;  on the other hand, M.
Bouillaud, and many  others,  have subsequently assigned its seat (which, to
say the  least,  is very  probable) to the  large arterial trunks placed on the
posterior abdominal plane, Avhere  they are subjected to considerable pressure
from the developed uterus, and  they have  denominated it on this account
the abdominal souffle;  and still more recently, M. Paul Dubois has endeavored
to prove that  it originates in the  vessels Avhich ramify in the substance of
the uterine Avail  itself, Avhence he has  called it the xderine souffle.  But as
we shall take occasion hereafter to discuss these three opinions, Avhich em-
brace all our present knoAvledge on the subject, we will pass them over here.
   In general,  the belloAvs murmur may be heard as soon as the uterus, by
rising above the superior strait, becomes accessible to the stethoscope—that
is, a little earlier than the sound of the foetal  heart; in fact, M. Delens
asserts he has detected it at the third month, and Dr. Kennedy tOAvards the
tenth, eleventh, or the tAvelfth Aveek.   M. Depaul has also made the same
observation ;  but  as there  is a very great difficulty in approaching the uterus
at so early a period, these facts are certainly exceptional.
   The murmur undergoes  some very singular modifications during the course
of  pregnancy : thus, Ave do not hear it  in every instance; again, it is not at
all unusual for it to escape detection for a long time after having once been
heard,  and then to  reappear  somewhat later;  sometimes  even Ave  may
auscult for several minutes in  vain,  Avhen it  suddenly appears  directly
under the ear, augments, becomes quite loud and  distinct, lasts for a feAV
moments, then diminishes, and finally  ceases altogether.
   In other cases, two or  three pulsations, attended by blowing, are heard
during  profound silence, but nothing  more after  that; and on  the other
hand, very frequent opportunities are afforded us of observing the prompti-
tude Avith which the sound changes its locality; for it seems to pass suddenly
from one point to  an opposite one, being sometimes  immediately beneath
the ear, at others very distant: only covering a single spot in the majority
of cases, but occasionally  extending to  two remote regions, and, what is very
remarkable, Avith equal force and clearness at both these points; further,
the extent over Avhich the sound is heard  is usually quite  limited, but in
Eome instances it becomes perceptible  over a very large surface, trespassing
upon nearly the  whole anterior abdominal region.
   On severa  occasions my pupils have had  opportunities of studying all 
DIAGNOSIS  OF  PREGNANCY.
259
 ihcse varieties, Avhich indeed are almost inexplicable, Avhatever opinion mav
 be adopted as to the cause of the sound.
   The  murmur  is modified during labor; for at the very instant Avhen the
 pains begin, and even before the patient herself is aAvare of them, it becomes
 at once louder, more sonorous, and more distinct, and at times exhibits some
 strange modifications: thus, at one time the  sound heard  resembles, par-
 tially at  least, the tone of a reed, or a tense cord thrown into vibration,
 though as soon as  the contraction becomes  stronger  and more general, it
 seems to groAV Aveaker, appearing  at longer  intervals, and finally becoming
 imperceptible; but Avhen the pain ceases, the sound returns, at first Avith the
 intensity it manifested at  the beginning of  the contraction, and  gradually
 regains the  same  sonorousness it had  during the gestation.   Such is the
 order presented Avhen the  contractions are  regular and energetic ;  but if
 they are false or irregular, the souffle  is not  modified, or at least is not any
 stronger,  except it be for a feAV instants only.
   It may likeAvise be perceived after the expulsion of the foetus, and even
 of the  after-birth: for example, M. Carriere says  he  heard it  tAventy-four
 hours subsequent to the delivery of the placenta.
   Generally, it extends tOAvards the inferior  lateral part of the abdomen;
 more rarely,  it is heard near the fundus uteri.
   The  folloAving is the result of 295  observations, made by M. Depaul, of
 Avomen Avho  had passed the fifth  month of  gestation; it will  be seen that
 it accords Avith my OAvn experience. It Avas  heard very distinctly 182 times
 on each side  of the uterus, at a short  distance from the crural arch; in 27
 cases, it appeared on one side only ; in 43, towards the fundus of the organ;
 and in  18, it  Avas spread over the entire surface of the uterus.  Finally, M.
 Depaul states, that in 12  cases, it Avas present in  three distinct situations,
 namely, the  fundus of the Avomb  and the  parts above the crural arches.
 During the first  half of the pregnancy, it Avas oftenest observed Avhen the
 stethoscope Avas placed upon the median line a little above the pubis.
   The character of the sound heard varies greatly;  sometimes it is short,
 abrupt, and separated from the succeeding one by a longer or shorter inter-
 val of complete silence, Avhich is dependent upon the frequency of the pulse;
 sometimes it is a prolonged roaring, a true "  bruit de diable," Avhich has its
 period of beginning, of increase, and termination,  the latter blending Avith
 the next succession.
   In short, it presents all the variations of rhythm Avhich have been attri-
 buted to the  chlorotic murmurs.   Though generally simple and  intermit-
 tent, it  is sometimes continuous and double (bruit de diable) ; finally, it may
 be both continuous and simple.  I have not yet met Avith the typical, double
 intermittent sound.   Like the murmur in the carotids, the rhythm  may
 change  in a few moments so as to present in  a very short time several of the
 varieties just mentioned.
  The quality of the sound also varies greatly; and  this not only in dif-
 ferent Avomen, but even  in the same Avoman, and sometimes  whilst  the
 exploration is going on.  Occasionally it is Avhistling, and resembles much
 the sound of  the Avind bloAving  through a badly closed doorway; again it
 becomes roaring,  so as to imitate  the  vibrations of a base cord;  at other
times it  is plaii tive, suggesting the cooings of a turtle-dove. 
260
PREGNANCY.
   The seat and mode of production of this sound is a question that  has
 given  rise to much controversy, though, as  the sound is  synchronous with
 the mother's pulse, it must be evidently connected Avith the maternal vascu-
 lar system.  Thus far all agree, but diversities of opinion immediately spring
 up when a more precise location of it is attempted; for the murmur is pro-
 duced  outside of the uterus, exclaims one party; not so, it is seated in the
 uterine or the placental vessels, say the others.
   1. The Murmur is produced in Parts distinct  from ihe Uterus. — When-
 ever a tumor  is developed over the course of a  large arterial  trunk, the
 compression exercised by it on the vessel produces a souffle, and it is not at
 all unusual, Avhenever a  pathological tumor is developed  in  the abdomen,
 to hear a murmur in such cases, very nearly resembling that of pregnancy;
 noAV, the uterus developed by a product of conception constitutes a consider-
 able tumor, one Avhich must  necessarily compress the vessels and produce
 the effect described.  This vieAV is advocated by numerous  partisans, who
 contend that the murmur does not begin to appear until  the uterus really
 compresses the iliac vessels by being elevated above the superior strait;
 that it is usually heard at the inferior lateral part of the  abdomen, and
 more frequently on the right  side, because the uterus is habitually inclined
 to the  right; and  lastly, that if, according to  the plan  of my friend, Dr.
 Jacquemier (which I  have since often  practised  myself), the female, after
 having been ausculted in the supine position, be made to kneel  down, with
 the body bent forward nearly horizontally,  and the elbows resting on  the
 ground, in a Avord, in such a  position as to throw the whole weight of  the
 uterus  upon  the  anterior abdominal wall, the murmur will no  longer be
 heard,  although distinctly audible  before.
   In support of this opinion the folloAving considerations may be adduced:
   The  abdominal souffle is, like that of chlorosis, partly due to the altera-
 tions Avhich the blood undergoes during pregnancy.   Whatever theory be
 embraced respecting the mechanism of these abnormal vascular sounds  in
 chlorosis, Avhether they be attributed to the diminution of the corpuscles, as
 M. Andral supposes, or to hydrsemia, according  to M. Beau,  and, we may
 add in passing, this latter theory seems to me to be the only admissible one,
 the great analogy between the blood of chlorosis and that of pregnancy can-
 not be  ignored.
   It is equally difficult not to recognize the entire resemblance between the
 souffle  of pregnant women and that of chlorotic patients.  They  exhibit the
 same varieties of rhythm, as also of tone and sonorousness; both are some-
 times mixed  or composed simply of buzzing, rasping, or whistling sounds,
 Avhich seem to be alike peculiar to the early stages of the affection.   Both
 present, if I may so express it,  the same mobility of duration, rhythm, and
 intensity, and appear to be similarly affected by the greater or less pressure of
the instrument, as also by changes in the circulation of the female as a con-
sequence of disturbances of temper, violent movements, &c.
   Is it not, therefore,  natural to conclude, that since pregnancy and  chlo-
rosis produce the same changes in  the blood, the souffle, which  is exactly
 alike iu both cases, is also due to the same cause ?
   But, it will be replied, in chlorosis the murmur is heard more especial!} 
DIAGNOSIS  OF  PREGNANCY.
261
in the cervical region; why, therefore, during pregnancy should it, if due
to the same cause, fix itself particularly in the abdomen ?   I would reply,
in the first place, that in some cases the cardiac and carotid  murmurs  have
been observed in pregnant Avomen;  still I admit that, most generally, they
are  not  heard even Avhen the  abdominal souffle is  present.   The latter cir-
cumstance can be readily explained, for it is in fact rarely that the altera-
tion of the blood is carried to the same extent as in ordinary chlorosis ; the
proportion of globules rarely descends beloAV one hundred, and the amount
of water is far from equalling the enormous proportion Avhich it reaches in
chlorosis.  Noav, if it be true, as M. Andral supposes, that the production
of abnormal sounds is an indication of a more advanced alteration, we can
comprehend Avhy they should not be perceptible in the carotids, Avhere only
poverty of the blood could produce them.
  The conditions are not the same in the  abdominal vessels, for there, to a
commencing hydrsemia,  is superadded a considerable diminution of the
calibre of the vessels,  Avhich diminution is  a result of the compression of the
uterine  tumor; and these two circumstances united are capable of produc-
ing a souffle Avhich they Avould be unable to  determine singly.  The  com-
pression of the arteries thus gives rise to a sort of insufficiency, Avhich ren-
ders still more sensible the slight increase Avhich  the total  amount of the
blood has undergone.
  It has been stated that Ave  have  several times  known  the sound to dis-
appear  Avhen  the  woman Avas  placed  on all  fours, but  that  in other  in-
stances  it still remained.  M. Depaul  recollects having  repeated  this ex-
periment, Aviththe effect of continuing to hear the uterine murmur, without
the slightest variation.  This last remark, made by such observers as MM.
Depaul and Carriere, deserves further attention on our part.  As M.  Beau
has  pointed out, it is much  more  difficult than Avould  be supposed, and
sometimes even  impossible, to cause the Avoman to assume  such a position
that the large arteries shall  escape all compression by the uterus.  The
abdominal  Avails of young primiparous women are too  resisting  to  yield
under the  momentary weight of  the  uterus, and  whatever position  be
assumed, they retain the organ strongly applied against the  posterior plane
of the abdomen.
  M. Beau  has also proved that this persistence of the abdominal souffle is
not peculiar to pregnancy, but that in the case of a Avoman  affected Avith a
cyst of  the ovary,  shoAvn to be such  at the  autopsy, it was impossible to
^rive the tumor any position in Avhich  it ceased to compress  the  arteries of
the pelvis, and consequently to put  an  end to the murmur.
  I would  add, that, whilst admitting that compression is not  the sole
cause of the murmur, but that the serous plethora of pregnancy also con-
tributes  to its production, it  might be  readily supposed that if the latter
reach a certain degree, it might of itself give rise to the abnormal sound,
even  should the position of the female entirely relieve the abdominal ves«
sels from pressure.
  The same remarks will  apply to the variable results which are some-
times obtained, Avhen, after having heard the sounds on one side of the
abdomen, the woman  is made to reverse her position.  Sometimes, Ave have 
262
PREGNANCY.
said, it ceases to be heard; at  others it persists, although the  inclination
of the uterus had  removed  the  pressure  from  the vessels on  the  point
opposite  the side upon Avhich the woman lies.  In  the first case, the ple-
thora was too  slight to maintain  a sound, the production of which Avas
partly due to the compression of the vascular  tube; in  the second, either
the inclination of the uterus had  not removed the pressure, or else  the
alteration of the blood was alone sufficient to produce the abnormal sound.
  Although MM. Barth and  Roger are disposed to attribute the abdominal
murmur to pressure, they nevertheless find  some objections which  prevent
their adopting the opinion in  its full  extent.   Wliy, say they, is  not  the
sound increased when the uterus is  pressed upon with the  stethoscope, and
why does it sometimes disappear Avhen the pressure is made rather stronger ?
It is, replies M. Beau, because the murmurs  are the  result of a certain
degree of pressure, Avhich if increased or diminished, the sounds are altered
or lessened.  The effect is the same as that which is frequently observed in
the  carotid murmurs, Avhich do  not increase, and  which  even  disappear,
when too  much pressure is  made  upon the artery ; and  as  these  latter
sounds are sometimes found to have their intensity someAvhat  increased by
a slight  pressure, so the  abdominal murmurs are occasionally notably in-
creased when the uterus is a  little pressed upon.
   Finally, how happens it, say MM. Barth and Roger, that in*certain cases
in Avhich no souffle Avas heard  upon auscultation of the abdomen, it could,
through the assistance of the metroscope of M. Nauche, be perceived upon
the neck of the uterus, which is situated in the centre of the pelvic cavity,
and therefore removed from  the vessels ?
   We may suppose, again replies M. Beau, that in the  cases  in  question
the murmur had its origin in  the hypogastric arteries.  Noav  the neck of
the uterus is nearer these arteries, than that part of the body of the organ
which is in relation with the abdominal parietes.  Besides, it  is  not  pos-
sible that certain organs which  are poor conductors of sound, such as a
mass of intestine or of omentum, might have been  interposed  betAveen the
surface  of the uterus and the Avails of the  abdomen, and thus have  pre-
vented  the transmission of the vibrations to the ear ?
   2. The Murmur is produced in the Uterus.—Those who locate the sound
in the uterine  circulation, differ essentially  as to its precise seat  and the
mode of its production.  Thus, M. de  Kergaradec attributes it to the pla-
 cental circulation; whilst M. Hohl, who also believes it is perceived at the
 point Avhere the placenta is inserted, locates the murmur at a point corre-
 sponding to the insertion of the placenta, and bases his opinion upon the
 following reasons:  1. In 21 cases  in Avhich  he removed the placenta  with
 his hand, he found it adhering Avhere the souffle was first heard;  2. In 15
 cases Avhere it was inserted  upon  the  orifice, the  murmur Avas  heard  very
 low down ; 3.  In  10 others the autopsy revealed the after-birth Avhere the
 souffle had been distinguished ; 4.  In 8 cases of version the same fact Avaa
 discovered directly; 5. In 12  cases of tAvin pregnancy, one murmur unly
 was  heard when but a single  placenta was present, and tAvo  distinct  ones
 when the after-births were separate; 6. Lastly, in a great number of cases
 the intensity of the sound appeared to be in direct relation Avith  the  bulk
 and extent of the placenta. 
DIAGNOSIS  OF  PREGNANCY.
263
  M. Hohl differs from M. Kergaradec by supposing that the sound results
from the passage of the arterial blood into the venous sinuses of the placenta;
but, to refute this  latter opinion, it is  only necessary to bear in mind  the
great variety in the seat of the murmur during pregnancy, and that in some
cases it is still perceptible after the  delivery of the after-birth.
  I am therefore,  like  M. Depaul, convinced, that  there  is no  relation
between the point where the souffle  is heard and that of the insertion of the
placenta
  The views of M. Dubois still claim a notice; for Avhenever, says this Pro-
fessor,  the  disposition of the uterine apparatus is  carefully studied,  the
freest communication will be found to exist betAveen the arteries and veins,
the uterine walls appearing to be transformed into an erectile tissue, or  one
of varicose  aneurisms;  and the column of blood brought by the  arteries,
and divided through their branches, mingles, whilst passing directly into
the veins, with the slower and less compressed  columns contained in the
canals of the latter.   This circumstance  is incontestably the cause of the
murmur and souffle  that is so remarkable  in  varicose aneurisms  and  the
accidental  erectile tissues, and it  is very likely that the same  cause pro-
duces it in  the uterine Avails.   Hence Ave  can comprehend why it is only
heard at that  period when the vascular modifications  of the organ are the
most marked; why it is most frequently audible over  the spot correspond-
ing to  the  placental insertion, because  the • development  of  the uterine
vascular system is the most considerable there; and finally, why this sound
may still be heard in some Avomen  after  delivery, Avhen the retreat of the
uterus is not  yet complete, and the circulation in  its  walls has not been
reduced to its condition in the non-gravid state.
  No one, since the researches of M. Dubois, has been able to rediscover the
large and free communications betAveen the uterine arteries and veins; it is
in fact certain, that they communicate directly in no other Avay than through
their  terminal  and capillary ramifications.  It is  plain, that  Avhen a sup-
posed  anatomical fact is proved to have  no existence, the theory which is
founded upon it can no longer be maintained.
  There are still some other points concerning the uterine circulation, which
have  recently been advanced: thus, Dr. Corrigan thought the passage of
the blood from the uterine arteries into the sinuses, Avas the cause of the
souffle; and M. Carriere, who admitted this opinion, added, that the circula-
tion  being much more  active at the point corresponding to the placental
insertion, the sound should be most audible on a level with that insertion.
  M. Depaul has quite recently repromulgated the views of Corrigan, adding
thereto the compressions produced both Avithin and Avithout by some portion
of the foetal ovoid, and  he attributes an important influence to these com-
pressions, which, hoAve\-er, had previously been  brought fonvard by M. de
Kergaradec, in explanation of the  frequent variations of the souffle in its
seat  and intensity.
  The cause of the sound, says M. de la Harpe de Lausanne, neither rests
on a particular condition  of the blood, nor on a modification of its course,
no;- yet in any peculiar state of the vessels, but simply on the  multiplicity
of the  vessels  concentrating  at the same  point;  Avhich multiplicity, by 
264
PREGNANCY.
increasing the currents a hundredfold,  increases the sounds in the same
ratio;  thus rendering those audible by multiplication, Avhich, taken singly,
were imperceptible to the  human ear.  Perhaps a comparison will serve to
illustrate this idea: if a person place himself, on a mild day, under a tree
that has been closely pruned, deprived of its leaves, and only having some
large branches left, he will  hear no  sound or rustling of  the  air; noAV let
him pass from this  tree to another  one better furnished with branches,
though still deprived of leaves, and  he will  perceive, if  the  same  air be
stirring, a commencing sound, produced  by the branches that are agitated
in the wind; again, the intensity of sound will become much greater, if he
once more changes to a fir-tree; for notwithstanding the leaves of this latter
are rigid and immovable, yet they are innumerable;  and just such is the
case with the placental murmur.   In fact, a liquid  cannot  circulate in a
tube without  producing a certain amount of sound  by the friction of its
molecules against the walls of the tube; only the sound is not detected by
the ear when the vascular canal is isolated, but the  contrary results, when
thousands of little canals are found  at the same point.
  [Amidst so many contradictory theories we shall not undertake to decide upon
the mechanical production of the bellows murmur, but will endeavor to determine
the seat of the sound, premising, however, that we do not believe  that it is pro-
duced in the  great  blood-vessels Avhich are situated behind the uterus.  The sound
is sometimes really so superficial that it cannot be produced in the aorta or the iliac
vessels; how, besides, will this  explanation enable  us to understand  the facility
with Avhich it  changes  place, a circumstance to which all  observers can testify?
Finally, we would  add that, in some very rare cases, the sound  is accompanied by
a thrill, which  is easily perceived by the finger, and felt, so to speak, to be pro-
duced behind the anterior Avail of the abdomen.  We regard it, therefore, as certain
that it is produced  in the uterus, and as we have already shown that it cannot have
its origin in the placenta, we agree with MM. Dubois and Depaul, that  it is located
in the walls of the uterus.  It is evident, therefore, that the term uterine souffle
is the only one which can be properly applied to it.]
  The abdominal souffle is not of great practical importance; its value, as
a sign, is limited  to rendering the existence of pregnancy probable.   It may
exist independently of pregnancy, and does not ahvays accompany it; it is
not influenced by the life  or  death  of the foetus, nor  is it  modified in any
degree by a state of suffering of the  child; it cannot, in any case, enable us
to determine certainly either the place of insertion of the  placenta, nor its
form, size, or the  changes Avhich  it  may undergo.   The  observations of
MM. Depaul  and  Naegele, Jr., prove, in opposition to  the conclusions of
Hohl, that  the diagnosis of double or  triple  pregnancies, is incapable of
assistance from the souffle, presenting as it does in these cases no modifica-
tions which are not also  observed in simple pregnancies.
  Summary. — It  is now  Avell understood that, in ausculting the abdomen
>f a pregnant woman, Ave may hear both the pulsations of the foetal heart
and the bruit de  souffle.   The first is a certain sign of pregnancy; but the
second, being also produced  by other causes, only becomes of importance
when Ave have previously ascertained that the  female has no other disease.
   The sound of the heart may aid in ascertaining the position of the foetus;
the souffle can communicate no information as to the place of insertion of 
DIAGNOSIS  OF  PREGNANCY.
265
 Lne placenta, and indicates nothing as regards the child's position; while
 any feebleness, and more especially any irregularity or intermittence of the
 heart's pulsations, furnish strong presumptive reasons for believing that the
 foetus  is  suffering, and that its life is compromised.
   When desirable to auscult a female who is supposed to be pregnant, Ave
 must request her to lie doAvn on her back; at the commencement of gesta-
 tion this precaution is indispensable;  but towards the  last it becomes less
 so, and  she  may then be examined standing.  In fact, whatever be her
 position  in the latter  months, this exploration is quite easy, on account of
 the dimensions of the uterus and the volume of the foetus, but at first it is
 nearly always necessary to flex the thighs upon  the  belly, so as  to  com-
 pletely relax the abdominal muscles, and  of course this could only be done
 in  the horizontal position.   The dorsal or lateral  decubitus is requisite to
 explore  thoroughly the fundus or sides of the Avomb, and  also to cause the
 foetus to  fall from either side; the thighs should also be flexed, or extended,
 according to  the  region examined.  The  unaided ear  Avill ansAver, but the
 stethoscope should generally be employed;  for,  by  using it, the sounds
 detected  can be  more readily limited, and the abdominal parietes more
 easily  depressed  so as to approach  nearer to the foetus; besides, many
 females object to the accoucheur thus applying his head flat on the abdomen.
 Experience has likewise convinced me that, when the unassisted ear is used,
 the clearness of  the  sensations is singularly diminished  by the frictions
 which the respiratory movements of the  abdomen make against the ear.
 When used,  the  enlarged extremity of the instrument should be deprived
 of  its mouth-piece, and its Avhole circumference be exactly placed over the
 region to be ausculted.
   It is also advisable  that the Avoman lie on a bed of sufficient height, other-
 Avise the accoucheur is obliged to stoop  too  much, and this  inconvenient
 position  is attended by such a degree of congestion as  to render it impos-
 sible to hear  anything.  And further, to avoid all  unnecessary searching, it
 is best to place the stethoscope at first directly over  the part  where the
 pulsations of the  heart are most commonly heard, that is, in front, below,
 and a little to the left side.
  It is equally desirable to ascertain from the female  Avhere she  generally
 perceh'es the foetal movements, for most  frequently the pulsations of the
 heart will be found on the opposite side, because the superior and  inferior
 extremities being always folded on the  abdominal plane, the back, in other
 words, the part  of the  foetus  which most  easily transmits the sounds, will
 evidently be turned towards the left, if the right side is the habitual seat
 of the  active  motions.
  Before the  fifth month,  the pulsations are  usually perceived in the lower
part of the abdomen on the median line, about half-Avay betAveen the pubis
and umbilicus;  consequently the instrument should be first applied there.
  The  instrument proposed by Nauche, under the name of metroscope, the
extremity of Avhich is intended to be introduced into the vagina and  applied
to the neck or inferior part of the Avomb, ought not to be used. 
266
PREGNANCY.
A Table exhibiting  the Signs of Pregnancy at various 1 'eriods.
            KATIONAL SIGNS.                         SENSIBLE SIGNS.
                             First and Second 3Ionths.
1.  Suppression of the menses (numerous  1.  Augmentation  in  the
   exceptions).
2.  Nausea — vomiting.
3.  Slight flatness of the hypogastric region.
4.  Depression  of the umbilical ring.
4.
S>.  Tumefaction  of  the  breasts,  accom-
   panied with sensations of pricking and
   tenderness.
                             Third and
1.  Suppression of the menses (a few excep
   tions).
2.  Frequently, the appearance or the con
   tinuance of the vomitings.
3.  A small protuberance in the hypogas
   trie region.

4.  Less depression of the umbilical cica
   trix.
6.  A ugmented swelling of the breasts, pro-
   minence of the nipple, and  slight dis
   coloration in the areola.
6.  Kyesteine in the urine.
                           size and weigh!
      of the uterus.
   2.  Descent of the organ.
   3.  The womb is less movable.
      Its walls have the consistence of caout-
      chouc.
      The neck is directed downwards, for-
      wards,  and to the left.

   6.  The orifice of the os tincae is  rounded
      in  priniiparse, but  more  patulous  in
      others who have  had children.
   7.  A slight softening of the mucous mem-
      brane covering the lips, and this mem-
      brane appears oedematous.

Fourth Months.
-   1.  The fundus uteri  rises to the level of the
      superior strait towards the  end of the
      third month, and is perceived at the
      close  of the fourth about the middle of
      the space between the  umbilicus and
      pubis.
-   2.  A perceptible flatness on percussion in
      the hypogastric region.
-   3.  A rounded tumor, as large  as a child's
      head  of a year old, may be detected  by
      the abdominal palpation.
-   4.  By resorting to  this process  and the
      vaginal touch jointly, the displacement
      en masse, and the volume of the uterus
      may easily be ascertained.
-   5.  The neck has  the same  situation and
      direction during the third month as in
      the preceding  ones ;  at the fourth it is
      elevated and directed backwards and to
      the left side.
   G.  The softening of the  periphery of the
      orifice  is much better marked.  The lat-
      ter is more open  in  multiparse,  even ad-
      mitting the extremity of the finger; but is
      closed and always rounded in primiparae.
Fifth and Sixth Months.
1.  Suppression of the  menses (some rare
   exceptions).
2.  The disturbances in the digestive organs
   generally disappear.
3.  Considerable development of the whole
   s\ib-umbilical region.
The fundus uteri is one finger's breadth
below the umbilicus at the end of the
fifih month;  and  the  same distance
above it at the expiration of the sixth.
Foetal  irregularities, and active move-
ments, which are very perceptible.
The sound of  the heart and abdominal
souffle  are now perceptible. 
DIAGNOSIS OF  PREGNANCY.
267
            RATIONAL SIGNS
4.  A convex, fluctuating, rounded abdomi-
   nal  tumor,  salient, particularly on the
   middle line, and sometimes  exhibiting
   the lictal inequalities.
5.  The umbilical depression is almost com-
   pletely effaced.
6.  The  discoloration  in  the  areola  is
   deeper ; glandiform tubercles;  areola
   spotted.
7.  Kyesteine in the urine.
            SENSIBLE SIGNS.
4.  Ballottement.
5.  A tumor is felt at the anterior superior
   part of the vagina, which is sometimea
   soft and fluctuating, at others rounded,
   hard, and resisting.
6.  The inferior half of  the intra-vaginal
   portion of the cervix uteri is softened.

7.  The whole ungual part of the first pha-
   langeal bone  can penetrate the cavity
   of the neck in multiparas. The latter is
   softened to the  same extent  in primi-
   paras, but the orifice is closed.
1.  Suppression of the menses (the excep-
   tions are very rare).
2.  Disorders of the stomach (rather rare)
3.  The  abdominal  tumor  has the  same
   characters, except that it is more volu-
   minous.
4.  A complete effacement of the umbilical
   depression, the dilatation of the ring,
   and sometimes a pouting of the navel.
5.  Numerous discolorations on the skin of
   the abdomen.
G.  Sometimes a varicose and cedematous
   condition of the vulva and  inferior ex-
   tremities.
7;  Deeper  discoloration of  the   central
   areola, and an extension of the spotted
   areola.  Sometimes there are numerous
   stains on the breasts ;  flow of milk; com-
   plete  development of the  glandiform
   tubercles.
8.  Persistence of kyesteine in the urine.
Seventh and Eighth Months.
1.  Increased size of the abdomen.

2.  The fundus uteri is four fingers'breadth
   above  the  umbilicus at  the seventh
   month, and five or  six at the eighth.
3.  The organ is nearly always inclined tc
   the right.

4.  More violent  active movements of the
   foetus.

5.  Sounds  of  the heart and abdominal
   souffle.
6.  Ballottement is very evident during the
   seventh month, but more obscure in the
   eighth.
7.  The softening extends along  the neck,
   above the vaginal insertion.   In primi-
   parae, the cervix is ovoid, and seems to
   have diminished in length; in others it
   is conoidal, the base being below, and
   sufficiently patulous to admit all the first
   phalanx.  The neck at its superior fourth
   is still hard and shut up.
First Fortnight of the Ninth Month.
1. The vomitings frequently reappear.
The abdominal tumor has increased; the
skin is much stretched, and very tense.
Difficulty of respiration.
All the othei symptoms persist, and are
increased in intensity.
 1. The fundus uteri reaches the epigastric
   region and gains the border of the false
   ribs on the right, side.
2. Active movements.  Sounds of the heart
   and abdominal souffle.
3. Often there is no proper ballottement,
   but merely a kind of rising of the tumor
   formed by the head.
4.  The neck is softened  throughout  its
   whole length, excepting the circumfer-
   ence of the internal orifice, which still 
268                            PREGNANCY.
RATIONAL SIGNS.
         SENSIBLE SIGNS.
remains closed and resisting. In women
who have previously borne children, the
finger may be introduced into the cervix
to the extent of a phalanx  and a half,
and in  fact is only arrested by the
internal  orifice,  which is  closed  and
wrinkled, though, in some cases, already
beginning to open.  In primiparae, the
softening is equally extensive, and the
neck  is swollen  in the  middle  in an
ovoidal form; but the external orifice,
although partially opened, does not per-
mit the introduction of a finger.
                        Last Fortnight of the Ninth Month.
1. The vomitings often cease.
2.  The abdomen is fallen.

3.  The respiration less oppressed.
4.  More difficulty in walking.

5.  Frequent and ineffectual desires to uri-
   nate.
6  Hemorrhoids;   augmentation  of  the
   oedema and varicose state of the lower
   extremities.
7  Pains in the loins, and colics.
1. The fundus uteri has sunk lower than
   in the first fortnight.
2. Active movements; sounds of the heart
   and bellows murmur.
3. Ballottement often imperceptible.
4. The head more or less  engaged in the
   excavation.
5. In multiparse, the internal orifice softens
   and dilates;  the finger can then pene-
   trate through a cylinder, as it were, an
   inch and a half in length, and come into
   contact with the naked membranes.  In
   primiparse, the internal  orifice experi-
   ences  the  same modification, but the
   external  remains closed.   During the
   last week, in consequence of the spread-
   ing out at the internal orifice, the whole
   cavity of the neck becomes confounded
   with that of the body, and the finger, in
   reaching the membranes, only traverses
   a thin orifice in primiparae, but a round-
   ed  collar in the others of a variable
   thickness. 
OF TWIN  PREGNANCY.                     269
                          CHAPTER  VII.

                          OF TWIN PREGNANCY.

   The term compound or multiple pregnancy has been  applied to that in
 which two or  more  foetuses are  inclosed  in the uterine cavity.   Certain
 females  seem  to be  greatly disposed to these anomalies ; thus, cases are
 recorded where six, seven, and even eleven children have been born at three
 successive confinements.
   Double pregnancies are quite frequent:  that  is,  one case is met Avith in
 about seventy  or eighty labors.   Triplets, on the  contrary, are very rare,
 since  there Avere but five  in  the records  of 37,441  accouchements  that
 occurred at La Maternite  in Paris.  Further, we  cannot call in question
 those instances in which there were said to  be four at a birth; for such men
 as Viardel, Mauriceau, Hamilton, and many others,  furnish examples of it.1
 Both Peu  and Lauverjat declare that they have  witnessed cases of five at a
 birth.2   And lastly,  must we consider  those cases of six, seven, eight, and

  1 The following statistical account is extracted from Churchill's work.  In 161,042
 pregnancies, there were 2477 cases of twins, or  1  in 69, and 36 triplets do., or 1 in
 4473 (English accoucheurs).
  In 36.570 pregnancies, there were 582 cases of twins, or  1 in 110, and 6 triplets, or
 1 in 6095 (French accoucheurs).
  In 251,386 pregnancies, there were 2967 cases of twins, or 1 in 84, and 35 triplets, or
 1 in 7185 (German accoucheurs).
  Total, in  448,998 cases, there were 5776 instances of  twins, being  1 in 77|, and 77
 triplets, or  1 in 5831.
  The same author furnishes the accompanying information as to  the sex of the twins:
 Dr. Joseph  Clarke states, that in 184  twin cases, both  children were boys  47  times,
 girls 08 times, and one boy and one girl 71 times.
  Dr. Collins reports 240 cases, in which there were two males 73 times, two females
 67 times, and male and female 97 times;  and  Dr.  Lever 33 cases, two males 11, two
 females 11,  and male and female  11.
  2 M. Pigne" informed  me that he saw a single placenta  at Strasbourg, from which
 five separate cords arose, although only a single sac existed, which was composed of
 three membranes, decidua, chorion, and amnion, in which the five embryos were in-
 closed.
  Dr. Kennedy (London Med. Gazette) presented to the Royal Society  the history of a
 woman who aborted at three months of five embryos.  There were three ovums, one
 being double, and each ovum had a placenta and  its own proper membrane.
  M. Bourdois (Gaz. Mid., p. 569, 1850) describes  a quadruple pregnancy, in  which
 the delivery occurred at the seventh month.  The second child was born twelve hours
 after the first, and the other two  a few minutes subsequently.   The second accouche-
 ment was attended  by a new discharge of waters;  there were two placentas, one of
 which had three cords and was adherent, and some portions of it remained behind in
 the uterus.
  Dr. Hull,  of Manchester, deposited five little twin foetuses  in  the Museum of the
Loudon College of Surgeons, that he had obtained  from a woman who aborted at the
fifth month of gestation.
  Chambon  records an instance of quintuple pregnancy, where the children survived
their baptism.
  A woman of Naples was  delivered of five infants at seven  months.  (British and
 Foreign Med. Review, 1839.)
  Dr. Kennedy (Every)  states (in the Dublin Med. Journal, Jan. 1840),  that a woman 
270
PREGNANCY.
nine children, or even more, at once, so many examples of which are found
in the authors, as true statements or as fabulous tales ?
  It is a very difficult matter to point out the causes of this anomaly in the
present state of our science ; true, numerous explanations have been offered,
but  all are nothing more than pure hypotheses: for example, it  is said
that a single fecundation may affect both ovaries, or tAvo of the Graafian vesi-
cles in the same ovary; and again, that several impregnations may occui
successively in a short period, that is, before  the first fecundated ovule has
arrived in  the uterus.   Both  take it  for granted that two ovules  are de-
tached, either at the same time or successively, from the ovary, and, conse-
quently, that two corpora lutea are developed.   Several well-attested  facts
prove,  however, that a different state  of things may take place; thus, for
instance, two ovules have sometimes been found in the same Graafian vesicle,
and it is evident that the rupture of this vesicle  alone, in such a case, might
produce a double fecundation;  at other times, two yolks have been seen in
the same ovule, and in such a condition a tAvin  pregnancy might certainly
occur, although but one ovule be fecundated.
  Hereafter we shall see, that these peculiarities serve to explain the varied
disposition exhibited by the membranes* be compound gestations.
  It is frequently possible to recognize the presence of twins during preg-
nancy ; indeed, the abdomen is ordinarily more voluminous then than at
other times, and the belly is generally  flattened on the median  line, instead
of presenting  there a well-marked protuberance; the  middle  is depressed,
in consequence of the two children lying one upon each side; nevertheless,
this  sign may fail Avhen one child happens to  be  placed before the other.
  The form of the uterus varies also with the position of the foetuses, their
number, and the amount of amniotic fluid.   Thus, Avhen the head of one is
above, and that of the other below, there may result  therefrom tAvo corre-
                               sponding depressions and projections, as M.
             Fia-73,             Hergott has represented.  Should both pre-
                               sent by the  head, the fundus of the Avomb
                               will be very much dilated, and the contrary
                               is the case Avhen they present by the pelvis.
                               In a case Avhich  occurred at  the Clinic of
                               Strasbourg,  the shape of  the Avomb  was
                               irregular and oblique; the tAvo heads occu-
                               pied the angles  of the uterus, and  formed
                               tAvo tumors separated by a depression ; the
                               one at the right being much  the  higher.
                               The tAvins were born by the feet.
                                 The slight bloAvs perceived by the mother
                               are sometimes felt at one and the same time
                               in two distant parts of the abdomen; and
                               the importance of auscultation  as  an ele-
                               ment  in  this diagnosis  has  already been
pointed out.   (See p. 256.)

aborted of five embryos between the second and third months of gestation; and finally,
Dr. Francis Ramsbotham has collected  three cases of quintuple pregnancy from the
public journals.
 
OF  TWIN  PREGNANCY.
271
   The belloAvs  murmur can, I  think, rarely furnish useful  information.
 Still, it is asserted  by Hohl, that in sixteen tAvin pregnancies, the murmur
 was heard seven times on both the right and left sides simultaneously, and
 nine times on  one side only; and he affirms,  that Avhen the latter Avas
 the case, there Avas a common placenta, Avhilst  in the other instances there
 Avere tAvo.  He is also of the opinion, that a  double souffle is diagnostic of
 a double pregnancy,  even though  the sound  of the heart be heard at  a
 single  point only.  We cannot admit the last  conclusion, since we have
 already denied the very relation Avhich Hohl Avould establish betAveen the
 seat of the murmur and the insertion of the placenta; besides Avhich Ave have
 often heard a souffle on both the right  and left  sides in single pregnancies.
   Again, as the tAvo foetuses  mutually  interfere Avith each other, neither of,
 them presents  itself to the vaginal  touch; and of course the ballottement
 is  then exceedingly difficult, if not wholly  impossible;  for, even  if the
 finger  should  easily  reach the  presenting  part, the  presence of another
 child Avould interfere Avith the ascending  moArement of the first.   Desor-
 meaux, hoAvever, cites a case  Avhere  the ballottement Avas manifest in  a twin
 gestation, but even here a large quantity of Avater Avas present at the same
 time.   Whilst in charge of the Clinic  of the Faculty, in  1845, I observed
 on tAvo occasions the same fact noticed by Desormeaux; for the  existence
 of dropsy of the amnion rendered the ballottement very perceptible, although
 tAvo children were present.
   The  course of twin pregnancies is sometimes  accompanied by peculiar-
 ities Avhich it is  important  to be acquainted Avith.   Thus, the  tAvo foetuses
 do not  ahvays attain to the development which Ave have indicated.  One of
 them may die, and yet the other continue  to groAV.   In such cases, Avhich,
 hoAvever, are rare, the dead body may remain in the Avomb, Avhere it hardens,
 withers, and is expelled during labor.
   In my course  of  1853, I exhibited  a placenta obtained from a woman
 who Avas delivered at term of a living and Avell-developed child.  It was
 provided  with  tAvo  amniotic bags,  one of Avhich belonged to the  living
 child, and presented no' unusual appearance.   The  other, which was much
 smaller, contained barely a trace of fluid, but  inclosed a  small  mummy-
 like foetus, about  the  size  of one of four  months'  development.   On the
 other hand,  the dead foetus  may irritate the uterus,  bring  on contractions,
 and be expelled, Avhilst the other remains and is developed as usual.
  Lastly, the twin that perished during  pregnancy may still remain  in the
 womb, in consequence  of the adherences Avhich its placenta has contracted
 with that organ, for a long period after  the expulsion of its living brother,
 that occurs at the ordinary term of gestation.
  Guillemot  furnishes one  of the most curious observations of this kind
 (Heureux Ace, livre ii. p. 225) on record, in Avhich the  artificial extraction
 of the dead body did not take place until tAvo  years after the accouche-
 ment.   But Avhat is the cause which thus determines  the death of one
 foetus ?
  Mauriceau and Pen  thought it might be attributed to the fact  that one
 child, by receiving all the nourishment,  becomes strong and vigorous at the
 expense of the other,  thereby rendering it feeble  and languishing, and
causing  its early death. 
272
PREGNANCY.
  M. Guillemot believes that one child, in its growth, gradually compresses
the second against the  uterine Avail, and  the  latter, not  having sufficient
space for its development, soon after dies.   Lastly, M. Cruveilhier explains
the atrophy of the foetus by a gradual separation of the placenta, founding
his  opinion on a single case, in which the  hemorrhage was great enough to
account for the early death of one of the twins; but in the greater number
of cases  that  have been recorded, no  mention whatever is made of any
hemorrhage during the  pregnancy;  whence, of course, the opinion of M.
Cruveilhier Avould not be applicable to them.  For  my own part, I believe
these cases, in which the death and atrophy of one foetus takes place, should
rather be attributed to some  disease of the infant  or placenta, or of some
parts of its envelopes.  It may be urged, indeed,  that these alterations are
not observed at the  time of accouchement, which is not to be wondered at,
considering the state of degeneration exhibited by  all parts of the ovum;
and, although no positive fact sustains this opinion, it seems  to me  more
admissible and more rational than the others.
  It not unfrequently happens that tAvin pregnancies terminate before full
term, OAving, doubtless, to the great distention of  the uterus, which is often
as large at seven or eight months as in a simple pregnancy at nine months.
The same labor generally suffices for the expulsion  of both, though such is
not always the case; for, after the first child is  born, the  uterus may re-
tract upon the  remaining tAvin, and leave  it  unexpelled for  eighteen or
twenty-four  hours.   A  still  longer interval, several months even, may
separate the tAvo parturitions;  and it is upon such facts as these that  some
persons have improperly admitted the doctrine of superfcetation.   A  refer-
ence to the latter is, however,  unnecessary to explain these observations, for
the cause  of premature  delivery is  dependent solely on the enormous dis-
tention of the  uterus, because as soon  as  one infant is expelled the Avomb
retracts, the cause of irritation no longer exists, and Ave can  readily con-
ceive that the  gestation may continue on until term.  A child born at seven
months may live equally well Avith  one  delivered at the end of  preg-
nancy.
  The peculiarities  just studied in tAvin pregnancies  may  also present
themselves in cases of triplets, &c.  Thus, in a case cited by Port?1., after
the delivery of the first child and its placenta, Avhich were healthy, he Avas
obliged to extract two others  that had apparently been  dead for a long
time, and were thoroughly dried.
  Again, the membranes are not  ahvays disposed in the  same manner in
these pregnancies ; and on this head Ave may admit, Avith M.  Guillemot, Avho
has  particularly studied the subject, four distinct varieties: thus, in  the
first, two ovules are fecundated, and each embryo becomes  developed, and
is surrounded by its OAvn proper membranes; in the second, the ovule con-
tains two germs, though each foetus has but a single envelope, the  chorion
being a common membrane; in the third, both embryos  are inclosed in  a
single cavity, Avhich appears never to have been divided by any membranous
diaphragm; and, finally, the last variety  is met Avith Avhen  the ovule con-   \
tains a second germ, and both become developed together, Avhich gives  rise
to what are  called monstrosities by inclusion.  Adopting  this classification 
OF  TWIN  PREGNANCY.
2f3
as the basis, let us noAV proceed to the  different  modes  uf termination
presented by these pregnancies, according to the  species  to Avhich they
belong.
  1. In the first variety, both ovules are developed, retaining their proper
membranes, the chorion and  amnion ; at  first, each ovum has its  own re-
flexed decidua, but generally that portion  of the latter which  forms the
partition is very thin, and becomes absorbed as the gestation advances, and
a single decidua then appears to envelop both.
  The tAvo  chorions  repose  against  each other, being  only separated by
some very fine areolar tissue, so that the children  are divided by one very
thick  partition composed  of  four layers.   The placentas  are  sometimes
separate, though usually confounded Avith  each other, or else are united by
a  kind of  membranous bridge;  but,  notwithstanding the  continuity of
tissue, there rarely exists any vascular  communication betAveen  them, and
this fact is so uniform that the exceptions to the laAv are very rare indeed.
From all which it must therefore be evident that two distinct ovules have
been fecundated, whether they  are deposited separately, or are contained in
the same vesicle.   The first variety is the most frequent.
  2. In the second variety of compound pregnancy,  the chorion is common
to both tAvins, and each foetus has but a single envelope formed of the am-
nion—the tAvo laminae of Avhich, resting against each other, constitute the
median partition.   MM. Dance and Mancel have furnished an example of
this variety in which there Avere but tAvo children.   Brendelius reports that
a woman Avas delivered of tAvo girls  after three days' travail, but she died
before the extraction of the third infant, which was found dead on opening
her body; the placenta was single and very large, and the chorion had been
common to all three, although  each foetus had a distinct amnion.
  There is therefore  only a  single placenta,  and  a communication nearly
ahvays  exists betAveen the ramuscules of the tAvo cords, as I have verified
myself, on a placenta, which  Avas presented by one of my former  pupils, an
Interne of the Ursuline Hospital, Avhere he obtained it.   In this, as  in the
preceding variety, one foetus may die, the  other continuing to live; but it is
easily foreseen  that an  expulsion of the  tAvo  children  cannot take place
separately.
  3. Further, it may happen that the  foetuses are not separated by any
partition, and are all shut up in the same amniotic cavity;  and to the ex-
amples of this kind, already cited, I may add a case observed by  my friend
and  colleague, Dr. Fournier.   The two cords arise, most frequently at least,
from a distinct point of  the placenta; but sometimes  they are observed to
come from a common  trunk,  Avhich bifurcates  at a variable distance from
the placental surface.  In this variety, the expulsion of one foetus must
evidently be folloAved  by that of the other; but I do not knoAv to Avhat ex-
tent Ave can justly say that the death of one necessarily endangers the other's
life,  if not  speedily delivered by nature.   (Baudelocque.)  This inclusion
of tAvo foetuses in the same amniotic cavity is often met Avith in those cases
where one of them is destitute  of an important part of its body: thus, the
monstrosity that I presented to the  Royal Academy of Medicine Avas in-
closed in the same sac with its tAvin brother.
       18 
274
PREGNANCY.
     But it  is nearly or Avholly impossible, in the present state of ovological
  knoAvledge, to explain this  strange  anomaly, the existence of Avhich, hoAV-
  ever, has several times been clearly verified.
     In accordance Avith Avhat Ave  have said respecting the formation of the
  amnion (see Art. Ovology), this membrane emanates from the embryo itself,
  and consequently the amniotic membranes should equal the foetuses in num-
  ber ;  but, Avithout admitting the theory of Pockels and  Serres on the devel-
  opment of the amnion,  a theory which, notwithstanding its want of proba-
  bility, derives, from the facts alluded to, a  certain degree  of support, we
  cannot explain them but by supposing that tAvo amniotic membranes existed
  primitively, and that the partition produced by their contact has been some-
  how destroyed.   Most generally, there are numerous communications exist-
  ing  between the  umbilical ramifications, as we have stated, when  the cho-
  rion, and  especially the amnion, are common to both,  which is not ahvays
• the case.   Thus,  Dodd  reports a case of triplets, where the  placentas were
  consolidated into one, tAvo of the children being inclosed in a common cho-
  rion, Avhilst the third had a special one;  the umbilical vessels did not com-
  municate with each other.   In another  instance,  recorded by Davis, the
  three foetuses had a common decidua; two of them were surrounded by the
  same chorion and amnion, but the third had its chorion and amnion distinct
  from the others;  the placenta formed a single mass, but the  vessels had no
  communication with each other.  (London Med.  Gazette, 1841.)
     4.  Finally, the fourth variety of compound  pregnancy  that  we have
  admitted, along with M. Guillemot, constitutes what has been called a mon-
  strosity by inclusion.  It consists of the complete inclusion of the elements,
  whether more or less numerous, of one foetus in the body of another foetus,
  which is otherwise  well formed.
     M. Ollivier (d'Angers), who has published  a very interesting article on
  this monstrosity, admits that the inclusion may take place  in two different
  ways : for instance, the  contained foetus is sometimes shut up in the abdomi-
  nal cavity of the other child, thereby constituting the profound, ox abdominal
  inclusion.  At others, it is merely enveloped by the integuments of the lat-
  ter, which form  an external tumor, without any communication whatever
  with the visceral cavities of the foetus that carries it; this is the cutaneous,
  or exterior  inclusion.   This latter  has again been subdivided into  two
  varieties, according as the tumor occupies the scrotum or the perineum; but
  as the character of this work evidently prohibits  me from  entering  into a
  discussion of the various opinions put forth as to the nature and the mode
  of formation of this kind of monstrosity, I can  only allude to them here;
  and I refer for more complete details to the memoir of M. Ollivier (Archives,
  1827), as Avell  as to that of M. Lesauvage de Caen, and  still more especially
   lo the admirable Traite de Teratologic, by M. Isidore Geoffroy St. Hilaire 
PAET  III.
                           OF  LABOR.

   LABOR is that function Avhich consists in the spontaneous or artificial
    expulsion of a viable foetus through the natural parts of generation.  The
term labor is used more especially to designate the  expulsion of the child;
the expulsion of the placenta being treated of under the head of Delivery,
of that organ.
  This definition of labor, differing as it does someAAdiat from those given
by most modern writers, has the advantage of furnishing me a basis Avhereon
to found a practical division ; for Avhen the expulsion of the foetus takes
place from the efforts of nature alone, it is called a spontaneous, or a  natural
labor;  but Avhen nature is inadequate to the accomplishment of this effect,
and art is obliged to intervene, the delivery is said to be artificial, laborious,
and also (though improperly) unnatural.
  This function  has also received different denominations, according to the
period  of pregnancy at which it is manifested : thus, it  has  been named
legitimate, timely, or  at term, when  occurring Avithin a Aveek before  or after
the expiration of the ninth month.  On the  contrarv, it is called premature
or precocious, if  it takes place during  the seventh, the eighth, or the begin-
ning of the  ninth month.  Again, the latter may be spontaneous or artifi-
cial, according  to Avhether it is  simply the Avork  of nature  or has been
brought on by the intervention of art.   This last case should be carefully
distinguished from Avhat the ancients called forced labor, in Avhich they not
only provoked  the manifestation of the uterine  contractions by a  more  or
less direct irritation, but effected the delivery at once.
  Lastly, it is called tardy, or retarded, when the delivery is not accom-
plished before nine months and.a half  or ten months.
  At Avhatever period  delivery may occur, it  is ahvays effected  under the
influence of the same  forces;  though  there  is an important distinction  to
be established in the phenomena, constituting Avhat practitioners are agreed
to call the labor.   Whenever Ave examine carefully  the Avhole of those phe-
nomena, Ave can readily make out  two very distinct orders of facts.   The
one is  nothing more than an expression of the vital action brought  into
play for the  expulsion of the foetus, Avhile the other is constituted of the suc-
cessive movements Avhich  the child itself executes  during such  expulsion;
the first is purely physiological, the second  embraces the mechanical  phe-
nomena of the labor. Though often confounded in practice, these tAvo orders
should be carefully distinguished in theory.
  We shall therefore  have to examine, in  as  many separate chapters, Ihe
causes  and  physiological.phenomena,  as also  the  mechanical phenomena
both of labor  properly so  called, and of  the delivery  of the placenta.
                                                             275 
276
LABOR.
 Again, although  in the vast majority of cases the woman is really able tc
 deliver herself, yet there are many precautions which the accoucheur should
^bear in mind, and a series of little attentions he must give to the patient in
 the course of the parturition; besides, the  child will likewise require his
 intelligent aid, either during the travail or immediately after its birth, and
 therefore Ave shall devote a chapter to the exposition of those attentions and
 precautions.
   We shall, in the first place, enter upon the study of natural labor at term,
 spontaneous premature delivery, retarded labor, and natural delivery of the
 after-birth ;  leaving the subjects of difficult labor and preternatural delivery
 of the placenta,  to be treated of hereafter under the head of Dystocia.
 Premature artificial delivery will be described in  connection with the other
 obstetrical operations.
                          CHAPTER  I.
          OF THE  CAUSES OF  NATURAL  LABOR  AT TERM. '
  These have been  divided into the efficient  and the determining causes.

  § 1.  Efficient Causes.
  For  a long time the foetus was regarded as the principal agent of its own
delivery, and as the  chick breaks the shell of the egg, so it was supposed to
effect the rupture of the membranes which contained it.  The advocates of
this opinion, Avhich is no longer admitted, except by some persons out of the
profession, relied chiefly on the fact of dead children being expelled  more
sloAvly from the Avomb,  and with more difficulty than others; and further
also because, in  certain  instances, the child has been known to escape from
the uterus some time after  the mother's death.  But, in reality, these  two
facts have no value  whatever in the question before us;  for the  death of
the foetus,  Avhen recent, does not  materially  retard  the  parturition,  and
writers Avere altogether  in error as to the  influence attributable thereto.
  The living infant is expelled more  rapidly, not in consequence of  being
the agent of its own discharge, but because its movements irritate the uterus
and  solicit its more frequent contractions; after  its  death the organ is, on
the contrary, deprived of that natural irritant.  Besides, whenever  the foetus
has been defunct for a long time, another cause of retardation is  added to
the former; for where the  product of conception  has undergone  a partial
decomposition, the contractility of the uterine Avails is unfavorably influ-
enced  thereby.  In  fact, the vitality of the organ seems to be in relation, to
a certain extent, with that  of the inclosed body; the blood being  no longer
attracted thither by the ordinary  stimulus, does not reach there in such
large quantities as before, and consequently the greater vital activity usually
manifested in gestation is lost; hence arise  atony of its walls, an excessive
feebleness of its contraction, and  slowness of the labor.  Again,  the foetal
trunk, being softened by the changes before described, collapses, as it Avere,
 and ceases to offer that resistance to the uterine Avail Avhich is neeessarv to the 
CAUSES  OF  NATURAL  LABOR  AT  TERM.         277
energy and the  maintenance of its  contraction.  Therefore, if it be  true
that the death of the infant renders its delivery more difficult, it is solely from
the unfavorable  influence that this occurrence  may have over the exercise
of the organic contractility.
  Instances of children  having been  delivered  spontaneously  after  the
mother's  death  are quite numerous,  and this is the  strongest  argument
adduced by those who believe that the  foetus is the  principal  agent in the
expulsion.  But numerous observations, among others those related by  Dr.
Planque (in La Bibliotheque de Medecine Choisie), prove  that those infants
were dead even before the mother.   Now these  facts,  extraordinary as they
appear, can be very naturally explained as folloAvs: Supposing the delivery
took place shortly after the parent's death, the motor faculty of the uterus
is not so dependent on the nervous system as to be entirely lost immediately
upon the  cessation of vitality in the latter, and  is  evidently retained for
some time after  the  mother  has succumbed.  Thus, Leroux has observed
the uterus contract a quarter of an hour  after the last breath; and Osiander,
after having  performed the Csesarean section on a corpse, found the uterus
as much contracted the next day as it usually is in a Avoman just after her
confinement.   It is, therefore, very natural to suppose that such  deliveries
are owing to the  contractile  action of the Avomb, Avhich, says Desormeaux.
it, like other hollow muscles, still preserves for  some time after death ;x and
finally, let us add, that the real death  in many cases may have been preceded
by an apparent  one, and  possibly that the former may not  have occurred
until just at the instant of, or immediately after the  delivery took place.
But Avhen the expulsion of the foetus did not occur before the lapse of  two
or three days, Ave must suppose, Avith M. Velpeau, that the  labor Avas Avell
advanced at the time of the mother's death, and gas being rapidly produced
in large quantities in  the  intestinal canal, the  uterus  was thereby mechani-
cally compressed on  its exterior, and the ovum consequently forced  out
entire.   Perhaps the subjoined  case, reported  by Hermann, might be ex-
plained in that  Avav.   (Edin. Med. and Sure/. Journal, NeAV Series, N~> vi
p. 431.)
  A young Avoman  died in her  tenth month, and the  third day after, the

  1 Dr. Tyler Smith states that the reflex action may continue for some time after the
complete cessation of the respiratory movements, and in some cases be powerful enough
to effect the delivery when the patient has died during labor; but that, in most instances,
the post-mortem expulsion of the foetus is due to a peristaltic contraction of  the uterine
fibres.   We find it  difficult to admit the existence of a vermicular contraction powerful
enough to produce  such a result.
  M. Brown-Se"quard has recently advanced what he regards as an explanation of thia
posthumous contractility. According to this learned physiologist, the contact of venous
blood with the muscular fibre  is sufficient to stimulate it to contraction.  I  have
observed, he says,  movements in  the uteri of recently killed  animals, whose spinal
marrow had been destroyed throughout its length.  I have seen these same  movements
in the uterus extracted from a living animal.  These, which could not be attributed to
reflex action, since there was no  opportunity for  the exercise of nervous influence,
were due simply to the contact of non-oxygenated blood, to prove which he relates the
following experiment.   The spinal marrow in two Guinea-pigs,  which  had reached
the end of gestation, wa« destroyed from the sixth rib to the  sacrum, yet labor began
and ended shortly after a ligature was drawn  tightly around  the trachea. 
278
LABOR.
attendants noticed a  strange  noise about the corpse.   A  physician  waa
hastily summoned, who found that twins,  s-till inclosed by the intact mem-
branes, had been just delivered.  The children presented no traces of putre-
faction, the placenta alone sliOAving a commencing alteration.
  But, besides  these, numerous other objections still remain against  this
theory: 1. The delivery exhibits nearly the same phenomena, at Avhatever
period of gestation it takes place; noAV, can any one suppose that the foetus,
which scarcely rhoves at all  in the early months, can at once acquire a
sufficient degree of strength to overcome the  great  resistance made at  that
time  by the uterine neck ?  2. It is Avell  knoAvn, that, if the child  present
by any other part than the head in labor at term, the presenting part  is so
high up, before the rupture of  the  amniotic pouch, that it can in  no  wise
contribute to the dilatation of the os uteri.  3. Again, the fcetal efforts cer-
tainly ought to affect the bag of A\Taters first, and therefore a rupture of the
enveloping sac should always be among the earliest phenomena of the labor;
hoAvever, such a rupture often does not occur  until the very last moments;
sometimes even the ovum escapes entire.   4. Would it be possible for the
most  healthy and vigorous  infant to make any exertions  strong enough to
surmount the resistance opposed to its delhTery in some of the instances of
tedious  labor?  &c, &c.   From all Avhich Ave  may conclude  that the foetus
has no influence over its OAvn expulsion, and that the efficient cause of the
delivery evidently belongs to the contraction  of the uterine Avails, aided by
that of the diaphragm and the abdominal muscles.
  Furthermore, to be convinced  that the womb acts the principal  part in
this  process, it is only necessary to examine a woman  during labor,  and,
more especially, to introduce the hand into the uterus in a case of  difficult
version.   It is  its  contractions alone Avhich generally produce the dilatation
of the os uteri, thus preparing a w7ay for the child's passage; and they also
perform the most important part in the later periods of the labor.  They are
even  capable of effecting the delivery themselves.   Thus, for instance, the
parturition does not  the less take place in animals, Avhere the belly is laid
open, and  the  abdominal Avails thereby rendered incapable of any further
action.  It also takes place in Avomen affected Avith procidentia uteri,1 as also
in those Avho suffer from a paralysis of the  abdominal  muscles, in conse-
quence of  an  affection of the  spinal marrow, or some one of the  nervous
centres.   Finally, the use of anaesthetics within certain  limits, destroys the
contractility of the voluntary muscles, together Avith the sensibility ; yet the
uterine contractility remains, and the delivery is accomplished.  Ordinarily,
however, in the second or expulsive stage  of  the labor, the uterine  contrac-
tion is assisted  by the simultaneous action of the diaphragm and abdominal
muscles.
  At the moment when the head  clears the neck of the  uterus, especially
when by  pressing strongly upon the floor of the pelvis it distends the
perineum,  compresses greatly the lower part of the rectum and neck of the

  1 According to  the report of Burdach, Wimmer has actually known the labor to take
place regularly in a  woman whose womb formed a tumor between her thighs, eleven
inches long and  seven and a half  inches broad; the opening in which was directed
iownwards. 
CAUSES  OF  NATURAL  LABOR  AT  TERM.          279
 bladder, and opens and dilates the vulva, the pressure upon these parts is
 bo violent that instinctively, not to say  involuntarily, the Avoman exerte
 herself poAverfully, in order to relieve herself as soon as possible from the
 insupportable sensation.  Thus, fixing her feet firmly against the foot-board
 of her  bed, and  clinging to anything around that may offer a solid resist-
 ance, the patient takes a full inspiration, dilates her chest, and then, retain-
 ing  the inhaled  air  in her lungs,  she strongly contracts  all the  muscles
 forming the abdominal inclosure.  This auxiliary contraction is so evident
 that nobody can doubt it, and authors only differ as to the kind of aid it
 brings to the uterine  forces.  Haller and others considered the uterine con-
 tractions as being  merely secondary,  and  attributed to the  abdominal
 muscles the principal part in the expulsion of the  child;  thus they suppose
 that the contraction of the organ simply serves to support the foetal trunk,
 to embrace it properly  like a cylinder,  and to prevent the great pressure of
 the diaphragm from crushing it in, Avhile at the  same time the act of inspira-
 tion and the contraction of the abdominal Avails force it outAvards.   But,
 from the facts before stated, we may judge of the  value of this hypothesis.
 True, in certain  cases of excessive feebleness of the uterus, and of a com-
 plete inertia of its Avails, the abdominal  muscles have proved sufficient to
 terminate  the  delivery; yet hoAV much  oftener has it happened  that the
 Avoman, exhausted by antecedent disease, and left Avithout energy or strength,
 has been unable  to assist the Avomb by any voluntary contraction Avhatever!
   Again, some Avomen  have been delivered  during hysterical  or  epileptic
 fits, in a state of total  loss both  of feeling and movement, Avhere evidently
 the uterine contraction alone could accomplish  it.   This harmony of action
 is therefore useful but not  indispensable, since the labor Avill often terminate
 under the sole influence of the merino forces;  but it will be nearly ah\rays
 impossible in cases of total inertia of the organ, hoAvever poAverful the con-
 tractipns of the abdominal muscles may be.
   The researches of Cloquet and Bourdon on the physiology of the process
 do not Avarrant the supposition of any active pressure by the diaphragm on
 the upper part of the uterus.   They ha\re proved, in fact, that the principal
 phenomena consist in a change of the acts of respiration, and that the object
 of such change is to furnish a solid point of insertion to the muscles passing
 from the chest  both to the  trunk  and upper extremities. When the air has
 penetrated into this cavity, the glottis closes spasmodically;  the abdominal
 muscles begin to  contract;  they  press back the  viscera, in  the caATity of the
 peritoneum against the diaphragm;  the latter contracts in turn;  and, being
 sustained above by the resistance from the air contained in the lungs,  gives
 to the base of the chest a degree of  immobility and solidity, Avhich affords
 a fixed  point for  the muscles inserted there; so that, in the effort of expul-
 sion, the diaphragm, by its contraction, only exhibits a poAver of resistance
 sufficient to sustain the thoracic  parietes, but not an active  force,  Avhich is
 to operate, like the abdominal  muscles, directly on the uterus.
  On the Avhole,  then, the  efficient cause of labor is inherent in  the Avomb
itself.   Its contraction  alone is brought into play during all the first  half
of the labor; but it is aided in  the second period by the abdominal  muscles,
 which become more and more active as the labor draAvs tOAvards its tormina- 
280
LABOR.
tion.  Most generally the  uterine contractions would be sufficient, but the
abdominal contraction alone could scarcely ever complete the delivery.

  § 2. Determining Causes.
  This name is applied to  everything that can determine the action of the
efficient causes; and, as before stated, this class consists both of unnatural
and  natural causes.  The second  only claim our  attention  here.  The
regular  and  almost fixed  period at which  the  gestation terminates in the
majority of Avomen, lias, in all ages, claimed the attention of physiologists.
By some, the determining  cause of labor has been attributed to the child,
and by others to the womb.
  1.  According to the partisans of the first opinion,  the  foetus, having
arrived at a certain stage of development, will have acquired such a degree
of muscular poAver that  the resulting movements of its  limbs will produce
such bloAvs and shocks upon the uterine walls, as will  irritate the organ and
determine its contraction.   2.  The Aveight of the infant  might also lead to
the same effect.  3. Being  confined in the uterine cavity, whose dimensions
have not augmented in proportion to those of the foetus, the  latter will be
incommoded.  4. Suffering from the prolonged accumulation of meconium
in the intestinal  canal, of urine in the bladder, and from  its contact  Avith
the amniotic fluids, which ultimately acquire acrid and irritating properties,
and no longer finding in the materials furnished by the mother the elements
necessary to its nutrition and respiration, the infant will  experience a neces-
sity of changing its  residence,  of seeking  a medium  more  suited to  its
ulterior  development; Avhich  necessity Avill  prove an instinctive  desire of
escaping from the  surrounding inconveniences, that will  cause it to  give
itself, so to speak, the signal of departure.  Surely, it is only necessary to
present such reasons as these in a summary manner, to obviate the necessity
of refuting them.  In short, the foetus is  as foreign to the determining as to
the efficient cause of labor.  The opinion favorable to the cause residing in
the uterus rallies around it a greater number of  partisans, but  all of these
do not explain the  mode of action in the same Avay.  Thus, according to
some, the Avomb only possesses the faculty of distention to a certain degree,
and,  Avhen carried beyond  that limit, the walls react  and  contract; others
believe that the term of nine months is assigned by nature for the fulfil-
ment of the new organization of the Avomb; and having  acquired at that
period all  the qualities necessary to the accomplishment of the  great func-
tion to Avhich it is  destined, it immediately enters into  action.   But most
of the modern  accoucheurs consider the folloAving explanation as the more
reasonable.
  Observation proves, say they, that the fundus and body of the uterus are
the parts first distended, for the purpose of forming the oavity which incloses
the product of conception ; and  the cavity  of the  neck subsequently par-
ticipates in the  dilatation, Avhich begins at its upper part, then gradually
descends, so that the ring formed of the external orifice has  alone undergone
but little alteration at the approach of labor.   Again, the Avails of the neck
whose tissue is denser and  more  resistant than  that  of  the body, undergo
certain changes,  which follow the same progression in dilating as the cavity 
CAUSES OF  NATURAL LABOR  AT TERM.           281
does; cheir tissue is saturated Avith juices;  they soften and become supple;
their fibres unfold, as it Avere, are  elongated  and developed;  and,  conse-
quently, the resistance of the neck to the escape of the ovum progressively
diminishes as the term of gestation draws near.
  According to this vieAV, the fibres  of the neck are considered antagonistic
to those in the  body, the contraction of which latter  is therefore reduced
to a simple tonic action, so long as the resistance of the neck is superior to
their-poAver; but Avhen  this opposition  is  diminished by the  progressive
dilatation of the cervix, the orifice alone remaining, the fibres of the  body
then begin to act more evidently, and their contractions become more and
more energetic.   (Diet, de Med., en  25 v.)
  According to Ant.  Petit, the  body only will  dilate prior to the  sixth
month; but at that period it commences borroAving from the cervical fibres
the elements of its ulterior distention, to which it  can no longer  contribute
itself; and such  contributions will continue to be drawn  during the last
three months, and  then, Avhen all the fibres held in reserve by the neck
shall have yielded,  the distention being carried to  the utmost, the accouche-
ment will take place.   M. Velpeau  adopts nearly the same  opinion.   On
the other hand, M. P. Dubois, who originally advocated the opinions avowed
by Desormeaux in  the first edition of the Dictionnaire, has  since taught,
in his course of 1837-8, the  folloAving theory proposed by Jones  PoAver,
in 1*19.
  The uterine  tissue at term may be justly compared to  that of the  other
holloAV  muscular organs: the  bladder  or  rectum, for example; and, like
these organs, it  is formed of tAvo muscular layers, the. external of which
has longitudinal  fibres, and the internal has circular ones; it also presents
a superior cavity, a dilatable and  contractile reservoir, to Avhich the struc-
ture  just indicated principally  belongs;  as  also a  closed orifice below,
formed  solely by the circular  fibres arranged as a sphincter muscle.  It
likeAvise resembles the  bladder and rectum in having tAvo orders of nerves —
the sympathetic and the spinal; those coming  from the ganglionic  system
are  distributed  to the body, Avhile  the  others, derived from the nervous
centres  of animal life, go to the  neck, Avhich is  a true sphincter for the
uterus;  the similitude  is further  maintained  by  the  presence  of a mem-
brane lining its  interior, and  by being covered  externally, though at the
superior part only, by  the peritoneum.
  The agreements  in  structure are  not the only ones claiming our atten-
tion ; for the Avell-marked sympathies existing in the rectum or bladder,
between the  reservoir and  its sphincter,  are found  quite  as distinctly
marked betAveen the body of the uterus and its neck;  for as an irritation
of the neck of the bladder or the  sphincter ani is capable of producing an
urgent desire to urinate,  or to go to stool, so irritations affecting  the cervix
uteri also solicit the contractions of that organ; moreover, it is Avell known
that  an extreme fulness or  distention of the  first-named organs acts  me-
chanically in tAvo Avays:  1. By irritating their  Avails by the direct contact
of the  contained substances;  2.  By dragging or pressing on  the  fibres
forming the sphincter, and  these latter reacting on those of  the body.
Xo\v, A\ha does not  recognize  in  this resemblance, says Dubois, an  easy 
282
LABOR.
explanation of the determining causes of labor?  For, so long as ihe cervix
uteri retains a certain length, its most inferior fibres,  those especially sup
plied by the nerves of animal life, and therefore enjoying a high degree of
sensibility, are not exposed to any kind of excitation;  but,  tOAvards the end
of the gestation,  and in  consequence of the  successive  expansion  at the
superior part of the neck, its Avhole length has disappeared  by contributing
to the gradual development of the organ ;  a circular collar alone remaining,
formed  of  the   horizontal  and the circular fibres,  which appertain  to
the external  orifice.  The  groAvth of the uterus  cannot continue Avithout
producing a severe  tension on the fibres of this collar ;  and further, being
brought immediately into contact with the  amniotic sac, and consequently
with the presenting part of the  foetus, they must necessarily suffer, must
be irritated  and  excited  by this  constant and unusual contact.  As this
double  cause of irritation is constantly acting, it must inevitably happen
with the fibres belonging to the body of the uterus,  as it does with  the
rectal  and vesical Avails Avhen their sphincter  is irritated, i. e. they must
immediately enter into contraction.1
   Dr. Tyler Smith, of London, has  lately endeavored to prove, in accord-
ance Avith the observations of Carus,  Mende, and Merriman, that the deter-
mining cause of labor must be sought for in the ovary;  that  natural labor
ahvays  corresponds Avith the tenth menstrual period, and that the congestion
of the'ovaries produced, by reflex  action,  first  a simple irritation, and
ultimately true contractions of the uterine parietes.
   Admitting as proved  that the menstrual ovulation goes on during preg-
nancy, it would still remain to be  shoAvn why it should be rather at the
tenth than at the  eighth or eleventh period that this influence of the reflex
action of the ovary should be strong enough to excite the contractions of
natural labor in the uterus.
   At one of the  late sittings of the  Biological  Society  (September, 1855),
M. BroAvn-Sequard suggested a theory Avhich  doubtless is subject to objec-
tions, but which certainly is one of the most ingenious of all that have yet
been proposed in  reference to the determining cause of labor.
   Like all the muscles,  those especially of organic life,  the muscles of the
uterus are very sensitive to the contact of venous  blood, and the carbonic

  1 Mr. Power cites the following case, communicated by his brother in support of hia
opinion,  and which we bring forward as being interesting in many respects.
  A lady, the  mother of several children, supposed  herself near  the term of a  fresh
pregnancy, and she  felt two or three slight pains ; but they soon passed off again, and
three months more elapsed  without her experiencing any  other pain.   Becoming
uneasy about her condition, she consulted  several physicians,  who,  after having  made
the usual examination, declared she was not pregnant.  The author's brother having
been called in, participated at first in the same opinion ; nevertheless, he found the
abdomen greatly enlarged,  and much inclined forwards, so  that  it descended in  front
of the thighs, almost down to the knees, when  the patient was  standing.   A distin-
guished  physician, a friend of the lady, who was present, then mounted on a  chair
above  her, and by passing a towel underneath the belly raised il up ; the vaginal
touch being once more resorted to, the child's head was distinctly felt.  A suitable
bandage retained the tumor in that position, and four or five days afterwards the pains
came on, and the woman was happily delivered of a very large living infant. 
CAUSES OF NATURAL LABOR  AT  TERM.           283
 acid gas, Avhich the latter contains in large amount, is capable of producing
 their contraction.  Of the experiments tending to prove this, one certainly
 seems very conclusive.  M. Sequard  applied a ligature to the trachea of a
 pregnant rabbit.  Six or eight minutes after the commencement of asphyxia,
 uterine contractions became manifest; the  ligature Avas removed, the con-
 tractions ceased;  it was again applied, and they reappeared.
   Noav, according to M. BroAvn-Sequard, at the end of gestation, the irri-
 tability of the uterine fibre is very great, and the development of the venous
 apparatus of the  organ such, that a considerable amount  of venous blood
 is contained Avithin its walls.  These tAvo conditions  together constitute, he
 thinks, the determining cause of the first contraction, since the excitability
 must necessarily be aAvakened  by the prolonged contact of carbonic acid.
 The effect of the first contraction would be to expel the blood from the veins,
 and the contractions Avould cease promptly with the exciting cause, did not the
 pain which it occasions stimulate the reflex  action of the spinal marrow;
 the latter, therefore, sustains it for  some moments.   But, as Ave shall state
 hereafter, the contractile  poAver of a muscle of organic life is  rapidly ex-
 hausted,  its fibre relaxes,  and  repose  soon  succeeds  to  activity.   This
 relaxation of the uterine  fibre allows the venous  blood to Aoav back into
 the uterine sinuses, so that after a time the series of phenomena just men-
 tioned recommences.
   I  have contented  myself with simply presenting the principal vieAvs that
 have been  entertained  as to the determining  cause of labor, although  it
 would be an easy matter to start numerous objections against all of them,
 Avhich perhaps could not  be  set  aside.  Thus,  the uterus  is as much dis-
 tended, in some cases, at eight months as it is in many others at nine, with-
 out the term of pregnancy being anticipated.   The muscular organization
 of the uterus is as perfect several Aveeks before  the tAvo hundred and  seven-
 tieth day as it  is at a later  period.   The  sort of antagonism fancied by
 some authors to exist betAveen  the fundus  and the neck of the uterus, is a
 pure hypothesis  unsupported by evidence ; besides, this opinion, like that
 of Antoine Petit, rests upon a  false  observation, namely,  that of the pro-
 gressive shortening of the neck after  the sixth month.

  [It is universally admitted that  delivery is effected by the  contraction of the
 uterus, but the question has been  raised, Why  does this contraction take place at
 the end of gestation ?  On  this point, Power's theory  seems to have  gained the
 assent of the majority of accoucheurs. It does seem to us, however, that the ques-
 tion  has been  badly put, for how can we believe that  the muscular fibres of the
 uterus do remain  inactive for nine months, and enter into contraction  only at the
 termination of pregnancy?   We feel justified in asserting that the uterus contracts
 throughout the entire period of gestation, feebly at first, and rarely, it may be, but
 more decidedly as the time progresses, so that it may not infrequently be detected
 by palpation of the abdomen at various periods.
  The contractions  are, doubtless, very slight at first, though real, and every one
 knoAvs that they accomplish  the effacement of the cervix at  the end of gestation.
 Should an accidental cause  increase their energy prematurely, the result is either
abortion or premature delivery.
  We Avould  therefore reverse the  question and ask Avhy, if the  contractions take
place  throughout the  entire period of gestation, do they expel  the ovum  only at 
284
LABOR.
term ?  The first reason to be adduced is, that the contractions, though feeble and
insufficient at the outset, grow stronger as the  development of the middle layer of
the uterus progresses, but not until the end of the ninth month have the muscular
fibres  acquired sufficient contractility to effect the expulsion of the child.  In the
second place we would add, that the contractions which occur during the course of
gestation, make a fruitless effort to dilate the firm and resisting tissue of the uterine
orifice.
  It is, therefore, by a wise precaution of nature that the softening of the cervix,
which takes place from below upwards, reaches  the  internal orifice only after the
expiration of the eighth month.   The internal orifice then yields to the contractions
which produce the gradual  effacement of the neck from above  downward.  The
term of gestation has now arrived, and the contractions increase greatly in strength.
At this point only, would I have recourse to Power's theory, which seems to afford
a true explanation of the recrudescence of the contractile forces of the womb and
the  prompt establishment of labor.]
                         CHAPTER  II.

          OF THE PHYSIOLOGICAL  PHENOMENA OF  LABOR.

  For  the  purpose of facilitating  the study of the phenomena of labor,
most writers have divided  them  into  several distinct groups, which they
have denominated the stages of labor;  and each one has built up his own
classification, so that Ave may now enumerate some twenty or thirty.   Of all
these, the division of Desormeaux appears to us  the most simple, and we
shall therefore adopt it.  His first stage extends from the beginning of the
labor to the complete dilatation of the cervix uteri;  the second includes all
the interval from  this time until  the child is  expelled; and the third
embraces the delivery of the placenta.
  Precursory Signs. — The term of gestation is most usually announced by a
collection of symptoms, to Avhich the majority of authors have  applied the
name of the " precursory signs of labor."  Thus, during  the last fortnight
of pregnancy, sometimes  a  little sooner,  at  others, only five or six days
before the delivery takes place, the uterus, which previously extended up
to the  epigastric  region, sensibly sinks loAver, and seems to  spread  out
laterally; and the mechanical obstruction to the  respiration  being thus
removed, the latter becomes more free; the stomach is no longer compressed,
and  digestion, if hitherto  impaired, becomes more easy; the  patient, no
longer  troubled  Avith nausea and  vomiting, and  respiring  more  freely,
becomes, it is said, gayer, more cheerful, and disposed to  movement.  Hoav-
ever true this last proposition  may be with  regard to some Avomen, it cer-
tainly does not apply to all; but, on the contrary, it has seemed to me that
;n proportion as the term approaches, their position becomes more and more
distressing;  and this, I think, may  be easily explained; because if  the
respiration becomes more  free, and the fundus uteri descends, the  inferior
part of the  organ must also  sink down in  the same ratio.  The head, Avhen
presenting,  engages in the excavation, carrying the lower portion of the 
PHYSIOLOGICAL  PHENOMENA OF LABOR.         285
     uterus before it; it sometimes even reaches the pelvic floor, and consequently
     gives rise to an annoying sensation of weight about the fundament, to great
     pressure on the neck of the bladder and rectum, strainings at stool, ineffectual
     desires to urinate, vesical tenesmus, dysury, and sometimes even to strangury;
     the oedema and varices of the inferior extremities and  genital parts then
     augment considerably; the  hemorrhoidal vessels SAvell up, and  the tumors
     of the same name, if they existed before, become more  voluminous and very
     painful; at the same time copious glairy discharges escape from the vulva.
        About the same period the  pelvic ligaments become softened, and the
     gliding of the  articular surfaces being rendered easier, the joints are more
     movable, and  consequently  Avalking  is uncertain, painful, and sometimes
     even impossible.   Lastly, to all these inconveniences and  pains, another is
     often added, which  singularly aids in making  the woman's  condition  still
     more distressing; it is this: the uterus,  in the last  periods of gestation,
     seems, by contractions, Avhich are short and distant at first, but soon increas-
     ing  both in  length and frequency, to prepare, as it were, for the more
     violent contractions of parturition.   Indeed, she often experiences the true
     pains from time to time, and should the accoucheur then examine the abdo-
     men, he, like her, will feel it hardening, and the uterus manifestly contract-
     ing.  At times, these contractions are scarcely painful, are not attended
     with bearing down, and can only be detected by placing the hand upon the
$    abdomen.
        We knoAV that the uterine globe is contracting, from its greater hardness;
     then, after a short  time,  relaxation occurs,  and  the  Avails regain their
     habitual suppleness.1
        In women  avIio have previously had children, we ascertain by the vaginal
     touch, that the membranes bulge out during contraction, and engage slightly
     in the  upper part of the cervix uteri.  These precursory phenomena are
     manifested much sooner in primipane than in others.
        According  to  certain Avriters, the pains  are felt first, and with more
     severity than at any other time, about four Aveeks  before term; so that some
     women, avIio have been pregnant before, do not hesitate then to affirm  that
     their labor will take place in the course of a month.  (Burdach.)
        Further, these pains are not Avholly useless, for  they tend to diminish the
     thickness of  the  neck, and  generally bring on its dilatation; thus, I have
     remarked  that, when  no cause  of dystocia existed, the labor was  usually
     much more rapid in those females Avho had been thus tormented by frequent
     pains during the last fortnight of their pregnancy.
        On the Avhole,  therefore, contrary to the proposition reiterated in all the

       1 These contractions, which are the precursory symptoms of labor, I regard as due
     to the changes which the upper  part of the neck undergoes in the latter weeks of ges-
     tation.  We have already stated that, in the last fortnight, the internal orifice softens
     ami yields to distention, then expands from above, so that the upper half of the neck
     gradually becomes confounded  with the cavity of  the  body; the lower part of the
     ovum will evidently engage in the dilated  portion, and soon come in contact with the
     parts in the neighborhood of the external orifice. This contact occasions a progres-
     sive  irritation of the irritable fibres  of the lower  half of the  cervix, which, by react-
     ing upon the body, excites its contractions, until finally, the entire neck being effaced,
     the irritation reaches its maximum, and labor commences. 
286                            LABOR.
classical Avorks, that women are more gay, cheerful, and disposed to action, I
have observed that they are in general more sad, and are greater sufferers,
than at other times; and although they appear to endure their pains better,
it  is simply because  they are encouraged  by the hope of a speedy delivery,
the announcement of which is recognized in the very sufferings they endure.
  First Stage.—The term of gestation finally arrives, and the labor begins.
In primiparae, this is made known by the opening of the neck, which until
that time had remained closed; and in other women, by the total effacement
of the  rounded collar presented by the os tincse.  The pains just mentioned
as occurring in the last fortnight of pregnancy, suddenly become  more
acute and frequent, and while they last the abdomen retracts, and the uterus
hardens, as may easily  be verified by examination. If the fundus was here-
tofore inclined tOAvards the  right or the left, it will noAV return to the median
line; the inequalities of the foetus can no longer be perceived through the
abdominal Avail; the cervix uteri, which is already someAvhat dilated, closes
partially during the pain, and its margins  are tense and  resistant, though
groAving thinner; the membranes  are distended, press at first on the neck,
then engage in it as  soon  as  the dilatation  is sufficiently advanced, under
the form of a segment  of a sphere, Avhose dimensions progressively increase
with the dilatation.
  The  organs  of generation  are  more humid;  the  glairy  discharges are
streaked Avith blood ; the pains continue to increase in force and frequency,     •
each one being ushered in by a slight shivering, or  horripilation; Avhile it
lasts, the pulse is hard, frequent, and full;  the countenance is flushed, the
surface and tongue dry, and the patient very thirsty; nausea and vomiting
often come on ;  she weeps, desponds, and becomes quite irritable, and, being
unconscious of the progress of her labor,  because no advance is perceived,
she cries out repeatedly, that she will never get over  it.  After the contrac-
tion, she is less  agitated; still, hoAvever, the cessation of the pain does not
seem to be perfect, the  calm is not yet complete, and the poor sufferer, still
under  the influence  of the last  pain, dreads incessantly the arrival of its
successor.  During the interval, the margins of the os uteri again become
mpple, thick, and  rounded; the  membranes that Avere smooth  and tense,
while the pain lasted, are noAV flaccid, and hang in folds, and the foetal head,
which  Avas  temporarily removed from the orifice, seems to return, and  is
much more accessible to the finger.   In proportion as  the contractions are
repeated, the os uteri gradually dilates more and more, until at last it  is
completely  opened;  the cavity of the uterus and the vagina thenceforth
forming but a single uninterrupted canal.
  Some females are able to conceal  these  early pains, but most of them
find it impossible  to do so for any length of time ; for, if conversing, they
will at once leave the phrase incomplete, and remain silent until  the pain
has diminished or stopped altogether ; or, if they happen to be walking up
and doAvn the  chamber, they stop short  and lean on a chair, or the first
article that comes  to hand, until it passes over.
  The  occurrence of violent shivering, and sometimes of general tremors, al
the termination of this stage, is by no means unusual, and  that, too, with-
out any sensation of cold being perceived.  The patient herself frequently 
PHYSIOLOGICAL  PHENOMENA  OF  LABOR.         287
 expresses surprise at  her trembling.  It is doubtless caused by one of the
 singular impressions produced upon the nervous system by the act of par-
 turition.
   Second Stage.—At  length, under the influence of  these  first pains, the
 duration of Avhich is very variable, the orifice is enlarged until  it forms a
 sufficient opening; and from that moment all the uterine forces are directed
 to the expulsion of the foreign body contained Avithin the organ.  Up to this
 time, the uterus alone Avas concerned in dilating the neck, but it noAV seems
 to call  in aid the contraction of the abdominal muscles, and consequently
 both the pain and the bearing doAvn are carried  to a much higher degree.
 The heat of the surface is much more considerable, the agitation extreme,
 and in some instances there is even a  marked disorder in the intellectual
 functions.   The pains are stronger, and the intervals shorter;  nevertheless,
 the Avoman bears  them Avith more patience, nay, she  even assists them by
 voluntarily contracting all the muscles of the trunk; and each pain is fol-
 lowed by a calm  more perfect than that in the first  stage.  Indeed, when
 the interval is rather long, some  females, exhausted by the previous fatigue,
 sleep profoundly,  and thus get a refreshing repose that should be respected,
 but  Avhich is soon interrupted by a neAv pain.   The inferior segment  of the
 membranes gradually engages in the orifice ;  the successive and repeated
 contractions cause the liquor amnii to flow tOAvards this point;  the amniotic
 pouch  becomes tense and  bulging at its lower part, and, being entirely
 unsupported by the parietes of the neck, it gives Avay,  and the contained
 waters escape Avith more or less  rapidity and  abundance, according to  cir-
 cumstances.
   Immediately, the foetus, urged on by the same contraction, applies itself
 to the os uteri, and the head, if that is the presenting part, engages  like a
 stopple in the orifice, thereby preventing a further discharge of the Avaters.
 The head is then said to be at the crowning.  The rapid discharge of a con-
 siderable quantity of the Avaters, Avhich then takes place, suspends the uterine
 contractions for several moments,  and, as the head no longer presses on the
 circumference of the neck, a small amount of fluid  is  again discharged.
 But  a more  energetic pain  shortly comes on, by Avhich the  child's head
 advances and clears the circle of the uterine orifice, and just at this moment
 the patient very frequently gives  a loud cry, an expression of the great pain
 caused by its passage.  Next, the head  descends into the vagina, the trans-
 verse folds of Avhich become effaced, the canal enlarging  and elongating for
 its reception.  When a rupture of the membranes takes place before the os
 uteri  is completely dilated, the  head often  descends to the  pelvic floor,
 though  still retained  in  the Avomb, and  does  not  clear the uterine orifice
 until it  engages in the inferior strait; though, Avhichever happens, the pains
 go on increasing in violence.  Each one is announced by a general shivering;
 the patient clings to anything around her, supports  her  feet against  the
 mattress, throAvs the head  backwards, takes a deep inspiration, and violently
 contracts all the muscles of her body.   The foetal head, being thus forcibly
urged on, presses against the floor of the pelvis, and causes it to protrude at
every pain ; and the consequent pressure on the rectum gives rise to illusory
desires of going to st?ol. 
288                             LABOR.
  After a greater or less  resistance, the perineum at  last yields, becomes
distended and bulging in front; the vulva partially opens, and the nymphse
are effaced, the  skin in the neighborhood contributing to the enlargement;
the head then appears in the dilated vulva, and the fiseces as well as the urine
are passed involuntarily; then the pain again ceases; the head, just apparent,
now seems to re-enter the excavation ; the overdistended perineum retracts
from its OAvn inherent elasticity ; the labia externa approach each other, and
the vulva again  closes up; at each  pain, the latter opens more and more, then
retracts, until, at last, all these parts, from  the force of the  repeated con-
tractions, become  incapable of any further  resistance;] finally,  a  horrible
pain comes on, forcing loud cries from the Avoman, Avhich is made up of two
others of unequal violence, for which nature seems to have reserved all her
powers ; this first brings the parietal protuberances to a level with the tuber-
osities of the ischium, and then expels the head altogether from the parts.
  In some instances, the delivery of the body immediately folloAvs that of
the head ; but in the larger number, some seconds elapse; then the pain is
reneAved, the uterus again contracts, and drives out the fcetal trunk, together
with the rest of  the amniotic liquid.
  The rapid sketch of these phenomena, just  given, has not afforded us an
opportunity of dilating upon any of them ;  nevertheless, some ought to be
studied  more carefully.   For instance, the pain, the dilatation of the uterine
orifice, the glairy discharges, and  the  rupture of the membranes, demand a
more particular  attention.   We shall, howeA^er, be brief in the physiological
considerations appertaining to each.

  §  1. The Pain, or Contraction.
  In most females, the pain is so  inseparable from the contraction, that, in
common language, the cause is readily confounded with the effect, and the
two expressions  are  used, indifferently,  to express the uterine contraction,
its returns, duration, weakness, and intensity.   We must remark, however,
that although the intensity of pain is generally in relation to the contrac-
tion, yet it is  not ahvays so, for the  perception of pain thereby produced
necessarily varies with  the susceptibilities  of the patient herself.  Some
experience trifling pains very acutely, and express themselves freely; others,
on the contrary, Avhose sensibility seems more obtuse, scarcely complain at
all  of the strongest contractions.   Again, there are certain females Avho have
the happy privilege of being delivered  almost without  any or at least with
but  very  inconsiderable pains.   For instance, I had an  opportunity of
observing a young primipara at the Clinique, Avho was aroused by the pains
at four o'clock in  the morning,  and Avas delivered  at six ;  she  suffered so
little during these tAvo hours, that she did not consider it necessary to alarm
any one, and  the  midwife  Avas only  summoned  Avhen  the pain became a

  1 Certain authojs attribute the retreat of the head  after each pain to a winding oi
the cord around the  child's neck, and therefore propose various measures for facili-
tating its delivery.  But this simply results,  says  Baudelocque, from  the elasticity of
the perineum and  the reaction of the muscles contained in its substance, as also from
the elasticity of the  cranial bones.   Consequently, we have nothing to do but to await
the spontaneous expulsion. 
             PHYSIOLOGICAL  PHENOMENA  OF  LABOR.         289

little more severe; she soon arrived, and found the head delivered.  This
case was still  more remarkable, from the fact of a partition existing in the
vagina, which divided its cavity into tAvo parts ; indeed it had been proposed
to incise this septum Avhen the hour of labor should arrhre.
   It is highly probable  that  the  dilatation of the  neck goes on quietly in
such cases, under the influence of contractions Avhich are not perceptible to
the patient from being  unattended Avith pain.  The pains  have received
different names according to the period of their occurrence: thus, the trifling
ones appertaining to the precursory phenomena of labor are named mouches,
from a comparison Avith the sensation caused by the pricking of a fly; those
of the first stage, in Avhich the neck is dilated, are termed preparative; those
of the second are designated as the expulsive; and  finally, in the last moments
of labor, Avhen the head forcibly distends the perineum and partially opens
the vulva, the pains are so violent in character as to have been denominated
the conquassantes?
   The pains are felt in  the lower  part of the abdomen ; and in the early
stages, generally folloAV a line draAvn from the umbilicus to the second bone
of the sacrum, but when the head presses against the pelvic floor, they run
more tOAvards the coccyx.   Sometimes they are felt in the lumbar and sacral
regions only;  the Avomen then call  them the pains in  the back ; and  the
patient has good cause  for dreading them, for  they do not much advance
the delivery, and ahvays leave behind  them a  feeling of discomfort and
prostration.  These lumbar pains often come on early in the labor, at other
times a little later, but they rarely continue till its close;  sometimes they
coincide Avith a great  obliquity of the uterus.  According to Madame
Lachapelle, they may generally be referred to too great a rigidity of  the
external orifice, either because this  experiences a kind of cramp, or that
owing to its unyielding  condition it receives the full force of the uterine
efforts, and consequently suffers more than Avhen  softened.
   These lumbar pains doubtless depend on the sensibility of the orifice, and
this can readily be explained by the origin of the nerves distributed  to the
neck, for  the  hypogastric  and lumbar plexuses furnish them;  Avhilst the
ovarian plexus  of the splanchnic  nerve alone sends its  branches to the
fundus uteri.  Various  plans have been  tried to  assuage these pains:  thus,
venesection, emollient injections, and the opiates,  have often  succeeded;
but there is one Avhich, of itself, may suffice in many cases to  relieve the
patient, that is, to raise her up by passing a tOAvel  under the loins.  The
pains haAre been divided by Avriters into true and false, according to Avhether
they are produced by a regular labor, or by some  disorder in the uterine
functions;  but as we shall endeavor to establish  the  diagnosis carefully
further on, Ave w ill only  remark noAV, that a true contraction ahvays  com-
mences in the fibres of the neck, and only reaches the fundus some seconds
aftenvards; and therefore every contraction beginning at this latter part is
irregular and abnormal.   (See chapter on Attentions to the Woman during
Labor.)

  1 I give these terms (mouches and conquassantrs) as found in the original, because, in
our American practice, they have no synonyms ; perhaps the words pricking and tearing
would express their sense. — Translator.
       19 
290
LABOR.
   The question now arises, what is the cause of the labor pain ?   Some sup-
 pose that it is produced by the tension of the fibres of the neck;  others, by
 the pressure on the nerves distributed to the internal surface of  the organ,
 Avhich are  necessarily compressed by the foetal walls during the contrac-
 tion ; and  lastly, certain accoucheurs have thought that it was OAving to
 the compression  of the parts contained Avithin  the pelvis: the nervous
 plexuses, for example.  But these opinions err in being too exclusive, since
 all of these causes  evidently contribute to the production of pain; indeed,
 there can be no doubt that the dilatation of the neck is painful during the
 first stage of labor,  more especially when the head is clearing it, this being,
 according to Madame Boivin, almost the only source of suffering; though,
 on the other hand, Avhen the child is so placed that it neither rests against
 the uterine orifice, nor yet on the superior strait,  the contraction is still
 painful;  and the pain must then be owing to  the pressure  on the nerves of
 the body of the Avomb.   Again,  in the last moments of parturition, Avhen
 the head is  passing the inferior strait, the perineum, and vulva, the enormous
 distention of those parts, and the  pressure on each of them, must  singularly
 add to the  pain  produced by the contraction,  as well as contribute towards
 giving it that  particular  character known under  the name of the conquas-
 sante, or tearing pain.
   Without denying that these various conditions  may be the first cause of
 the pain, M.  Beau  observes, that the suffering which  they produce is not
 seated in the uterus, but in the lumbo-abdominal  nerves.  He regards the
 pains of child-birth as  being, for the most part,  a  lumbo-abdominal  neu-
 ralgia, precisely as though the case were one of pathological disease of the
 uterus.  If, says he, a woman in labor  be examined  Avith  the  object of
 determining the  existence of the five  painful points  which characterize the
 lumbo-abdominal neuralgia, there will then be found, as in disease of the
 Avomb, points Avhich are painful  on pressure in the lumbar, iliac, hypogas-
 tric, inguinal, and vulvar regions.  In some cases, it is the lumbar  point;
• in others, the inguinal or iliac, &c.   Pressure  on  the same points is much
 less painful during the  interval  of the pains; in some cases, indeed, all
 tenderness then seems to disappear.
   Though the localization of the  pain in the lumbo-abdominal nerves may
 not explain its  intimate  nature  and first point of departure, it at least
 enables us to understand the numerous varieties Avhich it assumes; just as
 certain grave lesions, and some extensive displacements of the organ, are in
 some Avomen attended with no pain, Avhilst with others a trifling disorder,
 or a slight displacement, gives rise to extreme suffering.  Thus, some Avomen
 suffer very little from  powerful contractions, whilst others complain bitterly
 of  the slightest  expulsive effort.  (Here, as in the  pathological  case, it is
 impossible to fix a constant relation betAveen the intensity of the abdominal
 neuralgia and the contractile action of the uterus.
   The degree of pain, as M.  Beau remarks, is owing here, as in all other
 neuralgias,  to  the  nervous susceptibility of the female.  We Avere, there-
 fore, right  in saying  that the  pain  is not  intimately connected Avith  the
 contraction. 
PHYSIOLOGICAL  PHENOMENA OF LABOR.          291
   [The pain which accompanies the uterine contractions is not a unique fact in the
 organism, inasmuch as all rather severe involuntary contractions, in whatever organ
 they may take  place, are attended with pain.  I  Avould  mention in illustration,
 cramps in the muscles of the animal life, colic pains in the bowels, spasmodic
 contractions of the bladder, and palpitations of the heart.  Under ordinary circum-
 stances, it is true that the muscles of the limbs, of the intestinal  canal, of  the
 bladder, and of the heart, are constantly contracting without pain, but the moment
 they become affected Avith severe involuntary contraction,  pain is experienced.
 This would seem to be a law of pathological physiology which  is as applicable to
 the uterus as to any of the other organs.  We believe, therefore, that the pains of
 labor have their seat in the uterine Avails precisely as colic  pains are situated in  the
 walls of the intestines.  The painlessness of the  contractions which  take place
 during  pregnancy, is explained by  their feebleness, and are  comparable to the
 peristaltic motions of  the bowels of Avhich we are unconscious.]
   Still another question has been agitated by  physiologists, that is, Avhy is
 the  contraction   intermittent?  and here  far-fetched  reasons have been'
 adduced to explain  a very simple  phenomenon ; just as if any single muscle
 of the economy could contract permanently; as if it Avere not the nature of
 all muscular contraction to be interrupted by the fatigue of a too prolonged
 exercise, and as if it must not  have an interval of repose, in order to pre-
 serve its activity.  Besides, if the uterine contractions are dependent upon
 the nerves of organic life, why should they not be subject to the periodicity
 which marks the muscular  apparatus supplied by  branches from the great
 sympathetic?   We  are doubtless ignorant of the cause  of the  rhythmic
 intermissions in the  contraction  of the heart, as Avell as of the stomach and
 intestines; Avhat  cause is there, therefore, for  greater astonishment  at  the
 intermittence of  the uterine action,  subject as it  is  to the same nervous
 influence?
   It is certainly  very curious to study the influence of the contraction over
 the mother's circulation, Avhich exhibits, according to Holl, the  folloAving
 peculiarities during a pain.   In general,  the pulse  is  accelerated as soon as
 the contraction begins, increasing  in  frequency as it goes on, then diminish-
 ing, and gradually resuming the normal type.   Noav there exists so intimate
 a relation  betAveen  these tAvo phenomena, that, Avhere the pulse is gradual
 in its acceleration, where it arrives  little by little  to the  maximum of  its
 rapidity, is there sustained  for a certain  length of time,  and finally recedes
 by degrees, the pain also folloAvs  an equally regular .course; it gradually
 attains its  maximum  intensity,  remains  a  Avhile  stationary, and then
 decreases  with the  same regularity; but, on  the contrary, if the pulse
 accelerates by  jerks, the  contraction will be  short  and  precipitate,  and
 therefore Avithout effect.   Holl ascertained this regularity in the phenomena,
by counting the  pulsations by quarters of a minute during the Avhole time
a pain  lasted.   For instance, he noted the following variations in a con-
tradion Avhich lasted tAvo minutes:
	f First and second quarters, each,	. 18	pulsations
First minute,	} Third quarter,	. 20	!<
	(Last quarter,	. 22	11
	r First and second quarters, .	. 24	l<
Second minute,	J Third quarter,	. 22	(<
	( Last quarter, .	. 18	"
 
292
LABOR.
   Iii proportion as the labor advances, the pulse accelerates the more ; so that,
 a little Avhile before delivery, it has  the same frequency in the intervals as
 it had at first during the strongest contractions.   We have already pointed
 out the modifications in the bellows  murmur, noticed by the same observer
 during the pain, and shall not repeat  them noAV, merely remarking, how-
 ever, that they are sufficiently well marked  to indicate the uterine contrac-
 tion, even when the woman herself may be desirous of concealing it.

   § 2. Dilatation of the Os Uteri.
   The foetus  evidently has no part  in the dilatation  of  the  os uteri until
 the  bag of Avaters is ruptured.  It is not until after this event takes place,
 that the vertex,  by engaging  like a Avedge in the uterine neck, can hasten
 the  dilatation mechanically;  and it is  equally evident that, in any other
 than a vertex position, the presenting  part being more voluminous and
 irregular than the  head, cannot  perform the same  office,  and therefore,
 cozteris paribus, the orifice Avill open more slowly.  Hence, it is not the foetus,
 at least during the first part  of the  labor, Avhich is the efficient cause, but
 here also tne phenomenon is referable to the contraction of the uterine fibres.
   Now, in order to understand how this  occurs, Ave must  remember, says
 Desormeaux, that the walls of the womb are  applied to an ovoid body; that
 the longitudinal fibres are the most numerous, and  that the circular fibres
 of the cervix, although capable  of  stoutly  resisting their power, yet are
 gradually constrained to yield to the action of the longitudinal ones.  If we
 now imagine these latter fibres to enter into contraction, we shall readily
 comprehend that, being unable to  diminish the distended  uterine cavity, all
 their power must be exerted in drawing upon those points of the circle which
 form the orifice, Avhere each one is inserted, and thus remove them from the
 centre of the opening.  Wherefore, every portion of the orifice being equally
 operated upon, it will  present a circular form ; but if the foetus is placed
 transversely, and the womb dilated in that  direction, the fibres being re-
 tracted more in the same diameter, the orifice Avill be elliptical.
   The rapidity of the dilatation  bears a direct ratio  to  the force and fre-
 quency of the contractions.   In general, it is very slow in the commencement
 of labor, but much more  rapid towards its close: for instance, if the opening
 dilated to the  extent of one inch in four hours, it would only require two, or
 at most  three hours for its complete enlargement; this progresses more
 slowly, however, in primiparae than in other Avomen.  Again, the softness,
 or the rigidity and tension, of the neck during the intervals of pain, has a
 great influence over the rapidity of its dilatation ; and  the same may be said
 of the obliquity  of  the  orifice;  for  Avhen this latter is  carried  in front
 tOAvards the pubis, or, what is still more frequent, is strongly directed back-
 wards towards the sacrum — in either case, the neck is no longer placed in
 the axis of the contractions, and the head is  forcibly pressed towards some
 part, of the uterine Avail,  against Avhich all the expulsive force is lost.
  It  is likeAvise important  to bear in  mind, that  the posterior obliquity of
the neck  may be owing  to an  anterior inclination  of the womb, and may
also  exist Avithout the latter being at all changed from its normal  position;
 this results from the head having  been engaged a long time in the excava- 
              PHYSIOLOGICAL  PHENOMENA OF  LABOR.          293

 tion, and having pushed the anterior inferior uterine wall before it;  the os
 uteri being at the same time carried upwards and backwards.
   [When the orifice is directed very far backward, it is sometimes difficult to reach,
 and some practitioners make the mistake of supposing  that the dilatation  is com-
 pleted even when the  head is entirely covered by the anterior segment of the womb.1
   This  error is most liable  to occur in first labors, for then the edges of  thp
 orifice are extremely  thin, and when the head distends and presses down the lower
 segment of the uterus without interposition of the amniotic fluid, the sutures and
 fontanelles may be felt  so easily as to lead  to  the  supposition  that  the head is
 uncovered.   A mistake of this nature may  haATe serious consequences.  I haAre
 myself seen attempts made to apply the forceps under these circumstances.  To
 avoid misconception,  the hips of the patient should  be raised, the fingers  passed
 very far back and moved  over the contour of the head.  If the orifice is really
 dilated, the finger will penetrate very deeply and pass alongside of the head Avith-
 out meeting any obstacle.  If, however, dilatation  has not been accomplished, the
 finger is soon arrested by the neck of the vaginal sac—especially in front.]
   The orifice, which is  generally very thin in primiparae at the beginning of
 labor, becomes thicker tOAvards the last half of the first  stage; then it gets
 thinner, and  finally forms  a thick, rounded  collar, which the head  pushes
 before it as far as the  inferior strait.
   The  reason of these various changes, says M. Guillemot,  is very simple;
 for the pressure  upon the neck acts more forcibly on the periphery of the
 orifice than on any  other part, and the consequent thinning will disappear
 as soon as the uterine circle yields, and is carried  back towards the parts
 that have not suffered an equal pressure, but have maintained their original
 thickness; though soon after, in consequence of fresh pains, the tension on
 this neAV circle Avill  destroy its bulk and reduce it to the condition  stated.
 Finally, a period arrives when the neck  maintains its  thickness, notAvith-
 standing the dilatation it undergoes, because the uterine fibres, being exces-
 sively shortened, give  more density to this part.  I will  add that the thick-
 ness of the anterior lip is often greatly augmented, Avhen the engagement is
 far advanced, by oedema of the part, due to its compression between the
 head and the symphysis pubis; and further, that it is not at all  uncommon
 to find the posterior lip quite thin, Avhilst the anterior one still remains con-
 siderably thickened.

   § 3. Of  the Glairy Discharges.
   We have already  learned that an abundant secretion takes place in the
 vagina during the  latter periods of gestation ; but when the labor sets in,
 this  secretion augments very considerably, and discharges of viscid mucus,
 resembling  the Avhite  of an egg, designated  as the glairy discharges, Aoav
 from the Avomb and  vagina,  In some women they become sanguinolent at
 the approach of the travail; but in others  they are only so during labor.
 When blood is thus  mixed Avith the other fluids, it is said to  be an evidence
that the dilatation of the orifice is advanced; this, hoAvever, is  not ahvays
true, since, in some instances, several days elapse before the commencement
of parturition. In some cases, indeed, they are Avholly absent, and the labor

  1 Sometimes the orifice is so thin that the finger slips over it without perceiving it. 
294
LABOR.
 is then said to be a, dry one;  the genital parts experiencing a degree of heat
 and dryness almost akin to inflammation.
   With regard  to their origin, these discharges are not, as Ant. Petit and
 Baudelocque supposed, the product of a transudation of the amniotic waters
 through the pores in the membranes; but they simply result from the more
 abundant secretion of the  mucous cryptse in the neck and vagina; a secre-
 tion which is augmented by the greater irritation in those  parts, caused  by
 the labor.  As to the blood that  colors them, Avhether before or during the
 labor, it may come either from some slight  laceration in the borders of the
 orifice, from a rupture of some of the  minute vessels which run  from the
 internal uterine surface to be distributed upon the  membranes, or from the
 detachment of a  small portion  of  the placenta ;  or, according to Desor-
 meaux, it may escape  from the extremities  of the capillaries Avithout any
 discoverable rupture.
   These mucosities, commencing as we  have before seen in the latter Aveeks
 of gestation, serve to lubricate the genital passages, and while relieving the
 vaginal Avails and the parietes of the neck  from their engorgement, they
 have the  further  advantage of moistening those  parts,  of softening the
 perineum  and the vulvar orifice, and thus rendering the extreme distention
 which all  of them must shortly undergo more easy.  Their abundance is
 ahvays to  be considered a good sign, presaging a  prompt dilatation and an
 easy expulsion.

   § 4. Of the  Bag  of Waters.
   As the neck  progressively dilates, the  foetal membranes present and
 become engaged therein, forming a  tumor of variable size in the vagina,
 which is tense at the moment of contraction; and this is what is  understood
 by the formation of the bag of Avaters.   The sac varies in its shape Avith the
 figure represented  by the uterine  orifice; it is generally rounded and  hemi-
 spherical,  though ovoid Avhen the cervix uteri dilates more in one diameter
 than  another;  when  the membranes  are  formed of a loose, uncontracted
 tissue, and especially Avhen they contain but a  small quantity of liquid,
 they may form an elongated tumor in the vagina, without being a necessary
sign of a presentation of either the hand or the foot, as some have  incorrectly
supposed.
   We must acknoAvledge, however, that the bag of waters is usually less
voluminous in vertex presentations than in others;  and, consequently, that
a very great protrusion of it nearly always announces an unfavorable posi-
tion.  This occasioned the remark of Madame Lachapelle: " I  do not fear
the flat sacs."  As soon as the pain  ceases the tumor disappears, the fluid
that formed it re-enters the uterine  cavity, and  the flaccid, relaxed  mem-
branes hang in folds.

  [The bag of waters, says Prof. Depaul, sometimes assumes another  form which
[ have called the double bag, and is indicative of a twin pregnancy.
  1 first met with it whilst Interne  at  the Maternity Hospital  in  1839, and waa
much  puzzled by it, inasmuch as I had  never  met  with  any account of it and
became aware of its significance  only after the birth of the twins.
  Some years  after  I met with the same  thing at the lying-in hospital of th« 
PHYSIOLOGICAL  PHENOMENA  OF  LABOR.         295
 The form of the  bag of waters
when the os uteri is fully dilated.
Faculty, and remembering my former observation at the Maternity, did not hesitate
to assert that there were two children, — which, in fact, were  soon born.   These
are, howovor, the only cases which I have met with, nor ought  their rarity to be a
matter of surprise when we consider all  the conditions required in order that two
ovums, which are liable to assume such various positions in the cavity of the uterus,
should be equally forced upon  the mouth of the womb by the contractions.   Still,
it is well to record the fact in order that it may be made available upon occasion.]

  The formation of the sac is easily understood.           fig. ,4.
The uterine cavity is gradually diminished, and
the amniotic  liquid, pressed on  all sides,  natu-
rally  floAvs tOAvards  the  point  that offers the
least resistance, and such  point is evidently the
opening in the neck Avhere  no Avails  are found.
The reason Avhy so much difficulty  existed in
comprehending hoAV the membranes  could pro-
ject  into  the vagina  under  the  influence of
this pressure of the  liquid, was  because the
amniotic  cavity Avas supposed  to be distended
to the utmost by the Avaters, and consequently
that  there  must  either exist  a very  great
extensibility of the membranes, or else a trans-
udation of  the  fluid  through the  Avails of the
ovum;  but both  hypotheses are false.   For  it is only necessary to  press
upon  the abdomen of a pregnant Avoman  to become satisfied  that in most
females a very slight pressure will be sufficient to flatten the ovum, Avhether
in its vertical, transverse, or antero-posterior diameters.   This is Avhat takes
place in labor, excepting that the ovum can only elongate  below, on account
of the uterine pressure upon all other parts, and thus produces the amniotic
tumor.
   When  the  dilatation is  completed  and the  contraction energetic, the
inferior part of the membranes, being  no longer supported, soon yields to
the impulse, and becomes ruptured, thereby permitting a variable quantity of
liquid to escape.  Where  the pouch  is voluminous, and gives Avay just at
the moment of a strong pain, the rupture takes  place Avith such a loud noise,
that women in their first labor are often much alarmed, and then also the
waters gush out in  large quantity.  But Avhere the pouch  is flat, and only a
small quantity of fluid is  interposed  between the head and the membranes,
the latter are  lacerated Avithout any noise, and but a little liquid oozes out
after  their  rupture;  because, the head by engaging at  once in the os uteri
obliterates it completely and blocks up the waters.

  [When the membranes are ruptured, the folloAving peculiarities may be observed
in  the discharge of tlie amniotic fluid.  At the beginning of each contraction, it is
forced toward  the loAver segment of the  uterus and a small quantity is discharged
from the vulva.   At  the height of the contraction the flow is  arrested, because the
direct application of the head against the orifice stops  it completely.  Finally, when
the contraction subsides, the  head will close the orifice imperfectly and allow a fresh
quantity to escape externally.]
In the vast majority of cases, the membranes are lacerated on that portion 
296
LABOR.
of the bag corresponding to the uterine orifice.  But sometimes the rupture
occurs much higher up; and  this fact, Avhich is almost inexplicable in the
present  state of our knowledge, should nevertheless be  knoAvn, because it
accounts for the circumstance of  the inferior segment of the ovum being
then found intact after the discharge of a certain quantity of Avater, and of
our having to puncture the  membranes subsequently in  this part.   Some-
times they are ruptured in the beginning of the labor, Avhich is thereby usuallv
rendered longer and more difficult for the  mother, as also more  dangerous
for  the  child, especially when a considerable quantity of Avater  escapes at
the same time.   Besides  these  varieties,  I have  several times noticed a
remarkable peculiarity that  seems to have escaped the attention of practi-
tioners generally; I allude to  the  occurrence of a rupture before any con-
traction of the uterus Avhatever.  This constitutes in a feAV females the first
phenomenon of the labor; but  the  pains  do not come on  for some time
afterwards, occasionally not  for several days.   Now, this  premature lacera-
tion has seemed to me to be  coincident with a presentation of the vertex
that is deeply engaged in the excavation; for although the  patient felt no
previous pain, and even in certain cases was  sleeping profoundly Avhen the
waters escaped, it is highly probable that the uterus had  already been con-
tracting  for some time, and the occurrence  may be referred to those non-
painful  contractions hitherto  described;  unless, perhaps,, it may possibly
depend on an excessive distention of the amniotic pouch.
  Sometimes the membranes are very hard, thick, and resistant, the rupture
only taking place at an advanced  stage of the labor, when the head clears
the vulva, for instance;  or it may occur in a circular manner, and the head
escape covered by a kind of hood.  The child is then said to be born with
a caul, and the vulgar, from that circumstance, prophesy a happy fxdure.
  The infant may also be born hooded, Avhen a rupture of the membranes
first occurs at  an elevated  point, one not  corresponding at  all Avith  the
uterine  neck; and  should the head then push  before it a  portion of the
amniotic pouch, serious accidents might result in consequence: for instance,
this late rupture might delay the labor, or the tension experienced by the
membranes, extending to the placenta, may cause its premature detachment,
especially Avhen it is inserted on the sides of the organ, and thus produce a
uterine hemorrhage.
  In ordinary cases, the rupture takes place  at  the  commencement of the
second stage.
  The subjoined is a statistical summary made by Churchill,  at the Western
Lying-in Hospital, during the years 1841  and 1842, Avhich  will enable the
reader to judge of the varieties that  may be met with.
  The period elapsing  between the commencement of the  labor and  the
rupture of the  membranes has been  noted in 984 cases.  Thus:
                In 167 females,  this time was          2 hours.
                « 335
                » 165
                » 113
                "  71
                «-  33
                u  48   u        «<
•om 2 i	o 6 "
" 6 <	' 10 "
« 10 '	' 14 "
" 14 '	' 18 "
" 18 '	< 22 "
" 22 <	' 26 "
 
PHYSIOLOGICAL PHENOMENA OF LABOR.         297
In 23 females this time was from 26 " 30 hours.
» 8	!<	" 30 " 38
« 9	((	'« 38 " 40
« 4	l<	about 50
u 2	H	" 60
.< 4	(<	" 70
" 3 "	I(	80
'' 1 female	<<	105
                  984

  The same observer noted the time  from the rupture of the membranes
until the child's birth in 812 cases.
In 396	women,	this time was	1 hour.	
" 142	£<	a	2 hours	
" 120	ii	"	4	k
" 50	ii	li	6	<«
" 34	ii	"	8	a
" 17	11	(I	10	k
" 26	a	cc	15	u
" 11	a	a	20	n
" 3	a	i(	28	a
" 4	"	(<	35	((
" 1	woman	(<	40	a
" 1	i i	(<	50	i<
" 1	a	(1	150	a
                     812

   § 5. Of the Duration of Labor.
   The duration of labor is  exceedingly  variable, even when no obstacle
 opposes its natural course.   Some Avomen  are  delivered in an hour or two,
 whilst others are not for several  days;  and between these  tAvo extremes,
 there is every intermediate grade.
   The published statistics are hardly reliable,  for most of them have been
 collected in hospitals ; and it is a fact, that the majority of women, dread-
 ing to be taken into the  apartment devoted to  the patients in labor, conceal
 their  first  pains, and give up  only Avhen  they can restrain  themselves no
 longer.   Therefore, Avhen interrogated after delivery, their statements  are
 not found to coincide with their record, and make their labor appear much
 longer than  the  latter  Avould  indicate.   This  correction seems  to  me of
 importance, for most physicians of limited experience, having learned that
 the duration of labor is from five to six  hours, are apt to become alarmed
 unnecessarily Avhen  they find it continuing  even  longer than from  ten to
 twelve hours.
  In general, it is longer in primiparae than in others;  and this  difference
 is chiefly OAving to the resistance of the perineal muscles, which is much
 greater in the former, though it is also influenced by the dilatation of the
 neck,  which is effected in them  very sloAvly.
  The Avhole length  of their  labor is usually from ten to twelve hours, but
it should be  knoAvn  that, in at least one case in  five, it may not  terminate
under fifteen, eighteen, or even  twenty hours, and this Avithout any  injury 
298                            LABOR.
 whatever resulting  either to the mother or the child.  Women who have
 had children  are  delivered much  sooner, only suffering, in ordinary cases,
 about six or  eight  hours.  According  to Alph. Leroy  and Velpeau, the
 pains are apt  to observe periods of six hours:  that is, the labor lasts either
 six, twelve, eighteen, twenty-four, or thirty hours.  I  think, if their obser-
 vation be correct,  it Avill be found subject to very numerous exceptions.
   But, supposing  the labor has really commenced, can Ave predict the hour
 of  its  termination with  any degree of certainty?  This question, Avhich is
 nearly ahvays addressed to the accoucheur, is oftentimes a very difficult one
 to answer, for habit  alone can enable us to judge by the dilatation, or the
 suppleness of  the  neck;  by its tension, its hardness, and resistance; by the
 frequency and intensity of  the  pains; by the  time it has already existed,
 and by the greater  or  less resistance of the vulva  and perineum, of the
 probable length of the labor.
   It must also be  remembered, in regard to the duration, that the first stage
 of  labor  is to the second, as two, or even three, to one; and, further, this
 difference is still more marked in Avomen who  have  had children, than in
 primiparae; and that the first half of the dilatation of  the  neck is much
 sloAver than the second.  But how many exceptions  are  there to this laAv!
 For instance, the dilatation  is sometimes regular, and  sufficiently rapid,
 everything seeming  to promise an easy and prompt termination ; yet all at
 once the pains become feeble  and languishing,  and our art is often obliged
 to interpose in  aid of the uterine  contractions; while, on the contrary, it
 not unfrequently  happens that the neck is expanded Avith an excessive
 degree of slowness, after which, a  few moments will suffice to effect the
 delivery.
   The form of the vagina, according to Wigand, should also be taken into
 consideration, in making a prognosis as to  the probable duration of the
 labor: thus, if this canal is large throughout, the Avhole time will be short;
 and, on the other hand, the dilatation of the cervix,  and ^he expulsion of
 the  child will be very slow,  should the vaginal cavity  be  regularly con-
 tracted throughout its extent; again, if the vulvo-uterine canal is large and
 spacious superiorly, but contracted and unyielding near the external orifice,
 the first part of the  labor will be prompt, but  the last slow and  difficult;
 and, finally (though more rarely), if its upper extremity is very narroAv, the
 inferior being  at the same time largely dilated, we may conclude that the
 parturition will progress slowly at first, but will then terminate speedily.
  It is a very  singular fact, that an hereditary influence is sometimes nv1'-
 fested in the process, it being not at all uncommon to find the same pecu
 liarities  transmitted  through  three or  four  successive  generations;  the
 mother,  the daughter, and the granddaughters being remarkable  either
 for the sloAvness or rapidity of their labors.
  In general,  it is impossible to predict with  any degree of certainty the
 hour of its termination ;  yet most people seem to imagine that the physician
is bound to give the  most particular information on this  point.  He must,
however, always be very guarded in his replies, for should  the  labor over-
run the fixed time by some  hours, it would give rise  to the most  anxious
solicitude, and it is therefore  prudent  not to be  too  precise.   When  such 
            PHYSIOLOGICAL PHENOMENA OF LABOR.          299

questions are addressed to me, I am in the habit of saying, that, if  the
contractions are regular, and  no  accident  occurs, if,  in  a Avord, all things
go on right, the delivery Avill take place at the hour I  name.
  In  fact, it is absolutely impossible to  foresee all that may happen;  be-
cause, in certain  cases, the  dilatation of the os uteri, Avhich, perhaps, only
amounted  to one inch, after  five  or six hours of labor, is suddenly com-
pleted;  and, at other  times,  this  process  being very little advanced,  the
margin of the orifice is lacerated under the influence of  a strong pain, and
the delivery effected, perhaps,  just as the physician has announced  that the
labor will still last for  several hours.  In examining a young  woman, preg-
nant  for the first time, I  found the orifice dilated to the size of a quarter
of a dollar, and, supposing that the labor Avould last for  some time, I Avith-
drew, but scarcely had  I reached the foot of the staircase, when a messenger
came running after me in great haste ;  I immediately returned, and found
the head on the point of clearing the vulva, Avhich Avas already considerably
opened.  After the labor was over, I ascertained  that  the Avhole left side
of the vaginal portion  of  the  neck had  been lacerated.
  A young primiparous female experienced the first pains at four o'clock in
the morning.  Throughout  the day the  contractions Avere very feeble, with
intervals  varying from a quarter of an  hour to an hour.  The dilatation
Avas so slow, that at four o'clock in  the afternoon the  orifice had barely
attained the size of  a dime. After five o'clock, the  pains Avere rather
stronger and quicker;  at  nine p. m., the  neck Avas  very thin, and  presented
an  opening of  three-quarters of an inch  in  diameter.   Being obliged to
leave the patient for an hour, I thought I might do  so Avith safety, but imme-
diately  after my departure the  contractions  became powerful,  and  at  a
quarter before ten, she gave birth  to  a very small child, Avhich barely
weighed five pounds.   The  small size of the foetus accounts for the  rapidity
of the labor; and yet  this lady had enjoyed good  health during  her preg-
nancy, besides having  reached her full term.
  The Avoman's age has not the unfavorable influence upon the duration of
labor, even in primiparae,  Avhich is accorded to it by some authors.   " There
has ahvays." says Madame  Lachapelle, "been  an opinion prevalent on this
point Avhich I can by no means adopt; it is, that the  dilatation of  the pas-
sages is  more difficult in Avomen  advanced in years than in others, and
there is not an accoucheur avIio does not dread the first labor in a female
of thirty or thirty-five years of age ; nor is there a Avoman in that condition
who does not anticipate Avith terror the .hour of  her delivery.   My expe-
rience has, hoAvever, so often  proved the fallacv of such prejudices that I
cannot adopt them.
  " No doubt, the labor is  often sIoav and  painful in middle-aged Avomen
who have had no children, yet the same is the case with the  youngest.   I
dare affirm, indeed, that there is no more difficulty in the one  case  than in
the other, and that if four young primiparous females out of ten have easy
labors, four out of ten  of  the  oldest will  also be delivered Avith promptitude
and facility." 
300
LABOR.
  § 6.  Of the Effect of Labor upon the Mother and Child.
  a. Effect of the Labor upon the Mother.— Independently of the numerous
accidents which  are liable to occur, and which will  be studied  hereafter
under the head of Causes of Dystocia, the parturient  process has a decided
effect upon the physical  and moral condition of the  female, which, unfor-
tunately, almost  uniformly escapes attention.  This effect may be exhibited
in both the first and second stages, and  even continue  for a  feAV  hours or
days after delivery.
  The commencement  of labor is preceded in many females by a state of
anxiety and  prostration, and  often by feelings  of fear and  disquietude.
This usually ceases after the first pains are experienced, all the poAvers of
the organism seeming then to be devoted to the accomplishment of the great
function about to be performed.  All others are modified or suspended, the
appetite is  lost, and  if the patients have eaten  shortly before,  they not un-
frequently reject all that  has  been taken by vomiting.   If much  time be
occupied by  the  process  of dilatation, they weep, and become  irritable
and despairing.
  This  excitability diminishes as soon as the second stage commences, and
the patient begins to feel that her labor has really begun.  From that time
her attention  seems  concentrated on a single object, and she is indifferent
to everything else.  During  the expulsive pains, her condition approaches
that which characterizes  inflammation or fever; thus,  the circulation is
quickened in  a degree which seems connected with the force of the contrac-
tions ;  the heat and moisture are sensibly augmented,  and the red and even
livid features sometimes covered with profuse perspiration; again, in  some
cases the skin may be dry and hot.
  The intensity  of the pains occasionally  throAvs the patient into a state of
extreme agitation, and so disorders  her faculties  that she commits acts of
violence upon her attendants.
  This agitation, which is very moderate when  the labor progresses  regu-
larly, becomes extreme Avhen  the latter is retarded  or prolonged inordi-
nately.  The beginning of each pain is then  marked  by an almost convul-
sive trembling of the extremities.  The face is burning, and the entire body
bathed in  perspiration, the eye is  fixed  and  haggard, and  the features
changed; the unfortunate sufferer screams, laments, desires to  die,  and begs
to be either killed or relieved of her agony.  The well-marked disorder of
the intellectual faculties is sometimes carried to complete delirium, during
Avhich the patients utter the most extravagant expressions.  Two such cases
have come under my own observation.  The delirium is almost ahvays pre-
ceded and  accompanied by great loquacity, and  the  pains are hardly felt.
I kneAv a young  lady, after a rather lengthy labor attended Avith extreme
suffering, suddenly to cease  complaining, assume a smiling expression, and
after a few incoherent  phrases, to sing in full voice the  grand air  of  Lucia
di Lammermoor.  I cannot  express the  terrifying effect produced by this
song upon myself and the attendants.   (A bleeding,  followed by the imme-
diate application of the forceps, had the effect of calming the patient, and
there  was  no recurrence of delirium.)  Montgomery also states, that he
nas known women to be completely delirious for a few moments, just  as the
head was escaping ,*rom the mouth of the womb. 
PHYSIOLOGICAL PHENOMENA OF LABOR.         301
  These great disturbances of the economy are not confined to cases of very
tedious labor, for the same symptoms have been Avitnessed in very short onea
with poAverful and very rapid pains.  The cerebral excitement which their
violence produces, may be carried  even to  the point  of insanity; so  that
medico-legal jurists have accounted for infanticides by this momentary  dis-
order of the intellect, which would othenvise have been inexplicable.
  The disorder is sometimes confined to the affective faculties.  I have seen
a mother, says Ed. Rigby, after a very short and  painful labor, exhibit an
unconquerable aversion to her child, and express herself in reference to it
in terms Avhich contrasted strangely with the tender and affectionate remarks
which she had uttered  but a few moments previously.
  These disorders  of the intellectual and  affective faculties generally  last
but a short time, and are not significant of great  danger; sometimes, how-
ever, the shock to the system is so great, that death takes place suddenly,
either during the course of the labor, or shortly after delivery.   A poor
woman, in the Charity Hospital, says Davis, had been  in labor  for  five
hours; the membranes ruptured, and a large amount of water escaped;  the
discharge Avas immediately followed by'a feeling of great weakness ;  having
a desire to go to stool, she sat  down upon  a chamber, made a few efforts,
and fell fainting.   She was placed in the horizontal position as soon as  pos-
sible, but  had hardly been replaced in  bed before she had ceased to  live.
The autopsy revealed nothing which Avould account for the death.  Denman
also mentions several  cases of sudden death  during labor, which it  was
impossible to explain.
  In some of these  instances, however, the  sudden  discharge of a large
amount of Avater might, to a certain extent, lead us to attribute the mortal
syncope to the same cause Avhich is thought to produce it so often after de-
livery :  namely,  the sudden afflux of a  great quantity of blood to  the
abdominal vessels, Avhich had  been suddenly relieved from the pressure to
Avhich they were subjected during pregnancy.
  An undue importance has,  I think, been attributed  to  this  too rapid
depletion of the organ as explanatory of sudden death after labor.  In some
instances, it may have  all the influence accorded to it, though it is certainly
incapable of accounting for all knoAvn facts.
  The violent efforts  made by the Avoman in the second stage of labor may
also occasion a rupture of some part  of the respiratory organs.   This ex-
plains the cases of emphysema of the  face, neck, and  upper part of the
breast,  mentioned by several authors (Martin, of Lyons).  In a serious case
related by M. Depaul, death resulted apparently from  double  pulmonary
emphysema  occurring  suddenly during the violent  expulsive efforts of a
long and painful labor.
  The fatal effect of  the process  of parturition upon  the nervous system of
the mother, after as Avell as during labor, cannot be mistaken ; and I believe
Avith Churchill that it consists in a shock ol greater or less intensity to the
cerebro-spinal system.  This shock, which  is an effect of the extraordinary
agitation produced by  parturition, is altogether similar to that occasioned
by extensive Avounds, and which sometimes destroys  unfortunate workmen
who have had a member  crushed by a machine, or to that produced by an 
302
LABOR.
extensive burn.  The sudden death, which neither the circumstances of the
accident, nor the  lesions discovered at the autopsy are capable of explain-
ing, is attributed by surgeons to nervous shock.
  Not only, says the author just cited, may such a nervous shock take place
in certain labors, especially difficult ones, and have a disastrous result, but
it exists to a greater or less extent in almost every case.  Moderate atten-
tion will make this manifest.   Thus, after  an ordinary labor, the  general
sensibility is almost ahvays extreme:  although the senses  are more  acute
than usual, the eyes have lost their lustre, and are Aveak and  languishing;
the least light hurts them, as the slightest sound offends the ear ; and if this
extreme delicacy be not respected, serious accidents may ensue.
  Under ordinary circumstances, patients recover from this slight collapse
after a feAV hours' rest; but Avhen the labor has been protracted, or an opera-
tion, such as turning, has  been demanded, the symptoms  are much more
severe.  The patient is much Aveaker, and the expression of features is fixed
and dull; she lies motionless in bed,  Avith closed eyes, or opens them from
time to  time, Avithout, hoAvever, fixing them upon any object in particular;
she pays no regard either to her child or to herself; the limbs are in a state
of complete relaxation ;  the pulse is sometimes sIoav, at others frequent and
irregular, though always Aveaker than usual, and the breathing slow and
difficult, or quick and panting.
   The patient may remain  in this condition for a long time,  and recovers
from it  sloAvly and  gradually.   If the shock has been  too  great, she may
grow Aveaker and Aveaker, until the prostration ends in death.  The autopsy,
under these circumstances, fails to throw any light upon the cause of death.
   This singular state of  affairs is not ahvays manifested immediately upon
delivery ;  for sometimes considerable  time elapses, during Avhich the patient
expresses herself  as feeling very Avell, then suddenly complains of unusual
Aveakness, exclaims that she is about to faint, and yet  is unable to  account
for the cause of her condition.   There are no particular abdominal  symp-
toms, no evidence of hemorrhage, and  the uterus is Avell  contracted; still
the disorder increases, the pulse groAvs Aveaker, the face becomes pale  and
assumes a cadaverous expression, and the patient is so prostrated as to be
able to  express her feelings only by a groan.  Suddenly she  experiences a
sensation of violent constriction of the chest, and expires before anything
can be done for her relief.
   Opium, says Churchill, has seemed to me the most  effectual remedy in
these cases.  Five drops of laudanum may be given every half hour, then
every hour, and finally at longer intervals.   It appears to  calm the general
disturbance, diminish the cerebral shock, and give to the whole system suf-
ficient time to recover its exhausted forces.  Small  quanties of wine and
brandy may, at the same time, be given at  intervals, in doses sufficient to
assist in re-establishing the strength,  but not in such quantity as to produce
a general reaction.  The induction of sleep will be assisted by entire quiet-
ness of both body and mind, and when so fortunate a result is obtained, the
strength is recruited, and  the pulse and respiration become calm ; if, on
the contrary, the prostration continues, the case is one  of the  most danger-
ous character, and demands the increased use of external and internal stim* 
MECHANICAL  PHENOMENA  OF  LABOR.
303
ulants.  Ramsbotham recommends that pressure should also be made upon
the abdomen, doubtless Avith the object of preventing the afflux of fluids
tOAvards the abdominal vessels.
  If the agitation, spasm, and delirium, of Avhich we have spoken, appear
during labor, blood should be taken immediately from the arm, provided
the general condition of the patient admit of it, and the delivery be accom-
plished as soon as possible.
  The same course is also indicated by the sudden occurrence of a marked
disorder of one of the organs of the special senses, — amaurosis, for example.
  b. Tlie effect which labor may have upon the foetus depends upon a multitude
of circumstances, most of Avhich will  be studied hereafter.  Thus, having
described  the mechanism of labor in each presentation, Ave shall treat of
the effect which each is liable to  have upon the health and  life of the child.
The various causes of dystocia are quite as unfavorable to the latter as to
its mother.
  We have but  these observations to make in this place;  namely, that all
things else being equal,  the mortality of male infants is much greater than
that of females, Avhich is due, as we have said before, to the greater size of
the former, and the proportionally longer  duration of the labor in conse-
quence ; the extreme sloAvness of this process, Avhich so often proves  fatal to
the foetus, has this unfortunate effect only Avhe'n it affects the second or ex-
pulsive  stage.  Until the  membranes  are ruptured,  and even  until the
dilatation is  completed, the labor may be prolonged indefinitely without
injury to the foetus, provided a certain amount of fluid remains in the uterus.
  It Avere hardly necessary to observe that any cause of  dystocia is liable to
affect the mother's health injuriously, and she is more liable to consecutive
inflammations and other unfavorable complications of labor Avhen delivered
of a boy than of a girl. 
304
LABOR.
                        CHAPTER III.

          OF  THE MECHANICAL  PHENOMENA OF LABOR.

                            ARTICLE  I.

                OF THE PRESENTATIONS AND POSITIONS.
  When  speaking of the  child's  attitude in the uterine cavity, we  stated
that it was  generally so situated that  the  cephalic  extremity formed the
most  dependent part.  But it  may also happen,  under  the  influence of
causes hereafter to be studied, that  some other point of the great axis shall
correspond to the uterine neck: that is to say, the  upper or cephalic extre-
mity, the inferior or the pelvic  extremity, or even  some part of the middle
portion or trunk, may first present  itself at the superior strait.  Noav, it is
very evident that such different circumstances of  presentation must neces-
sarily influence  the mechanism of the labor, as also the facility and the
promptness of the delivery, and it is therefore highly important to understand
well all those diverse situations before commencing the study of the me-
chanism proper.  This study comprises the presentations  and positions, as
they are called; and in using these terms we Avish to designate by the Avord
presentation the part  that first offers at the  superior strait; and by that of
position, the relations of this presenting part Avith the different points of the
same strait.               *
  The older accoucheurs only endeavored to recognize  the presenting part,
without investigating its relations with  the various points of the circumfer-
ence of the strait; but since the days of Solayres, and more especially since
those of his pupil  Baudelocque, everybody has. had a classification of his
OAvn; and the number of presentations and positions,  considered as so many
separate  and  distinct ones, varied  Avith each author who Avrote on the
obstetrical art.
  We give, in the following tables, the classification of Baudelocque, and
the principal ones of  those who  have succeeded him. 
GENERAL TABLE  OF  THE CLASSIFICATIONS.
WAKES OF AUTHORS.
PRESENTATION.
' Vertex or Summit,
BAUDELOCQUE,
Face,
-  Feet,
Knees,
Breech,
RELATIONS OF THE F03TAL PARTS WITH VARIOUS POINTS OF THE
                    PELVIS.
 Occiput at the left acetabulum,  ....
 Occiput at the right ncetabulum,  .  .
 Occiput at the symphysis pubis,
j Occiput at the right sacro-iliac symphysis,
 Occiput at the left sacro-iliac symphysis,
[Occiput at the sacro-vertebral angle,
 (Chin at the  symphysis pubis,
 Chin at the  sacro-vertebral angle
 Chin directly to the right,
 Chin directly to the left,  .
f Heels at the left acetabulum,
1 Heels at the right acetabulum,
 Heels at the symphysis pubis,
 Heels at the sacro-vertebral  angle,
 (Front of the tibias at the left acetabulum,  .
      "      "      at the right acetabulum,
      "      "      at the symphysis pubis, .
             "      at the sacro-vertebral angle
 (The sacrum at the left cotyloid cavity,   .  .
 The sacrum at the right cotyloid cavity, .  .
 The sacrum at the symphysis pubis,  .
 The sacrum at the sacro-vertebral angl

NAMES OF THE POSITIONS.
1st.  Left, occipito-cotyloid.
2d.  Right   "      "
3d.  Occipito-pubic.
4th.  Right occipito-sacro-iliac.
5th.  Left occipito-sacro-iliac,
6th.  Occipito-sacral.
1st.  Mento-pubic.
2d.  Mento-sacral.
3d.  Right mento-iliac.
4th.  Left mento-iliac.
1st.  Left calcaneo-cotyloid.
2d.  Right calcaneo-cotyloid.
3d.  Calcaneo-pubic.
4th.  Calc.ineo-sacral.
1st.  Left tibio-cotyloid.
2d.  Bight tibio-cotyloid.
3d.  Tibio-pubic.
4th.  Tibio-sacral.
1st.  Left sacro-cotyloid.
2d.  Right sacro-cotyloid.
3d.  Sacro-pubic.
4th.  Saoro, or lumbo-sacral. 
NAMES OF AUTHORS.
BAUDELOCQUE,
GARDIEN,
PRESENTATION.
Trunk,
Vertex,
Face,   .
Feet,   .
Knees,
Breech,
Trunk,
CAPURON,
Vertex,
Face,
RELATIONS OP THE FCETAL PARTS WITH VARIOUS POINTS OF THE PELVIS.
 Occiput,
 Neck,  .
 Back,  .
 Loins, .
 Face,  .
 Front of neck,
 Breast,
 Abdomen,
 Front of pelvis,
   "   of thighs,
 Side of the head
   "  of neck,
 Shoulder,
 Side of thorax,
 Flank,   .  .   .
[Hip,   .  .  .   .
 Four positions for each of these pre-
   sentations, viz.:
 Head above the pubis,.....
" Head above the sacro-vertebral angle,
 Head to the left,.......
 Head to the right,......
NAMES OF THE POSITIONS.
o
05
1st. Cephalo-pubic.
2d.  Cephalo-sacral.
3d.  Left cephalo-iliac.
4th. Right cephalo-iliac.
Six positions,, the same as Baudelocque,.....Same denomination as Baudelocque.
Four positions, the same as Baudelocque.....
Four positions, the same as Baudelocque,
            Four positions for each of these, viz.:
Right side, .   .  ["Head to the left,.....
Left side,  .   .  J Head to the right,  ....
Anterior plane,  1 Head in front, /.....
Posterior plane, [_ Head behind,......
1st.
2d.
3d.
4th.
Left cephalo-iliac.
Right cephalo-iliac.
Ceph'alo-pubic.
Cephalo-sacral.
 f Occiput at the left acetabulum,   .   .   .
J Occiput at the right acetabulum,     .   .
1 Occiput at the right sacro-iliac symphysis,
 {_ Occiput at the left sacro-iliac symphysis,
  (Chin at the left acetabulum,   ....
  Chin at the right acetabulum,  .  .   -
  Chin at the right sacro-iliac symphysis,
  Chin at the left sacro-iliac symphysis,   .
1st.  Left occipito-cotyloid.
2d.  Right occipito-cotyloid.
3d.  Right occipito-sacro-iliac.
4th.  Left occipito-sacro-iliac.
1st.  Left mento-cotyloid.
2d.  Right mento-cotyloid.
3d.  Right mento-sacro-iliac.
4th.  Left mento-sacro-iliac. 
CAPURON.....-	Knees, .... Trunk, . . .
LACHAPELLE, . . -	Vertex, . . . Face, .... Pelvic Extremit ^Trunk, ....
VELPEAU.....,	Vertex, . . Face, .... Feet..... Knkes, Bin; ec ii, .
f Four positions for each of these three presentations, ac-
   cording as the heels, the anterior tibial surfaces, or the
   posterior face of the.sacrum correspond to the—
 Left acetabulum,.............
 Right acetabulum,.............
 Right sacro-iliac symphysis,    ..........
 Left sacro-iliac symphysis,..........
                      ' In  each of these four the head may
 Right side,  ...      be found above  the—
 Left side,   .   .  .    Left acetabulum.......
 Anterior plane,   .  1 Right acetabulum......
 Posterior plane,  .   | Bight sacro-iliac symphysis,  .
                      [ Left  sacro-iliac symphysis,
First position.
Second   "
Third    "
Fourth   "
1st. Left cephalo-cotyloid.
2d. Right cephalo-cotyloid
3d. Right cephalo-sacro-iliac.
4th. Left cephalo-sacro-iliac
Occiput at the left acetabulum, ....
Occiput at the right acetabulum,  .   .   .
Occiput at the right sacro-iliac symphysis,
Occiput at the left sacro-iliac symphysis,
Occiput directly to the left,.....
Occiput directly to the right,   ....
Chin directly to the right,   .   .  .   .  '.
Chin directly to the left,  .......
Loins to the left,........
Loins to the right,........
Loins in front,.........
Loins behind,.........
                f Head left,     ....
                J Head right,   ....
                1 Head left,     .....
                [ Head right,   ....
Right side,

Left side,
1st. Left occipito-cotyloid.
2d. Right occipito-cotyloid.
3d. Right occipito-sacro-iliac.
4th. Left, occipito-sacro-iliac.
5th. Left occipito-transverse.
Gth. Right occipito-transverse.
1st. Right mento-iliac.
    Left, mento-iliac.
    Left lumbo-iliac.
2d  Right lumbo-iliac.
3d. Lumbo-pubic.
4th. Luinbo-sacral.
1st. Left cephalo-iliac.
2d. Right cephalo-iliac.
1st. Left cephalo-iliac.
2d. Right cephalo-iliac.
2d.
1st
Like Baudelocque,.............
Like Lachapelle,.............

As many positions for each of these three presentations
  us for the vertex.

Right side,
Left side.
Posterior plane,  I. Head to th
Anterior plane,  [
  Two positions for each of these, viz.:
-! Head to the left,.......
e right,
Same as liaudelocque.
Same as Lachapelle.
The same corresponding denomi-
  nations  for  each  of  the  six
  positions.
1st. Left cephalo-iliac.
2d. Right cephalo-iliac. 
308
LABOR.
CLASSIFICATION  OF  PROFESSOR MOREAU.
             / NATURAL LABORS.
             1 ARTIFICIAL LABORS.
FIRST CLASS.—Natural Labors.
TWO  CLASSES.
  FIRST  ORDER.
Presentation  of  the -|
 cephalic extremity.
    1st genus.
Vertex presentation.
    2d genus.
Face presentation.
     3d genus.
Presentation of the
  sides of the head.
2 subdivisions.
Right side.

Left side.
 SECOND ORDER.
Presentation  of  the <
  pelvic extremity.
THIRD ORDER.
  FIRST ORDER.
Accidental   artificial
  labor.
 SECOND  ORDER.
Essentially  artificial
  labor.
  THIRD ORDER.
Labors which are the
  result of malforma-
  tion.
1st position.-
  pito-ilium.
  ,  ,    -,       T  c,    ■  fanterior,
  1st nnsitinn --Left 0CC1- I
                        ■I transverse,
                         ^posterior.
                t,.  ,.     ( anterior,
-  2d position.— Right oc-  „
     r .   ...      a     J transverse,
    cipito-ihum.          ]    .   .
      r                  (posterior.
  3d  position.<—Occipito-pubic.
 _ 4th position. — Occipito-sacral.
                         C anterior,
1st position.—Right
  mento-ilium.

2d position.— Left
  mento-ilium.
4 transverse,
 ( posterior.
  anterior,
  transverse,
  posterior.
     1st genus.
Breech presentation.
    2d genus.
Foot presentation.
1st position. — Lobulo-pubic.
2d position.— Left lobulo-ilium.
3d position—Right lobulo-ilium.

1st position.—Lobulo-pubic.
2d position.—Left lobulo-ilium.
3d position.—Right lobulo-ilium.
, ,            T  „,      f anterior,
1st position.
  cro-ilium.
Left
     3d genus.
Presentation of
  knees.
the
2d position. — Right
  sacro-ilium.
Accidental  natural
  labor.
SECOND CLASS.
     1st genus.
Accidents on the mo-
  ther's part.
     2d genus.
Accidents on the part
  of the foetus.
   single genus.
Presentation of  the
  trunk.
2 subdivisions.
                         1 transverse,
                          ( posterior.
                           {anterior,
                           transverse,
                           posterior.
   3d position.— Sacro-pubic.
   4th position.— Sacro-sacral.
   1st position.— Left calcaneo-ilium.
   2d position.— Right calcaneo-ilium.
   3d position.— Calcaneo-pubic.
   4th position.— Calcaneo-sacral.
   1st position.— Left tibio-ilium.
   2d position. — Right tibio-ilium.
   3d position.— Tibio-pubic.
   4th position.— Tibio-sacral.
   Single  genus.— Presentation of  the
     trunk.   (See below.)
Artificial Labors.
  1st. Right side.  .

L 2d. Left side.   .

      1st genus.
  On the part of the child,
      2d genus.
  On the part  of the
f 1st position.— Left cephalo-ilium.
\ 2d position.— Right cephalo-ilium.
("1st position.— Left cephalo-ilium.
X"
2d position.— Right cephalo-ilium
mother.
                 APPENDIX, OR THIRD CL.< SS.— Anomalies.
Anomalies either in the seat, c< urse, or products of gestation, or lesions of the womb. 
               MECHANICAL  PHENOMENA OF LABOR.           ii09

   The reader will see, by the foregoing table, that Baudelocque  primarily
divides the foetus into two extremities:  the one represented by the apex of
the  head,  the other  by the feet, knees, or  breech;  and further, that  the
remainder of the  child's surface is divided off into four regions,  which are
again subdivided  into several others.   After having determined the foetal
regions, the presence of which, at the superior strait,  constituted a presenta-
tion, it was equally necessary to understand the positions.   For  that  pur-
pose certain points of departure were selected, both on the pelvis and on the
presenting part of the child.  Of  course, these points varied according to
the presentation:  thus, in a vertex one, Baudelocque took  the occiput and
forehead as the points on the foetal head; he then  divided the pelvis into an
anterior and  a posterior half;  on the first of which  the right and the  left
cotyloid cavities and the symphysis pubis, and on the second the right and
left  sacro-iliac symphyses, and the sacro-vertebral  angle, were selected as
the points  of departure; he  next established six positions of the  vertex, in
each of which the occiput corresponded to one of those points on  the pelvis
 just indicated.
   In the presentations of the breech, knees, and feet, he retained  the same
three points on the anterior half of the pelvis, but on the posterior half he
only adopted one: the sacro-vertebral angle.   On the foetus, the heels were
the points of correspondence in foot presentations, the  sacrum for the breech,
and the front surface of the  legs for those of the  knee.  Consequently,  but
four positions were admitted for either  the breech, feet, or knees.
   Lastly, for  the  presentations of  the  numerous  regions indicated  by the
table on the anterior, posterior, and lateral planes of the foetus, he selected
on the mother's pelvis the two extremities of the antero-posterior diameter
(the symphysis pubis and the sacro-vertebral angle), and the two ends of
the transverse diameter, as the points of departure,  so that he pointed  out
four possible  relations, that  is to say, four positions  for each one of these
presentations.  Thus, Baudelocque  admitted altogether one hundred and
two  distinct positions.  But it was soon ascertained that so great  a number
was  wholly useless in practice:  and besides, it had the serious disadvantage
of disgusting pupils  with the study of midwifery.  The classification of
Baudelocque  was  therefore  modified to some extent, and  we  have succes-
sively traced, in our  table, the principal of those  modifications;  still, even
after adopting the latter, the obstetrical art was yet greatly cenfused, and it
remained for M. Naegele to simplify this branch of medical  science, much
more than it had  ever been  done  before his  day.   To him, therefore, we
must attribute this honor, as also to Dubois, and Stoltz, of Strasbourg, who
first  endeavored to disseminate throughout France the views of the Heidel-
berg professor!  It  must be acknowledged,  however, that the  labors of
-Madame Lachapelle, and the  teachings  of Ant. Dubois, have  not been
altogether foreign to this improvement.
   We should also observe that the  classification of M. Moreau is far more
simple than all those of Baudelocque and his followers; indeed, this  pro-
fessor has adopted (as seen by the table) most of the  ideas  upon which  the
arrangement  of Naegele is founded, and  we only regret that he has con-
sidered the presentations of the sides of the head and certain of the positions 
310
LABOR.
as distinct, which we hope to demonstrate hereafter d( not deserve to be so
regarded.
   In fact, there is no region of the child  which may not present at  the
superior strait during the labor, and therefore, if 'we are to consider all the
points of its surface that may be accessible to the finger as so many distinct
presentations, their number would be very considerable; but if, on the con-
trary, the expression is only applied to the presence of a region large enough
to occupy the whole superior strait, more especially to  one requiring a
notable difference either  in the mechanism of its spontaneous expulsion, or
in the manoeuvres to be resorted to, this  number would then be much more
limited.
   Upon such opinions, advocated long since  by Madame Lachapelle and
Ant. Dubois, M. Naegele has founded the following classification, which is
now admitted and taught by Dubois and  Stoltz  in France, namely, three
principal regions are distinguished in the foetus:  1. The head, or cephalic
extremity; 2. The  pelvis,  or pelvic extremity; and  3. The trunk; either
of which parts may offer first at the superior strait.
   When the cephalic extremity presents, it is ordinarily flexed on the chest,
and the vertex then advances first;  but  it may also be extended or thro.vn
backwards on the  posterior plane of the  foetus, in- which case the  face
engages first.  We have therefore to distinguish between a vertex presenta-
tion and one of the face,  for the mechanism of  labor is very different in the
two.  When the pelvic  extremity presents, the legs  are usually flexed on
the thighs, and  the latter on  the abdomen;  but it  may happen, from a
variety  of causes that we shall hereafter designate, that these divers parts,
which are usually folded up in this manner, are separated from  each other:
ihus, they sometimes engage altogether in the excavation ; at others, either
during the course of the labor itself, or some time  before, the inferior mem-
bers stretch out and lay along the front of the body, and the nates then
descend alone.   Again, the legs may be swept  down  either by the gush of
the waters, or by some other cause, and engage first; hence, in this latter
instance, if the deflexion of the lowrer members is complete, the  feet are the
first to clear the vulva ; but if, on the contrary, the thighs be extended, and
the legs remain flexed on them, the knees will be the first to  show them-
selves at the external orifice.
  Now it must be evident, on the least reflection, that these  latter circum-
stances can effect no modification in the mechanism of the labor itself, and
accoucheurs are certainly in error in considering  them as  so many distinct
presentations ; consequently, we shall describe them under the single title of
the presentation  of the pelvic extremity; merely remarking that, when this
extremity presents,  all  its constituent  elements  may happen to engage
together at the same time,  or they may be separated, and then  the breech,
or the knees, or feet, will offer first at the vulva.
  But before proceeding any further, we will follow the example of M.
Dubois  (from whom  this article is borrowed  almost verbatim), by laying
down precisely the limits  of  the fcetal  regions  embraced in  the double
expression of the cephalic and  the pelvic extreini y: thus, when  the head or
the pelvis presents at the superior strait, it usually  does so nearly "plumb:" 
              MECHANICAL  PHENOMENA  OF  LABOR.           311

that is to say, the long  diameter of the foetus is almost parallel t<  the axis
of this strait; so that the sagittal suture in  the vertex  presentations, the
facial median line in those of the face, and the fissure between the nates in
those  of the  pelvic extremity, occupy very nearly the centre of the abdo-
minal  strait.
  But very numerous exceptions to this rule occur, because the mobility
of the foetus in the uterine  cavity, and  the  frequency of the  uterine obli7
quities, may cause the child's long diameter to be inclined  forwards, back-
wards, or towards the sides.   Hence, it is evident that the presenting  part,
participating in this inclination, will not be  so regularly placed as usual;
thus,  if it were a vertex presentation, and the inclination  were anterior, the
summit would no doubt descend, though it wTould be accompanied by the
forehead in  consequence of this defective position;  or,  if the inclination
were on the  posterior plane, instead of the  forehead, we should have the
occiput or occasionally  even the neck.  Again, if it is lateral, that is, if the
foetus is bent towards one side, the vertex and one  side of the  head  may
be  recognized  at the  same  time; and the  sagittal suture,  instead of
corresponding to the axis of the superior strait, will  then be found  either
behind or in front, according to the direction of the inclination; but such
inclinations  do not deprive the vertex  presentation of its  character, they
only convert it into a defective or irregular presentation.
   The observations just  made  iri  regard to vertex presentations equally
apply to those of the face and breech, and we may therefore have regular
and irregular ones of these parts just in the same way.  To resume, we shall
include in the class of vertex  presentations, all those designated by Baude-
locque under the names of presentations of the occiput, nape, and lateral
parts of the head; in face presentations,  those of the forehead, chin, cheeks,
front and sides of the neck ; and in the breech, those of the sacrum, genital
parts, front of the thighs, &c.;  whence  all the  surface comprised between
the sinciput  and the shoulders belongs to the  cephalic  presentations, and
that between the summit of the nates and the haunches is referred to the
pelvic ones.
   If we now take off all the foetal parts included in the cephalic and pelvic
extremities, there will  only remain the trunk proper: that is, the portion
extending  from the shoulders to the  hips, and this part may also present
the first.  Now  with regard  to this,  Madame Lachapelle  has  long since
remarked that, when  the trunk  offers at the superior strait, it always  does
so by one of its  sides:  that is to say, the anterior or the posterior median
line of the bodv never corresponds to the axis of the superior strait.  There-
fore, she divided the trunk into two lateral  halves, either of Avhich  may
come down first; hence there are two trunk  presentations,  one of the right
lateral plane, the other of the left  lateral plane; the whole anterior and
posterior right moieties being included in the first, and the same parts on
the left being embraced in the  second;  and as the shoulder, which is then
the most prominent part, is nearly always found at the centre of the superior
strait, when  the lateral planes offer first, that skilful midwife  designated
them as presentations of the shoulder.   M. Dubois, however, still  retains the
name of the presentations of the lateral regions; and these, like  the others, 
312
LABOR.
may either be regular or irregular.   They are regular when Jae lateral line
is directly at the  centre of the abdominal strait, but  irregular where  the
anterior or the posterior region of the trunk occupies this strait in a greal
measure, owing to the child being  more or less inclined forward or back-
ward ;  and it is to such irregularities that we  must refer all those presenta-
tions of the back, loins, front of the chest and  abdomen, described by the
older authors.
  On the whole then we  admit five presentations, viz., one of the vertex,
one of the face, one for the pelvic extremity, one for the right lateral plane,
and one for the left lateral plane.   Besides the presentations, Baudelocque,
and all  those who followed him, described  a great number of positions;  in
each of which, according to their account, the mechanism of the labor was
different.   But M. Naegele, in  consequence of  a  better conducted study of
this  mechanism, has  succeeded in  changing  entirely this  branch  of the
science, and  has further proposed  a reform  in the positions, at least  as
important as what he has already made in the classification of the presenta-
tions.  Thus, he simply divides the  pelvis into two lateral halves, the right
and  the left, and these  form  the only points of departure at the superior
strait;  on the foetus, the points admitted by Baudelocque are retained.  For
instance, in a vertex  presentation, the occiput may offer  at  any one point
whatever of the left lateral half of  the superior strait,  thereby constituting
the first position of the vertex; or it may correspond in a similar way with
the right lateral half, thus producing the  second  position ; further, as the
mechanism is just the same, whether the occiput be at first  at the front, in
the middle, or behind, Ave shall  only consider these circumstances as so many
yarieties of the same position;  which  shades  or  varieties, in the  great
majority of cases, do not. change the mechanism of the natural labor  in
any Arise, and therefore do not  deserve to be received as important elements
in a classification, but of AA'hich, hoAvever,  more account should be taken
than appears to  have been  done by M. Naegele, for they may be usefully
recalled in explanation of certain anomalies, as also for successful interven-
tion  in some cases of difficult labor.
  What has just  been stated  concerning the vertex equally applies to  the
positions of the face and  breech;  since in the  former the chin may be
directed towards some point, either on the right or the  left lateral half of
the pelvis; and in the latter the sacrum  may have a similar relation Avith
some point of its right or left  half; therefore Ave adopt a first, or the right
mento-iliac, and a second, or the left mento-iliac position for  the face; and
likeAvise for the breech Ave have a first, or the left sacro-lateral, and a second,
or the right sacro-lateral position.   Lastly, the  tAvo presentations  of  the
trunk have each tAvo positions: for example, the right side of the foetus pre-
senting, the head may happen to be placed either above some point on the
left lateral moiety, or over a similar part on the right one.   Hence, there
are two positions:  first, the left cephalo-iliac, and second, the right cephalo-
iliac; or, if the child's left side presents in the same Avay, the head may be
either to the left or the right, thus  giving rise to two new positions, the left
and the right cephalo-iliac position. 
MECHANICAL  PHENOMENA OF  LABOR.
313
  [Perhaps it would be better to adopt M. Jacquemier's expression and say, that
,fvlien a shoulder presents, the acromion is directed sometimes toward the left and
sometimes toward the right side of the pelvis.  Hence we have two positions, left
acromio-iliac  and right acromio-iliac.  The same idea is, therefore, expressed,
whether we say that the right shoulder presents in a left cephalo-iliac or in a left
acromio-iliac position, but the assumption of the acromion as the point of reference
makes the nomenclature clearer and more uniform.]

  There is scarcely a necessity for adding that the anterior, transverse, and
posterior  varieties, admitted for vertex positions, are also retained for the
tAvo fundamental ones of the face,  the  breech,  and the right and left sides.
    SUMMARY.

'Left occipito-iliac, .  .  3 varieties,
1. Vertex presentation, .
2. Presentation of the face,
3. Presentation of the breech,
 {anterior,
 transverse,
 posterior.
 {anterior,
 transverse,
 posterior.
 {anterior,
 transverse,
 posterior.
 {anterior,
 transverse,
 posterior.
i anterior,
 transverse,
 posterior.
( anterior,
( transverse,
[ posterior.
Left mento-iliac,  .  .   3 varieties,
Left sacro-iliac,
Right sacro-iliac,
3 varieties,
4. Presentation of the right f Left cephalo or acromio-iliac,   .  , ]
    lateral plane,          . [ Right cephalo  or acromio-iliac,  .  .  j
5. Presentation of  the  left ( Left cephalo or acromio-iliac,   .  .  |
    lateral plane,  .   .  .   . j Right cephalo  or acromio-iliac,  .  .  1
anterior,
transverse,
posterior.
  We would observe, hoAvever, that in shoulder presentations the varieties
of position  are far less important  than in the other presentations, and  that
it matters very little Avhether the acromion and the head be more or less in
front or behind.
  But all the presentations and positions just indicated  have not  the same
frequency, nor are they all equally favorable to the spontaneous expulsion of
the child.  There are some even, such as the positions of the trunk, in Avhich
this  is most generally  impossible, but  there is no one, however, in Avhich it
absolutely cannot take  place;  therefore,  Ave shall have  to  examine  the
mechanism of natural labor in each  of these  presentations successively,
reserving to ourselves  the privilege of reverting  in the  fourth  part of this
work to those which usually offer an insurmountable difficulty; and as the
vertex presentations are the most  frequent and  favorable of all, we shall
com mence with, a description of them. 
314
LABOR.
                          ARTICLE  II.
                    OF THE VERTEX PRESENTATION.
  This presentation is far more frequent than all the others put  together:
thus, in 20,517 births reported by  Madame Boivin, 19,810 children were
born by the vertex; and  in 2020 cases reported  by M. Dubois, there Avere
1913 of this variety.   Again, Avhen the vertex presents, the occiput is much
oftener directed towards  the-left than  the right side:  for instance, in the
1913 cases just cited, M. Dubois noticed  1367 left  occipito-iliac, and only
546 right occipito-iliac positions.  Nor are the three varieties  pointed out
for each  position equally  frequent:  thus, in the  1367 cases Avhere the occi-
put was directed to the leftside, it Avas inclined forward, that is, towards the
left cotyloid cavity, 1355  times, and only 12 t'mes backAvards, in the direc-
tion of the left sacro-iliac symphysis, or nearly so. But in  the 546 instances
of right occipito-lateral positions an opposite result Avas observed;  for the
occiput was only found 55 times at the right acetabulum,  but 491 times  at
the right sacro-iliac  symphysis ; so that, contrary to the generally received
opinion, the posterior right occipito-iliac position is much more  frequent
than the anterior one.  We have given these results as ascertained by M.
Dubois himself, because they are entirely consonant with  our own observa-
tions, and with those of M. Stoltz, of Strasbourg.
  In one hundred cases of vertex presentations, it has been  found on an aver-
age, says M. Naegele, that in seventy the occiput is directed in front and  to
the left, and behind and to the  right in thirty ; he considers the other varie-
ties as being very rare and altogether exceptional.
  In these results, no question  seems to be  made of the varieties Ave have
designated as  the  transverse ones, and it is highly probable that they have
been  approximately added  to  one  of the four preceding  groups, for these
positions are not very unusual; indeed, I have often met with them myself
at the Clinique.
  " These positions," says Madame Lachapelle,  " are  more frequent than
those Avhere the occiput corresponds to the left sacro-iliac symphysis;" and,
I will add,  than those where it is at the  right acetabulum; also, that the
left transverse occipito-iliac position is more common than the opposite one.

  § 1. Causes.
  As Ave have already spoken of the cause of the vertex presentations, Avhen
treating of  the child's attitude in the uterine cavity, Ave shall  not  now  go
over the same ground, but will only remark, that most accoucheurs attri-
bute the frequency of the dependent position of  the head  to its OAvn specific
weight;  Avhilst M. Dubois, after having endeavored to refute the  general
opinion, has considered this position as the consequence  of an instinctive
determination of  the foetus itself.  (See art. Fodus.)  HoAvever, it  is not at
all difficult to explain why the left anterior, and  the right  posterior occipito-
iliac varieties are the most frequent of any, since it is evidently owing to
the presence of the rectum on the left side. The habitual distention of this
bowel by fecal matters obliges the forehead or occiput  to turn towards  the
 front whenever either of  these parts is directed  backwards and to the  left. 
                 MECHANICAL  PHENOMENA  OF  LABOR.            315

 It is far more difficult  to say why the occiput is so much more frequently
 found in  front than behind, although this very probably depends on  the
 same causes as those Avhich determine the vertex presentation.
    Thus, the posterior half of the head weighs far more than  the anterior,
 and the same is true of  the  trunk;  further, Avhen the Avoman is  standi no-
 sitting, or on her knees, or even lying on the side, the anterior wall  of  the
 abdomen is the most dependent portion, towards Avhich the child's  heaviest
 parts, that is to say, its posterior plane, must necessarily tend.

    § -J. Diagnosis.
   [The  presentation of the vertex  and  its positions may be determined by three
 different kinds of examination, riz., palpation of the abdomen, auscultation, and the
 vaginal touch.
   Palpation of the Abdomen.— If the hands be placed upon the abdomen and  the
 walls of the uterus depressed, parts of the foetus may be felt and with a little prac-
 tice distinguished quite readily.
   To obtain the best results from this method, the Avoman should lie  upon her back
 with the walls of the abdomen as much relaxed as possible, and by gentle pressure
 be accustomed to the contact of the hands.   At the outset it is not  uncommon for
 the examination to be interrupted by a contraction of the womb, which,  of course,
 should be allowed to subside.  After some trials, however, the abdominal musclos
 and the walls of the  uterus yield to the  pressure, so that the hand which explores
 the hypogastric region is  enabled to distinguish with  some precision a voluminous,
 hard and rounded mass  which  recalls exactly the size and form of the  head of a
 child.  Above it may often  also be  recognized the entire dorsal region of the foetus,
 bo that it only becomes a  question between a presentation of the vertex and one of
 the face.
   A circumstance which may embarrass physicians, avIio have but little experiqpice
 in this kind of research,  arises from  the fact, that near the end of pregnancy, and
 especially in primiparous  cases, it often happens that the entire head has descended
 into the cavity of the pelvis and necessarily escapes  detection by the hand which
 ioufines itself to a superficial examination of the  hypogastric region.  In this case,
 if the ends of  the fingers  be placed  above the body of the pubis and  pressed down-
 ward as though to push the  Avails of the abdomen into  the  lesser pelvis, the head
 of the child Avill soon be  felt filling the entire cavity.  I have in hundreds of  in-
 stances succeeded in this way in diagnosing the vertex presentation, and that with-
 out causing either pain or a.ccident.
   The presentation being determined, if the accoucheur can feel to which side  the
 back of the child is turned, the palpation has enabled him to diagnose both presen-
 tation and position.
   In the occipito-posterior positions, the greatest width of the womb is still at the
 upper part, as stated in the account of the normal condition ; but the fundus is  not
 so evenly rounded unless the quantity of fluid be very great: most commonly, says
 .M. Stoltz, an arched  projection  may  be detected at the fundus, and beneath it a
 sensible depression.   The  anterior  plane of the foetus being directed forward, the
 inequalities  formed by its extremities, which are discovered with difficulty in occi-
 pitoanterior positions, are detected  more readily.
  A certain  degree of importance ought, therefore, to be accorded to this kind  of
 exploration, though Ave should be careful not to over-estimate its value.  In the most
 simple cases we are  sometimes liable to be deceived,  and  a mistake  becomes easy
 when the walls of the abdomen are thick or the quantity of Avaters great.   Finally,
 it should  be  understood that  in some Avomen the uterus is so readily excited to con-
traction, that it becomes impossible  to depress its Avails sufficiently to arrive at any
result.  Still another consideration  which lessens the A'alue of  palpation is, that, 
316
LABOR.
though it may be easy before labor comes on, it becomes difficult or even impolitic
ai that time; all which is readily explained by the  severe pains Avhich it provokes
and the facility with Avhich it excites the contraction of the uterus.
  Auscultation. — The diagnosis of the presentations and  positions  of the vertex
may also be determined by auscultation.  As Prof.  Depaul has treated this subject
thoroughly in his Traite d'Auscultation Obstftricale, I will merely state here, that in
the presentation of the cephalic extremity, the  maximum intensity of the pulsations
of the heart are heard above a horizontal line passing through the umbilicus.  Tc
this  law there are very few exceptions in  a normal  condition of the  pelvis, and
whatever relates to deformities need  not detain us here.
  Auscultation is not less important  in order to determine the position.  As in the
foetus the lungs are flattened against the vertebral  column, the sound of the heart
is transmitted to the ear through the dorsal region whose curvature is  applied
against the walls of the uterus; therefore, as the greatest intensity of the sounds of
the heart is perceived over  the spinal column, and as both it and  the posterior
fontanelle are directed toward the same side, we learn where the occiput is situated.
In the left anterior occipito-iliac position the heart beats  in front and to the left,
whilst in the  right posterior occipito-iliac  position it is heard behind and to the
right.  The same reasoning indicates  certainly the point at which the head ought
to be  heard for  each  particular  position.  To avoid  being  deceived by the data
which auscultation  supplies, Ave ought ahvays to determine  and fix precisely, not
the point where the heart is heard merely, but the point where the sound is loudest.
Without this precaution auscultation would be as deceptive as useful in the endeavor
to determine the position.]
   Vaginal Touch. — Before labor, and even  during the last few months of
gestation,  the vertex can often be recognized as presenting; while in every
other presentation the part that offers first, from  being irregular, voluminous,
an^ badly adapted to  the form of  the inferior uterine  segmt^t, and of the
superior strait,  is always so high up, and separated from the uterine Avail by
so large a quantity of waters, as to  be scarcely  accessible to the finger.
  The  vertex,  on the contrary,  presenting  a rounded spheroidal  surface,
reposes, almost without the intervention  of any liquid, on the uterine walls,
nay, even  presses them before it, and engages in the excavation, descending
in some cases as low down as the  floor of the pelvis.  Hence, Avhenever the
vertex  presents, it is easily detected through  the inferior portion of the
uterine Avail, unless, indeed, it should be retained  at the superior strait by a
considerable inclination of the Avomb, or by a malformation  of the pelvis.
  In  a  word (and  this reflection appears to me  essentially practical), Avhen-
ever the accoucheur does not easily reach  the  presenting part in the last
few days of the gestation, and  more particularly during the first periods of
labor, he should examine the woman very carefully; for it is then  exceed-
ingly probable  that the  head  is  not at the superior strait; or, even where
the cephalic  extremity does present flexed, there is reason to fear a Avrong
direction, or perhaps a faulty organization of the head  or pelvis; all which
circumstances may subsequently require the  intervention of our art.  We
would, hoAvever, remark,  that in women who have borne  children the head
often continues very high up until  the  end  of  gestation,  and does  not get
beloAV the superior strait until labor sets  in.1
  1 A variety of circumstances may  occur towards the end of gestation, or at the begin-
ning of the labor, dependent  on causes wholly  foreign  to any faulty positions, whereby
it might happen that no part could be detected by the touch:  thus, 1. It is sometimes
observed in women who have had  several children, and in whom the fundus uteri is 
MECHANICAL  PHENOMENA  OF LABOR.            317
   Supposing the labor  has begun, if the finger be introduced through the
 cervix uteri, it will immediately encounter a rounded, smooth, and resistant
 surface, Avhich is the anterior side of the head ; and then, by directing the
 index a little further upAvards and backAvards, in the direction of the sacro-
 vertebral angle, it will  come into contact with a membranous interval, that
 is, Avith the sagittal suture.
   A vertex  presentation is now ascertained;  and  the next step is to make
 out  the position.  For that purpose we first assure ourselves of the direction
 of the suture, and if it prove to be oblique, running from before backAvards,
 and  from the left  tOAvards the  right, the  position must  either be the left
 anterior, or the right posterior occipito-iliac one; but, on the contrary, if it
 be oblique in the other diameter, the position Avill either be the right anterior
 or the left posterior  occipito-iliac, &c.
   The direction being once determined, Ave have then only to find out where
 the  occiput  lies, to  complete the diagnosis; therefore, the finger, by raising
 up the margin of the os uteri, follows the  sagittal  suture until it reaches a
 fontanelle, Avhich is to be distinguished by the characters hitherto described.
 (See Head of the Foetus at  Term.)
   §  3.  Mechanism.
   The mechanism by which  the  expulsion of the  child is accomplished in
 positions of the vertex is very nearly the same in all cases where the occiput
 corresponds  Avith one of the points of the left lateral half of the pelvis;  but
 it differs in some respects from that  observed in the positions designated as
 the  right occipito-iliac ones.
   We must, therefore, examine it in both of these positions; and as, among
 the  admitted varieties, there are tAvo, the anterior in the  left  occipito-iliac,
 and the posterior in the right  occipito-iliac, Avhich are  almost  constantly
 met Avith, Ave shall take  them up successively as the types of our description.
   1. Mechanism of Natural Labor in the left Anterior Occipito-iliac Position.
 (The first, or the left occipito-cotyloid position
 of authors.) — In.this position, the occiput cor-
 responds to the left  ilio-pectineal eminence, the
 forehead to the right sacro-iliac symphysis,  and
 the sagittal suture lies  in  the direction of the
 left  oblique diameter of the pelvis.   (In order
 to avoid unnecessary repetitions 'and delays, Ave
 premise, once for all, that Ave shall  designate
 that oblique  diameter Avhich runs from the  left
 towards the  right  side, and from before back-
 wards, as the left oblique, and the one passing
 from the right tOAvards the left, and  from  in
 front posteriorly, as the right oblique diameter.)
 The  posterior  fontanelle is found to the  left
 and  in front, the anterior one is behind  and to
 the right.  The dorsal plane of the foetus looks
strongly inclined forwards;  2. In cases of twins; 3. In breech presentations; 4. Where
there is a large amount of water:  5. Where the uterus is not oval at its inferior part;
6. Where the head is hydrocephalus;  and lastly, where the pelvis is narrow. (Nsegele
translated by Pigni.)
Fig. 75.
Representing the head in the left an-
   terior occipito-iliac position. 
318
LABOR.
forwards and towards the  left side;  Avhile its anterior plane i9 diiected
backwards and to the right; the  right shoulder is in front and to the right
side; the left one is behind  and towards the mother's left.
  Before the bag  of Avaters is ruptured, the child's  head is slightly flexed
on the front of the chest, and the following are the relations of its diameter
with those of the superior strait:  the occipito-frontal corresponds to the left
oblique of the strait, and the bi-parietal to the right oblique;1 and, of course.
the occipito-frontal circumference of the head is parallel Avith the periphery
of the abdominal  strait, and the axis of this  strait corresponds Avith the
trachelo-bregmatic diameter2 of the head.
  When the membranes are ruptured,  a variable quantity of liquid escapes;
then the uterus contracts and applies itself more directly to the fcetal trunk;
nevertheless, as but little fluid passes  away in vertex positions at this time,
there usually remains a sufficient quantity of it to render  the  pressure of
the uterine Avails on the child far from being immediate.
  After the  rupture, the  object of the  contractions is to expel it from the
womb;  the foetus  becomes  more curved anteriorly, and its superior  and
inferior  extremities more closely folded up ; and from that moment, properly
speaking, the mechanical  phenomena of labor begin.

  [The various movements communicated  to the foetus  during labor  tend  to facili-
tate its expulsion,  as will appear from the  description of them  about to  be given
under the usual term of the stages of labor.

  1 We may  remark, however, with M. Dubois, that this last relation is not absolutory
exact.  For  instance, if the head of the foetus at term be found at the superior strait,
so that the occipito-frontal diameter is parallel with the left oblique, the shape of the
head will prevent  the  bi-parietal  one  from corresponding with  the right oblique
diameter.  In fact, in this position the posterior extremity of the bi-parietal  diameter
is at the  left sacro-iliac symphysis, but the  anterior extremity, instead of terminating
opposite  the ilio.-pectineal eminence, is found very near  the middle of the horizontal
branch of the pubis.
  2 M. Nosgele and Professor Dubois  (who adopts, at least in part, the views of the
Heidelberg Professor) do not believe that the head presents at the superior strait, in
the majority of cases, so regularly in  all its relations as we have just described, for
they say  the head does not offer perpendicularly to the plane of the strait, but on the
contrary, in an oblique  direction; whence  the right  parietal protuberance, which is
also the  anterior one, would be lower, relatively to the plane, than the left; and the
bi-parietal suture, instead of being found in the direction of the axis of the  head,
would be a little  behind it, according  to M.  Dubois, and would even look towards the
second bone of the sacrum, agreeably to M. Naegele.
  But, notwithstanding these imposing authorities, we believe the occipito-frontal cir-
cumference  is closely parallel to  the  plane of the strait in most cases, although the
parietal boss is certainly one of the most dependent parts of the head,  and the  finger
first strikes upon it in practising the  vaginal examination.  But those facts  by Avhich
M. Naegele sustains his views prove just the contrary; because the plane of the abdominal
strait, being directed very obliquely downwards and  forwards, the portion of the head
in contact  with  the  anterior arch  of the pelvis should be its most dependent part;
and further, the  finger first encounters the  anterior parietal protuberance, because the
introduction takes place under the symphysis pubis, that is to say, almost perpen-
dicularly to the  superior strait,  and therefore the index can only reach, in a very
oblique  direction, the anterior portion of the head, whose greatest circumference  ia
parallel  to the plane  of the superior strait. 
               MECHANICAL  phenomena  of labor.           319

  Five principal stages have hitherto been reckoned in vertex presentations; they
are, following the order in which they occur:  1st.  flexion; 2d. descent; 3d. rota-
tion; 4th.  extension or disengagement; 5th. restitution.  To these  five  stages we
think it proper to add a sixth for  the expulsion of the body.  At the end of this
chapter (see Recapitulation of the Mechanism of Labor), we shall state more fully
the reasons which  induce  us to alter the number of stages as usually described,
remarking only for the present, that we think it gives the advantage of a classifica-
tion which is both more  rational  and  applicable  to  every presentation.  In the
Recount of the mechanism of expulsion  for each presentation we shall,  therefore,
describe six stages.
  It will be seen that this innovation does not call for a change in the  generally
received opinions,  inasmuch as we have only to reunite the fifth and sixth stages
to restore the old classification.]

   These phenomena, or stages  of the mechanism, are  five in number, as
folloAvs:  in the first, the head  is more strongly flexed on the chest;  in the
second it  traverses all the space betAveen the superior  and  inferior  straits,
and  reaches  the floor of  the pelvis; there it experiences a movement of
rotation which carries  the occiput behind the symphysis pubis, thus con-
stituting the third period; in the fourth, the head undergoes the process of
extension, by Avhich all the superior and  anterior parts  of the vertex and
face become  completely disengaged at  the  anterior  commissure  of the
perineum;  and then, after its perfect expulsion,  the child's cephalic extre-
mity performs a  fifth and last movement, designated  by Baudelocque as the
period of restitution, but Avhich M. Gerdy has proposed to name the exterior
rotation.
   A. First Stage, or Stage of Flexion. — After the rupture of the membranes,
the foetal  trunk, being compressed on all sides, transmits to the head, through
the spine, the impulse derived  from the uterine contractions.  The head,
being  forcibly pressed on, has  a  tendency to
clear the uterine orifice, and to engage in the
excavation.  But it then encounters resistances,
either from the os  uteri, Avhich  is not yet suffi-
ciently dilated, or from the superior strait, or
the Avails  of the  excavation; and being thus
placed between  a  power and a resistance, the
head  must  naturally become still  more flexed
on the chest; in fact, the force of  expulsion
transmitted  by the vertebral column, falling
upon  the  occipital foramen, that is, on a point
much nearer to the occiput than the chin, must
necessarily  (the  resistance being equal at the
two extremities of the occipito-mental diameter)
act more  powerfully on the occiput than on the The head in the 8ame P°siti01». thoush
          1                                             more flexed.
chin;  in  other Avords,  must press down  the
occiput into the excavation.  But, by depressing this  part, the  chin is forced
to ascend, thus producing the flexion of  the'head.1
  1 In  order to prove that the movement of flexion  results  from the  position of the
occipital foramen, relatively to the  chin and occiput, which  represents the two extre-
mities of the lever  whereon the spine is articulated, let us suppose, for a moment, that
 
320
LABOR.
  The head being in this way forcibly flexed, its relations are changed
that is, the occipito-bregmatic diameter has taken the place of  the occipito-
frontal, and  has  become parallel to the left oblique of the strait; but the
bi-parietal remains unaltered : the occipito-bregmatic circumference is now
on a level with the periphery of the strait, and the axis of the pelvis, Avhich
before corresponded with the trachelo-bregmatic diameter, now traverses the
head very nearly in the direction of the  occipito-mental diameter.
  This movement of flexion, therefore, evidently places the child's head  in
the most favorable position for  its passage, by constraining it to offer its
smallest diameters to those of the pelvis.
  B. Second Stage, or Stage of Descent.—The  head, pressed on by the  con-
tractions,  enters  the  excavation  and  reaches the floor of the pelvis.  In
making this descent, the occiput  presses in front  against the internal and
anterior face of the body of the ischium,  the obturator internus muscle, and
the external obturator vessels and nerves, Avhich pass out through the upper
part of the obturator foramen; while the forehead or bregma presses behind
on  the internal  border  of the psoas  and pyramidal muscles, the sciatic
plexus of  nerves, together with the gluteal and  the  internal  pudic vessels
and nerves.   The left side of the head likewise comes into mediate relation
with the same parts, and also glides over the anterior surface of the rectum.
But the descent of the head is not completed until  the occipito-bregmatic
circumference is nearly parallel to the plane of the inferior strait:  that  is,
when the two parietal protuberances  have attained  this level.  Noav, it is
evident  that,  to  reach this point, the left parietal boss  (which is found
behind) must  traverse the Avhole anterior face of the sacrum, whilst the
anterior one has only to  clear a much  shorter space; the  first  must there-
fore describe the arc of a much  larger circle than the second.  Perhaps a
more  exact  idea of the  actual movement of the head will be formed by
imagining the anterior  extremity of the bi-parietal diameter to  remain
nearly stationary in front and to the right, Avhile its posterior extremity
descends rapidly and traverses the whole posterior plane of the excavation.
the vertebral  column is attached to the occiput alone, when it is evident that the latter
only will descend; on the  other  hand, let it be made to  the  chin, which will then
descend the first, and lastly let it be done at the centre of the interval  between  these
two extremes, and an equilibrium will  be  produced, the same as results from equal
weights or resistances  placed in  the  dishes  of a balance  having equal arms. But
where  the  articulation  takes place nearer one extremity than the other, the descent
will occur at  this extremity, just  as it would happen in the above-cited balance, if,
without altering anything else, the arms were rendered unequal in their length.
  To conclude, lest the foregoing should not satisfactorily explain the phenomenon, I
propose the following rationale: the  head, urged on by the uterine contraction, com-
municated to it by the spine, meets with resistance  from the os uteri, which is not yet
sufficiently dilated.  Let us change, for an instant, the order of forces, making the
vertebral articulation a fulcrum, and the opposition  on the part of the neck the power;
uow, this power is evidently equal in all points of the periphery of the neck; but let
us observe  that, as the interval  between the chin and the occipital foramen is greater
than that betwixt the latter and the occiput, the resistance against the chin operates
on a longer lever than that against the occiput, and consequently the first must be the
more powerful of the two, and therefore it forces the chin to ascend.  But raising the
latter has the same effect as depressing the occiput: that is, still  producing a flexion
»f the  head. 
                MECHANICAL  PHENOMENA OF  LaBOR.            321

   C.  Third Stage, or Stage  of Potation.—The head, being arrested by the
 floor of the pelvis, executes a movement of rotation, during Avhich the occi-
 put passes from left to right behind  the symphysis  pubis, or rather behind
 the left ischio-pubic  ramus, and the  bregma  rotates into  the concavity of
 the sacrum, though remaining a little towards the right.
   The posterior superior part of the right parietal bone then appears plainly
 under the pubic arch; the posterior fontanelle is behind  the ischio-pubic
 ramus;  and  the sagittal  suture  crosses  the coccy-pubal diameter very
 obliquely.  Being forced  on by the energetic contractions of the womb, the
 vertex then depresses the soft parts of the  perineum, and by gradually dis-
 tending them, succeeds in converting the pelvic floor into a part of a canal
 which prolongs the posterior Avail of the pelvis doAvmvards and backwards.
 It is during this time that the rotation is accomplished: that is, the sagittal
 suture becomes parallel with the antero-posterior diameter of the inferior
 strait.  The occiput  engages in the arch of the  pubis, and projects  beyond
 the lower part of the symphysis, until  the back part of the neck comes into
 contact Avith it, when the  anterior progression of the occiput is arrested.
   D.  Fourth Stage, or Stage of Extension.—Just at  the moment Avhen the
 occiput engages in this manner in the pubic arch, the shoulders and upper
 part of the body enter the  excavation, and  in engaging there, the fcetal
 trunk, which is flexible, accommodates itself to the  direction of the canal,
 and consequently bends over a little  on its posterior plane.
   [The head then presses upon the perineum, distending it and transforming it into
 a groove or gutter which conducts the occiput to the vulvar  opening, so that if the
 patient be uncovered the accomplishment of the fourth stage may be witnessed by
 the observer.  At each contraction the head descends and the perineum is elongated;
 then, as the pain subsides the perineum contracts, at the same time pressing the
 head a little upward.   Finally, during a fresh effort the vulva opens and the occiput
 shows itself beneath the arch of the pubis.  At this moment the head is still flexed,
 but soon the nucha seems to fix itself behind the pubis, and the head, by executing
 a movement of extension, escapes completely from the vulvar orifice, bringing suc-
 cessively into view after the occiput, the vertex, forehead, nose, mouth, and chin;
 the latter, which is the last to  emerge, remains applied against the  posterior com-
 missure of the vulva and directed toward the anal region.
  This movement has received Avhat seems to us a curious explanation, for, accord-
 ing to the commonly accepted  view, the pressure transmitted by the spinal column
 to the head is divided  at the  occipital  foramen into two forces, one of which is
 applied to the occiput,  and the other to  the chin.  Therefore, Avhen the  occiput is
 engaged beneath the pubic arch, the portion  of force Avhich is transmitted to it ia
 lost upon the point of contact  between the vertebral column and the posterior part
 of the pubis, whilst the force directed upon the chin continuing to act depresses it,
 causing it to depart from the breast and thus producing the movement of extension.
  Now, this explanation seems to us fallacious; for is it not evident that whilst the
 occiput is beneath the  pubic arch, all the  soft parts which make up the perineum
 press  the anterior part of the head against which they are applied upAvard and
 backward, so that the movement of flexion is, at this juncture,  at its utmost limit?
  Our OAvn vicAv of the  disengagement of the head is as follows:  The body descends
into the cavity of the- pelvis,  whilst  the head is depressing and distending the
perineum,  and the chin remains applied to the breast not merely until the moment
when the occiput takes its place behind the pubic arch, but even until the  bregma
makes its appearance at the posterior commissure of the vulva.   Then it is that the
       21 
322
LABOR.
perineum acts like an elastic splint which, on the one hand, presses the head up
ward beneath the pubic arch, whilst on the other it slips rapidly over the face which
it leaves uncovered, and retracts toward the coccygeal region where  it  is attached-
   The disengagement of the occiput and vertex begins only when the head jb pressed
downward sufficiently by the body;  but at this moment the perineum, which until
then was but passively distended, resumes its  action and  retracts as just stated,
imparting to the whole head, whilst slipping over the face, a movement of extension
which has the arch of the pubis for its centre.   Therefore, it is only  in this second
period of the process of disengagement of the vertex, that the movement of exten-
sion is truly evident.
   If the perineum were entirely absent, the head would disengage at the outlet of
the inferior strait, Avithout exhibiting  its movement of extension.  In  the normal
condition, however, and especially in primiparae, the perineum, converted into an
elongated gutter, arrests the downward progress of the head and directs it forward
as upon an inclined plane.
   Do Ave not also know that in breech  cases, especially in primiparae, the pelvic
extremity in emerging from the vulva is directed just as obliquely upward and
forward as the lateral flexion of the body will  allow?   This flexion,  which no one
will deny to be produced by the soft parts of the perineum, is, in our  opinion, suffi-
cient to prove that the movement of extension  in delivery by the vertex <is effected
only by the curvature and elasticity of the genital passages,  for,  if the movement
of the head  at  this  time is very extended, it should be attributed to the  great
mobility of the  articulations  which permits the occiput to rise up in front of  the
pubis.  In breech cases the same phenomenon occurs, though the extent of motion
is greatly restricted by the rigidity of the spinal column in the lumbar region.]

   Whatever explanation be accepted, if Ave observe Avhat takes  place during
                              this movement of extension, the following points
                              are seen successively to appear at the anterior
                              commissure of the perineum, viz., the bi-pari-
                              etal  suture, the bregma (or fontanelle), the
                              coronal  suture, the  nose, mouth, and, last of
                              all, the  chin.   During this  process, the sub-
                              occipito-bregmatic,   the   sub-occipito-frontal,
                              and the  sub-occipito-mental diameters succes-
                              sively pass the antero-posterior  diameter  of
                              the inferior strait.   As  soon as  the occipito-
                              bregmatic circumference is beyond  the vulva,
                              the anterior border of the  perineum,  yielding
                              to its  natural  elasticity,  retracts  strongly,
                              slips over  the face, and embraces  the neck;
                              and just at that moment the head, Avhich Avas
                              before forcibly turned up in front of the mons
                              veneris, falls back from its OAvn specific weight,
                              towards  the anus.
   e.  Fifth Stage, or  Stage of Exterior  Rotation.   (Restitution.)  —The head
remains for a few seconds in  this position,  and then it is seen to  describe a
fifth and last movement, namely, the occiput inclines  towards  the  internal
surface of the left thigh,  and the face turns tOAvards the right thigh.  This
process  is usually  denominated  the  restitution, for the following reason:
Before the researches of M. Gerdy,  it Avas generally supposed  that when
Fig. 77.
 The head is seen in various degrees
of extension, the nape of the neck rest-
ing first behind, and then under, the
symphysis pubis. 
MECHANICAL  PHENOMENA OF LABOR.
323
 the head executed  its movement of rotation Avithin the pelvis the trunk
 did not participate  therein, and that the operation  could only take  place
 through the aid of  a certain degree of torsion in the  neck; and, further,
 that the head becoming completely disengaged, the neck untAvisted, and the
 head was restored to its natural relations  Avith the trunk.
   M. Gerdy was the first to demonstrate  the faultiness of this explanation;
 for, in fact, the trunk does participate in the head's  rotation, in such a Avay
 that the shoulders,  Avhich, in  the beginning  of labor, corresponded  to  the
 oblique  diameter,  are  nearly transverse after this movement  (the right
 shoulder, nevertheless, remaining ahvays a  little more in front than  the
 left).  The shoulders then reach the inferior  strait in a transverse position,
 presenting, therefore, their great, or bis-acromial diameter, to the smallest
 one of this strait; but here they encounter some resistance, under the influ-
 ence of which the rotation  is effected in the opposite direction to that of the
 head; the right shoulder, passing  from the  right  side  towards the  left,
 approaches the apex of the pubic  arch, while the left one gets into  the
 perineal concavity,  and the head, being free externally, necessarily folloAvs
 the movement communicated to the shoulders.
   The rotation of the head is not therefore an  isolated movement peculiar
 to itself, as Baudelocque supposed, but one secondary to the rotation of  the
 shoulders.
   I must remark, however, that, in  some cases, the  head  has appeared to
 me to execute a double  movement;  for, immediately after its expulsion, it
 turns very slightly; the occiput passing a  little to the  left, the forehead
 tOAvards the right;  after remaining some seconds in this position,  it then
 undergoes the secondary movement just described, Avhich is due to the rota-
 tion of the shoulders.  The first of these movements has already seemed to
 me to result from the untwisting of  the neck, and is the true movement of
 restitution of Baudelocque.
   f. Sixth Stage, or  Stage of Expulsion of the  Body.—The shoulders present
 at the inferior strait soon after  the head, and, as we have just stated, nearly
 ahvays in a transverse position.  The right one gets  under the right ischio-
 pubic  ramus, while the  left one lies  in front  of the  left sacro-sciatic liga-
 ment.   The  bis-acromial  diameter is  rarely  found   in the direction of  the
 antero-posterior diameter of the inferior strait.  The anterior or sub-pubic
 shoulder is the first  to appear in the vulvar fissure;  although, as a general
 rule, the posterior one,  after having traversed the  perineal curve, is first
 disengaged  at  the anterior commissure of the perineum, and the right one
 is subsequently delivered.1
  1 Contrary to the generally received opinion, M. P. Dubois supposes that the anterior
 shoulder is the first delivered.  That is certainly true in  a great number of cases,  but
 we have most usually observed the opposite fact; besides, there is a theoretical view
 which militates in favor of our opinion, that is, the left shoulder, being placed in con-
tact with the posterior  plane of the  excavation,  is situated,  much more than the ante-
rior one, in the direction of  the uterine axis, or the axis of the superior strait, and
therefore being subjected to a  more energetic uterine impulse, consequently must be
delivered first; further, it was necessary  this should be so, as the posterior shoulder
has much the  longer course to traverse.  Again, if I might  refer to my own observa-
tions, I would say that  in women who have before borne children,  more especially in 
324
LABOR.
   During the disengagement of the shoulders, the foetus bt comts flexed on
 its right lateral region so as to accommodate itself to the curvature in the
 pelvic canal;  and very soon after the  remainder of the trunk  is expelled,
 sometimes describing a very prolonged  spiral course in  its passage.
   2.  Mechanism of Natural Labor in the right Posterior  Occipito-iliac Posi-
 tion.   (The fourth of Baudelocque, and the third of M.  Capuron.)
   In the vast majority of cases, the mechanism of labor in this position
 scarcely differs from that just described, and therefore we only need allude
 here to the principal peculiar phenomena of the travail, Avithout repeating
 all the preceding details.
   It, likewise, is composed of five periods, or stages ; before the membranes
 are ruptured, the diameters of the head correspond Avith the same diameters
 of the  pelvis, as in the foregoing case, and the only difference  to be re-
 marked  is, that the occiput  corresponds to the right sacro-iliac symphysis,
 and the forehead to the left ilio-pectineal eminence.   The child's posterior
 plane looks backAvards and  towards the mother's right, while  its anterior
 plane is in front and to her left;  its left side is placed in front and on  the
 right, its right side behind and to the mother's left.
   A.  First Stage, or Stage of  Flexion.—The head  is  flexed  by the same
 forces as in the preceding case, and this flexion determines similar changes
 in the relations of its diameters Avith those of the pelvis.
   B. Second Stage, or Stage of Descent.—This stage presents nothing  worthy
 of particular notice.
   C. Third Stage, or Stage of Rotation.—The head  having reached the floor of
 the pelvis, undergoes a movement of rotation, in consequence of which the
 occiput traverses the whole right  lateral moiety from behind forwards, in
 such  a Avay that it passes  successively towards the  right extremity of the
 transverse diameter, behind the cotyloid cavity and under the right ischio-
 pubic  ramus, Avhile the forehead,  or bregma, revolving in an  inverse direc-
 tion, goes from before backAvards  tOAvards the hollow of the  sacrum; and
 thus, the position which was originally occipito-posterior, becomes converted
 into an occipito-pubic, or anterior one, and  the labor then terminates just
 as it does in those cases where the occiput was primitively in front.
  [d.  Fourth Stage, or Stage of Disengagement. — This presents nothing peculiar.
  e.  Fifth Stage, or Stage of Restitution. — The  movement in this  case is entirely
 analogous to that already described in connection with the left anterior occipito-
 iliac position, and is due to the  same causes.   It is the left shoulder, however,
 which gets behind the arch of the pubis, and the occiput is directed toward the
 right thigh.
  f.  Sixth Stage, or Stage of Expulsion of the Body.— This takes place under the
 conditions already described.]
  Irregularities in the Disengagement.—In some  instances, which  are rare,
hoAvever, this conversion does not take place, and the  occiput remains be-
 hind until the termination  of the labor.   The delivery is  then concluded
 in the following manner: the head is  strongly flexed on the  chest, and re-

those who have suffered from rupture of the perineum in former labors, the posterior
Bhoulder is the first delivered; and, on the contrary, in  primiparae, the sub-pubic one
has the precedence, the other being retained by the resistance from the soft parts. 
                MECHANICAL PHENOMENA OF  LABOR.           325

 tains its oblique position ; the forehead, corresponding to the body of the
 left  pubis, first reaches  the  inferior strait, and  the left coronal  boss then
 engages  under the pubic  arch, where we  can sometimes  distinguish the
 superciliary ridge just below the symphysis; and I even saAv the upper eye-
 lid in one case.   But though the forehead first
 appears at the exterior, the occiput,  urged on by
 the spine, Avhich transmits the force of the uterine
 contraction, traverses the Avliole curvature of the
 perineum (which  is  greatly distended  in such
 instances), and becomes  disengaged  the first at
 the anterior  commissure.  While the occiput is
 thus passing over the anterior surface of the sa-
 crum and  perineum, the coronal  boss and eye-
 brow, that  originally appeared  at  the vulva,
 reascend and become concealed behind the sym-
 physis.
   The occiput  is scarcely  clear, when the peri-
 neum by gliding Over the inclined plane formed   Disengagement of the head in the
 by the nape of the neck, retracts strongly, and      occipito-posterior positions.
 thus facilitates the subsequent delivery of the anterior portions of the head ;
 therefore, the head may be observed to  undergo  the process of extension
 around the nape as a centre1,  and to appear below the symphysis in the fol-
 lowing order:  namely, the anterior fontanelle, the coronal suture, the fore-
 head, nose, mouth, and chin.
   Lastly, the head, placed in the right posterior occipito-iliac position, may,
 when once  down in the excavation,  depart from  the chest, and the vertex
 presentation be thus  spontaneously  converted into  one of the face, at the
 inferior strait; Ave witnessed a case of this kind at the Clinique in 1838.
   This transmutation  takes place,  says  M. Guillemot, in the  folloAving
 manner:  the occiput being arrested by some point on the posterior part of
 the excavation, instead of advancing along the perineum towards the inferior
 strait, ascends in the  curvature of the sacrum by executing the movement
 of rotation  backwards, and being at the  same time thrown back upon the
 posterior  part of the chest.   While this is going on, the forehead and face
 descend  behind the  pubis  and pass  doAvnwards  and backAvards, until the
 chin engages under the arch, and then the head, Avhich is completely turned
 back, traverses the perineal strait, as in a face presentation.
  The disposition Avhich the inclined plane of the cervix  uteri impresses on
 the vertex in this  position, continues M. Guillemot, is a, frequent cause of a
 similar transmutation  above the abdominal strait.  The slight backAvard
 inclination of the head, which ahvays exists in these positions, may correct
 itself when  the  uterine contractions, by acting on the foetus, keep the chin
 applied to the neck ; but, on the other hand, the reversion may be carried
 still further, or be entirely completed, if any obstacle impedes the  descent
 of the occiput into the excavation; finally,  in cases of  uterine obliquity,
 where  the inclination of the vertex  is greater,  the backward tendency,
 instead of disappearing, Avould be  increased, and the occiput Avould then
ascend and the forehead descend.
 
326
LABOR.
   Like the author  quoted, I admit the fact, though I think it rare; but ]
cannot acknoAvledge, like him, the truth of the folloAving proposition, i.e.
that if the conditions of transmutation which then exist may be appreciated
by a comparison of the face labors Avith those of the occipito-posterior posi-
tions, we  should not depart far from the truth (I believe it would be a wide
departure) by announcing that, in every three occipito-posterior positions,
one of them would give rise to a face presentation.
   Lastly, whatever may be  the mode of the delivery of the head in the right
posterior  occipito-iliac  position,  the occiput ahvays  inclines towards the
internal surface of the right thigh, and  the face is directed to the left one;
this external movement (restitution) results from the internal rotation of the
shoulders, in consequence of Avhich  the  left shoulder, Avhich was originally
the anterior, gets  under the arch of the pubis, and the right one into the
hollow of the sacrum, and then the shoulders and the remaining part of the
trunk are expelled in the manner already stated.
   Observations relative to the Mechanism of Delivery in Vertex Presentation.—
The great care avc have taken in  describing the natural  labor in these two
varieties of the two fundamental  positions, will absolve us from repeating it
anew in the other varieties.
   In fact, the left transverse occipito-iliac position  does not  differ from the
anterior one;  unless, perhaps, the movement of rotation, Avhich  brings the
occiput in front, is somewhat more extended; and what Ave have stated con-
cerning the tAvo modes of termination in  the right posterior occipito-iliac
position applies equally well to the left posterior one; but we must add that
the movements of rotation Avill then take place from left to right, since the
occiput is primitively turned towards the left side.
   Lastly, in the  other two varieties, the right anterior and the right trans-
verse occipito-iliac ones, the mechanism  is  still the same as in the corre-
sponding  varieties of the left occipito-lateral position, the occiput, hoAvever,
turning from right to left so that  the rotation occurs toward the right thigh.
   From  the foregoing, the  reader will see that,  in  order  to study the
mechanism of labor in the vertex positions, Ave have been obliged to con-
sider each of the periods, or stages, composing it separately.   Thus, Ave first
examined the  movement of flexion, then of descent, next the internal rota-
tion, the  extension, and the external  rotation; but it must not be supposed
that these different movements occur successively, one after the other, in
the order just  described.
   1. The forced flexion spoken of as happening  before the descent, frequently
only takes place simultaneously Avith the latter.  Often, indeed, the head is
not flexed until the descent is completed, and it encounters the resistance
from the floor of the pelvis ; and then only, in the majority of cases, is the
flexion carried to its  highest  degree.   We can  imagine that  this Avould
nearly always be the case, since the head  is engaged in the  excavation in
most women long before  the  commencement of labor ;  and even in those
cases where it is still above the superior strait at the time of the membranes
being ruptured, the presenting diameters will alloAV if to traverse the upper
part of the excavation without meeting any marked resistance.
   The movement of flexion likeAvise presents some irregularities: for instance, 
MECHANICAL  PHENOMENA OF  LABOR.
327
 it is not at all unusual, more especially in the occipito-postei\or positions,
 for the chin, instead of approaching the chest, to depart from it; and, con-
 sequently, for the head to become more  extended, and the anterior fonta-
 nelle gradually so get tOAvards the centre of the excavation.  HoAvever, this
 anomaly is  usually temporary, for the head is flexed aneAV Avhen it reaches
 the pelvic floor.
   In some rare  cases, the opposite of the preceding, the posterior fontanelle
 occupies the centre of the excavation, either  because the flexion has gone
 beyond its  usual limits, or else, because  the trunk is inclined backwards ;
 but here, also, the resistance from the perineum  gradually brings  back the
 head to its regular situation.   (P. Dubois.)
   2.  The rotation sometimes commences prior to the arrival of the head at
 the inferior  strait, and  before the descent is completed.  So that, in such
 cases, the three  first stages of the labor occur at the same time; thus the
 head is flexed, descends, and rotates all at once.
   Some curious varieties of rotation are occasionally met Avith, Avhich should
 be knoAvn to the student.  For  instance, it  may be incomplete, the head
 still retaining a great obliquity pending.the Avhole duration of its disengage-
 ment ; or it may not take place at all, Avhich happens, a's Ave have already
 seen,  in  certain  occipito-posterior  positions,  or it may  also  occur  in  the
 transverse ones.  In this latter variety, which is the rarest of all, the occiput
 and the forehead disengage alongside of the internal surface of the ischiatic
 tuberosities ; the occiput escapes first, and then the forehead by a movement
 of extension analogous  to the ordinary mechanism.  Madame Lachapelle
 reports having  observed three cases of  this kind.   In some exceptional
 instances, the rotation exceeds the ordinary limits : thus, for example, if the
 occiput is placed in relation Avith  the right sacro-iliac symphysis  at  the
 beginning of the labor,  it may successively correspond with the right extre-
 mity of the transverse diameter, the posterior face of the right acetabulum,
 the symphysis pubis, and the left cotyloid cavity;  and  then, after a moment
 of repose, it retrogrades and places itself once more behind the symphysis.
 M. V. Dubois originally pointed out  this  fact, and I have  twice since had
 an opportunity of verifying its truth.
   Again, the rotation, by Avhich the occiput  is brought  in front, sometimes
 only takes place just as the head is overcoming  the final  resistances from
 the soft  parts ; on one  occasion, I observed and  pointed out this fact, in a
 primiparous Avoman, to all the students then  present at the Clinique;  the
 child's head  Avas in  the right posterior occipito-iliac position, and  it had
 descended to the pelvic floor  and had cleared the  inferior strait Avithout
 rotation taking place ; the perineum Avas forcibly distended, the vulva Avidely
 dilated, the parietal  protuberances Avere engaged, and the occiput had but
 a few lines to pass over in  order to escape at  the anterior perineal commis-
sure ;  when, under the  influence of a neAV pain, the head  rotated briskly,
the occiput gained the front, the torehead simultaneously rolling  into  the
perineal concavity, and the labor terminated almost immediately.
   The rotation Avithin  the excaAration is certainly one of the most  curious
movements executed by the fcetal. head during the A\diole  process of a natural
 labor; indeed, from  what Ave have hitherto stated,  it must  be evident that, 
328
LABOR.
whatever be the primitive relations of the occiput Avith  the various  points
of the circumference  of the  superior strait, it finally succeeds in getting
under the symphysis pubis.1  Noav, the physical cause of this movement is
nowhere given in the Avritings that have been published on the subject prior
to M. P. Dubois, who  has  paid particular attention to this  point, and who,
after refuting the influence of the inclined  planes, advanced by the  older
accoucheurs, as the cause of the movement, adds, "This cause  evidently
resides in the  combination of a great number of elements, viz., on one hand,
the size, form, and  mobility  of the parts Avhich  are  expelled, and, on the
other, the capacity, the shape, and the resistance of the  canal traversed by
them; and  such is the influence of this association, that  the foetal  parts
place themselves in the most  favorable conditions for delivery;  thus,  if an
active resistance is made to them at one point, they Avithdraw from that, and
seek another where there is more space and liberty.  The mobility of the
traversing  parts, and  the  extreme  lubricity of those which are  traversed,
render all this very simple and intelligible.   In  fact, every accoucheur must
have  remarked that, in those instances  Avhere the sacro-pubic diameter is
contracted,  the fcetal  head, if obli.que before  the labor, constantly places
itself then  in a transverse direction, that is, in the one offering the  least
possible dimension to the shortened diameter; and this fact  is nothing else
than a very simple effect of those same causes,  of Avhich  the rotation,  Avhen
extensive, is a very complicated consequence."  (Journal des  Connaissances
Medico- Chirurgicales.)
  M.  P. Dubois further relates the following experiment in  support of his
explanation of the process of rotation :  "  The flaccid and voluminous uterus
of a woman, who  died soon  after delivery, was  freely opened near the os
uteri, and her foetus was placed in it near the soft, gaping  orifice, in the
right  posterior occipito-iliac position of  the vertex; then several midwife
students, by pushing the  child  from above  dowmvards,  caused  it to  enter
the excavation without difficulty ; but  it required a much greater effort to
make the head traverse the perineum and clear the vulva;  and it Avas not
without some  surprise  that Ave noticed, in three different  trials, that, as soon
as the head passed the external genital parts, the occiput was in  front and
to the right, while the face turned backAvards and to the left.   Again, we
repeated the experiment a fourth time; but  now the head passed the vulva,
Avith the occiput remaining posteriorly.   We then took  a still-born child,
delivered the preceding day, which was  much larger than  the  other, and
placed it in the same conditions as the first,  and on two successive trials the
head  cleared  the vulva after  having performed  the rotation ; on the third
and succeeding essays  it was disengaged  Avithout  executing  this movement:
that is, the  process of  rotation continued until the perineum and vulva had

  1 M. Naegele  has only known the occiput to disengage posteriorly  seventeen times
out of twelve hundred and forty-four occipito-posterior positions; and even in those
cases  it was always possible to appreciate the  exceptional circumstances that had
favored  this irregularity: such  as, an  amplitude of the pelvis, or numerous former
labors, lacerations of the perineum, or the  softness, flexibility, reductibility, and want
of consistence  of the head,  or an  extreme smallness  of the child,  the  presence oi
i twins, £c, &c. 
MECHANICAL PHENOMENA OF LABOR.
329
 lost the power of resistance that produced it, or which, at least, had deter-
 mined its accomplishment."   (Loc. cit.)
   I do not knoAv whether the explanations and experiments of M. P. Dubois
 Avill render the cause of rotation very simple and intelligible to every reader ;
 but, as to myself, I am constrained to admit that they describe and confirm
 the fact, but that they do not  explain it.   True, there can be no doubt that
 the cause of rotation is to be sought for  in the form  and direction of the
 canal, and in the shape and size of the foetal head; but let us see if it Avould
 not be possible to ascertain the influence of those divers  circumstances more
 precisely.
   The uterus is situated very  nearly in the axis  of the  superior strait, and
 therefore the sum of its expulsive forces,  or,  to speak more clearly, the sum
 of the contractions, may be represented as operating according to the direc-
 tion of its axis.  Now, supposing the head to be in the right posterior occi-
 pito-iliac position, the occiput, urged on by the uterine contraction transmitted
 by the spine, Avill descend in the line of its axis: that is, from above doAvn-
 wards,  and  from  before backAvards; and it will continue on until it is
 arrested by the resistance from the inferior and lateral parts of the pelvis,
 or from the soft  parts constituting the floor  of the perineum.  There it is
 arrested, provided  the resistance be considerable, and thenceforth  the occi-
 put must necessarily change its direction.  In fact, the resistance may be
 represented by a force operating in a direction perpendicular to the surface
 Avhereon the head strikes, and which  is applied  to the fcetal  cranium at its
 point of contact Avith the posterior plane  of the excavation.   This point of
 contact, in the case before  us, is evidently the right lateral and  posterior
 part of the head, Avhich strikes against some point in the hinder Avail of the
 excavation ;  the child's head, or rather the occipital extremity of it, is from
 that time subjected  to two different  forces, one  of which acts from above
 dowmvards, before backAvards, and slightly from left  to right (this is the
 uterine contraction); and the  other from  behind forwards, and a little from
 below upwards (this is the resistance,  or force, represented by^the perpendi-
 cular to the surface impinged upon  by  the head).   By representing this
 force derived  from the resistance, and that from the uterus  communicated
 through  the spine in the line of axis  of the superior strait by a parallelo-
 gram, Ave obtain a diagonal or  resultant from  these two forces that  points
 out the direction of  the movement that  is to take  place.  Noav, by con-
 structing such a parallelogram, Ave observe that  the occiput must evidently
 pass fonvards, downwards, and to the  right; since the diagonal or resultant
 of the forces is directed from behind forwards, from above doAvnwards, and
 from left to right.1
   The extent of this doAvnward  progress,  and the rapidity of its execution,
 are ahvays  proportionate to the energy and  duration of the contraction,
 and to the  resistance offered by the pelvic floor.  This also  explains Avhy

  1 In an article published in 1840, two years  after the appearance of my first two
 editions. Prof. Simpson  advanced  nearly the  same theory,  adding that no one had
before given a satisfactory explanation of  this  movement of rotation.  Though glad
to find my theory confirmed by that of the  learned Edinburgh Professor, I  am sorrv
to Iipve to remind him that my first edition was published in 1840. 
330                             LABOR.
the rotation, after being a long  time delayed, is sometimes suddenly and
completely effected during a violent pain; as' also Avhy, under other circum-
stances, and more particularly in those instances Avhere the pains are feeble
or short, this  movement only takes  place  gradually, and requires for its.
entire completion a much longer period and more numerous contractions.1
  Lastly, this theory enables us to  explain  those differences noticed  in the
rotation according to the part of the excavation Avhere it commences;  thus,
it has been stated that  usually the  process only begins  when  the child's
head reaches the pelvic floor;  indeed, this could hardly be otherwise, since
until  that period  the  head, from  being strongly  flexed, and  offering its
smallest  diameters to  those of the strait,  had  encountered no resistance
whatever from the osseous portion of the pelvic canal; but we  can readily
imagine that if the head be voluminous, the pelvis  rather small, the supe-
rior  strait too much  inclined, or  the uterus  too oblique,  the resistances
might be felt much sooner, and the occiput hardly have  entered the exca-
vation, before it would strike  against the posterior Avail  and be compelled
to follow the neAV direction impressed upon it by the resultant (diagonal)
of the forces.
  This  explanation accounts  readily for the absence of  rotation, and the
disengagement of the  head in the  posterior position.  What, according to
M. Naegele, are the kinds of cases in Avhich this exception has been observed?
We have already stated them: they are those in Avhich the large size of the
pelvis, the slight resistance of the soft parts, occasioned by previous labors
or ruptures of  the perineum, or else the small  size of the foetus, or the re-
ductibility of  its  head, permit  its  passage  through  the  canal Avithout en-
countering resistance, and, consequently, Avithout any alteration of  the first
direction of the uterine force by a neAV one.
  3.  The trunk participates, as we have  elsewhere stated, in the  rotation
of the head ;  this, hoAvever, may not occur; at least two cases reported by
M. P. Dubois  would seem to prove  as much.
  4.  The rotation of the shoulders after the head is delivered may also pre-
sent tAvo  opposite conditions;  that is, it may either take  place in a partial
manner or else not at all, the shoulders then disengaging transversely.  This
last circumstance is not very unusual, and,  in my opinion, clearly tends to
confirm the vieAvs of M. Gerdy on the process of rotation; for Avhen it does
not occur, the head undergoes  no rotation.  But the  latter  should ahvays
execute this  movement, hoAvever great the  immobility of the  shoulders, if
the process is a consequence, as Baudelocque supposed, of the untwisting of
the neck.

  1This movement  takes  place gradually, says  M. Naegele, in a slow spiral direction;
for if the vaginal touch be resorted to  during the pain, the small fontanelle, which was
originally directed to the right and posteriorly, will then be found to place itself alto-
gether to the right, towards the descending branch of the ischium: but, in proportion
as the pain diminishes, it returns step  by step to the place it occupied before.  Again,
if the finger be kept in contact with the head, the posterior fontanelle, which in the
absence of a pain  is wholly to the right, will be observed, during the latter, to  turn
forwards towards the obturator foramen, from whence it  again departs as  the pain
goes off; and it keeps up  these alternate movements for  some  time,  unt:i  finally il
becomes fixed opposite this foramen. 
MECHANICAL  PHENOMENA OF  LABOR.
331
  Sometimes, on the contrary, the same movement that rendered the shoul-
ders transverse before the delivery of the head continues after the expulsion
of this latter in such a A\ay, that the shoulder Avhich Avas originally anterior,
instead of retrograding toAvards  the  pubic arch passes behind, Avhile the
other  that Avas primitively posterior gains  the apex of this  arch, and the
face then turns towards the internal surface of the right thigh in the  right
occipito-iliac, and to the left thigh in  the left occipito-iliac positions.

  § 4. Inclined, or Irregular Vertex Presentations.
  Under the name of inclined, or irregular presentations of the vertex, Ave
have  designated those (page 311) in  Avhich  the sagittal suture, instead of
being  placed very nearly in the  axis  of the  superior strait, looks either to
the fore or hinder part of the pelvis, as Avell  as those in Avhich the forehead
or the occiput is placed  at the centre of the strait, in consequence of the
incomplete or exaggerated flexion of the head.  Baudelocque and his school
have  considered these as so  many distinct presentations, which they have
accordingly denominated the presentations of the side of  the head, or ear,
forehead, and  occiput; but  we  shall follow the example of Lachapelle,
Naegele, Stoltz, and P. Dubois, by including  them  all in the general  term
of vertex  presentations.  In fact, they scarcely ever impede the course of
the labor, and seldom  modify its mechanism.
  For example, let us take the first position (the left anterior occipito-iliac),
and suppose it to be  inclined on its anterior (right) parietal region;  then
the right parietal protuberance corresponds to the centre of the  strait, and
the sagittal suture looks toAvards the first bone of the  sacrum.   When the
contractions take place, the head Avill descend just as in a  natural position,
excepting that, upon its entrance into the excavation, or  during the first
half of the descent, it Avill  undergo a  movement of correction, in conse-
quence of Avhich the posterior parietal protuberance will describe an arc of
a circle around  the anterior one as a centre, and both Avill soon appear on
the same plane, and the labor terminate as usual.   Of course, this process
of correction Avould operate in the opposite direction if the inclination were
on the posterior parietal region instead of the anterior; hoAvever, the'  recti
fication is then much more difficult, owing to the direction of the expulsive
force, Avhich has a continual tendency to augment the  inclination.
  In  those cases where the flexion of  the head is incomplete, as  in the fore-
head  presentations of Baudelocque,  it will  become perfected  during the
descent, and the same  Avill occur Avhen  it is exaggerated (the presentation
of the occiput  of Baudelocque);  the forehead becoming loAver and lower.

  § 5. Prognosis.
  The vertex presentations are the most favorable of all, and this statement
will be more  fully verified Avhen Ave study the prognosis of the  other pre-
sentations.
  But the vertex positions are not all equally advantageous; and Ave may
lay it down as a general proposition that those in Avhich the  occiput is
turned towards some point of the anterior  half of the pelvis, at the begin-
ning of the labor, are more  favorable  than those in which  it  looks pos-
teriorly. 
332
LABOR.
  In  occipito-posterior positions, the head, in the early part of the labor,
generally remains quite high and less flexed  than Avhen the occiput is in
front, a fact shown by the difficulty then experienced  in  reaching the pos-
terior fontanelle.  The descent, also, is very sIoav, and barely complete until
rotation has brought the occiput in front.
  In the latter case, as hitherto demonstrated, the labor may terminate by
two varieties of mechanism which  are altogether  different from each other:
that is, the occiput either  comes in front, so as to get behind the symphysis
pubis, or else it remains posteriorly throughout the labor.
  Whenever the posterior position converts itself into an occipito-pubic one,
the very considerable extent of the rotation  then  demands a rather more
energetic contraction on the part of the womb than where the occiput was
originally nearer to the anterior arch of the  pelvis, and the labor is, there-
fore, somewhat more painful, though in general it is not serious.
  But  the expulsion  becomes particularly difficult when the head main-
tains  its primitive position, and does  not rotate, as Ave shall endeavor to
prove; though  first, let us establish as an axiom, the evidence of which no
one can deny, that whenever a straight and an inflexible trunk has to pass
through a curved canal, it will do so the more readily as the canal is  shorter
and less curved, or the trunk itself is the more diminutive.
  Noav, in the folded condition exhibited by the child's body in vertex pre-
sentations, the trunk, which represents the great  longitudinal axis, may be
divided into tAvo portions; one of which, constituted by the spine and the
inferior extremities, is flexible, and can accommodate  itself to the pelvic
curvature, and, therefore, its expulsion should offer no difficulty; Avhile the
other, corresponding to all the space betAveen the vertex and  the atloido-
axoid  articulation, forms  a straight, inflexible stem.   Noav, it is evident
that in the primitive occipito-anterior positions, or in the posterior ones,
Avhich afterwards become converted into anterior, that portion of the straight
inflexible stem Avhich the long axis of the  foetus represents, is reduced to its
smallest possible  dimensions, and  it only has to  traverse the shortest and
least curved part of the canal, I mean the symphysis pubis; Avhence one
extremity is clear at the inferior, while the other  is scarcely engaged at the
superior strait.   But does the same thing occur in those occipito-posterior
positions that remain posterior until the end of the labor?
  We  knoAv the  occiput, in  this  latter case, is the first to escape at the
anterior perineal commissure, and it therefore has to traverse all the front
surface of the sacrum and of the  greatly  distended perineum.  But as the
child's neck is not long enough to  thus measure the Avhole posterior Avail of
the pelvic canal, the  chest must  engage in the  excavation  soon  after the
head, and the latter, as a necessary consequence, must  be forcibly flexed on
the breast.  Owing to this forced flexion, the straight inflexible stem extends
not only from  the vertex to the  atloido-axoid articulation, but even to the
first dorsal vertebra, and it is, therefore, much longer than usual; yet more,
it has to traverse the  whole anterior face of  the sacrum prolonged by the
perineum, that is to say,  the longest and  the  most curved part of the pelvic
walls.
  Whence it is evident tha* the expulsion of the foetus in this case must be 
MECHANICAL PHENOMENA OF  LABOR.
333
much more tedious and  painful  than in the others; however, we cannot
admit that  the  delivery  is absolutely impossible.  M. Capuron, Avho still
professes this latter belief, supposes (the occiput remaining posteriorly) that
the labor can  only take place when the  foetal  head is unusually small, or
the pelvis very large; but this opinion is  opposed at the present day by too
great a number  of facts, to require us to refute the theoretical proofs  upon
which he relies.
  There  is yet another reason for the occipito-posterior positions being more
difficult than the anterior ones ; a reason  to which sufficient importance has
not, in my estimation, been attached: I allude  to  the mode  in Avhich  the
uterine contractions are transmitted.  Observe, in fact, when the occiput is
in front,  that these are  communicated to  it by the spine, nearly in a direct
line, Avhilst  they only reach it when this part is posterior at  the close of
labor, by describing a well-marked  curve, owing to the extreme flexion of
the head on the  chest.
  Hence, there  Avould be, as every one knows,  a  great  loss  of force; and
observe further,  that such loss coincides precisely with an occipito-posterior
position,  Avhich,  for the reasons before stated, occasions, of itself, still greater
difficulties in the delivery.
  Now, to have  demonstrated that the labor is longer and more difficult in
those cases in which  the  occiput  remains posteriorly, is, in effect, to prove
that it was at the same  time more dangerous both to the mother and child.
  In fact, it is in such  instances especially that  a rupture of the perineum
is to be feared ;  it being very difficult indeed to prevent such an accident;
it is then, also, those  central  lacerations of the  perineum are  apt to take
place, in  which the posterior commissure of the vulva  and the sphincter ani
remain intact, Avhile the foetus forces a way for itself through the distended
perineum.
  Such, indeed,  is the effect of the length of* the straight stem represented
by  the fieiits, and of the length of the curve represented by the canal, that
in order  to accomplish  expulsion  it  becomes  necessary either: 1.  That
the straight  stem should break, or bend, so as to accommodate itself to  the
curvature of  the  canal,  Avhich is impossible;  2.  That  the  curved  eanal
should be straightened out; 3. That the Avails of the  canal should be rup-
tured ; 4, or finally, that the delivery should become impossible.
  Happily, in the majority of cases, the soft parts Avhich form the continua-
tion of the  posterior Avail, allow  themselves  to  be straightened out;  but
when they resist, nothing but their rupture can  alloAV of a spontaneous
delivery, their considerable thickness affording the only explanation of the
rarity of this accident.1
  The  head, by remaining  a long time in the  excavation, compresses  the
neighboring parts, thereby giving rise to retention  of  the urine, to eschars,
and to urinary or stercoral fistulse.
  And apart from all these inconveniences, it is  Avell known that the  labor
cannot be prolonged without danger; that the Avoman becomes fatigued and
sxhausted, and that the child remains compressed and painfully flexed.
  1 For an idea of  the resistance sometimes presented by the perineum, see the article
in the fifth part  of the book, on The Application of the Forceps in Occipito-posterioi
Positions. 
334
LABOR.
  It has ahvays seemed to me that in occipito-posterior positions, the left
one is attended Avith much greater trouble than the right, the engagemen*
of the  head being  generally more difficult, and its rotation much slower.
Quite often, indeed, the occiput remains behind, preventing, in first labors,
a spontaneous delivery, besides rendering much more difficult the  applica
tion of the forceps, Avhich then becomes necessary.
  Whenever a fcetal head is examined, just  after its delivery in a vertex
position, there is always to  be found a more or less considerable tumefaction
on  some point of the vertex, provided the labor has lasted long after the
membranes were ruptured; and the size of this tumor bears a direct pro-
portion to the more or less  rapid progress of the labor.  Its seat is so con-
stant that it is easy to determine  in Avhat position the child Avas born by a
simple inspection.
  For instance, Avhen the occiput escapes under the  pubic arch, the tumor
is  always located  on the  superior posterior  angle  of one of the  parietal
bones, i.e. on the right parietal in the left occipito-iliac, and on the left one
on the right occipito-iliac positions; and in those rare cases, Avhere the occi-
put is disengaged posteriorly, it is usually situated about the centre of the
vertex, often indeed  on the anterior  fontanelle; in a Avord, it is mostly
developed at the point Avhich corresponded originally Avith the os uteri, and
subsequently Avith  the void under the pubic  arch.   The mechanism of its
production is very easily  understood, for  the Avhole circumference of the
head is strongly compressed, leaving only a single point corresponding to
the void in the pelvis or arch, which is not subjected to that pressure, and
which must, therefore, become  the seat of a sero-sanguinolent infiltration,
just in the same Avay as the skin  does, when, by the application of a cup-
ping-glass  and the creation of a  vacuum, it  is thereby protected from the
atmospheric pressure that operates on every other part of the body.
  This tumor, when large, is the result of a slow and  painful labor; it is
always  single; and may be distinguished from  the cephalffimatoma, Avith
which it was for a  long time confounded, by the folloAving characters: the
former (or the tumefaction caused by labor) is  irregularly circumscribed,
whilst the  limits  of the latter are very distinct; in the former, the hairy
scalp  is of a well-marked  violet color, the tumefaction has an cedematous
consistence, retaining the impression of the-finger,  and is not fluctuating,
Avhilst the skin of the cephalrematoma is colorless, presenting a Avell-marked
fluctuation, occasionally even some pulsations, and  its  base is limited by
a  prominent  osseous  border;1 in some instances, hoAvever, this border
is  not  developed for  several  days  after  the  commencement of  the dis-
ease;  but the pulsations and the border  are never met Avith in the  other
variety.
  Lastly, the semi-sanguineous oedema of the cranium in neAv-born children
appears immediately after  birth,  and disappears in from twelve  to forty-
eight hours; but the  cephahematoma, on the contrary, though it may exist
at the  moment of birth, scarcely  ever appears until some hours after  the
delivery, and then  lasts for several weeks.
  1 This border is not always  present  at the beginning of the disease, sometimes not
making its appearance unti after several days. 
               MECHANICAL  PHENOMENA  OF  LABOR.    •      335

   Dr. Fortin relates that he Avas able, in one instance, to detect the presence
 Df a cephalhematoma  as  large  as a  pigeon's egg, before the labor Avas ter-
 minated ; and a similar statement has been made by several authors.
   The sanguineous  tumor just spoken of does not exist when the foetus dies
 prior to or during the labor, and before the membranes  are ruptured ; the
 inferences Avhich the medical jurist can draAV from this fact in cases  where
 it  is desirable  to fix the period of death of a neAV-born child, are clearly
 obvious.
                          ARTICLE  III.
                  ON THE PRESENTATION OF THE  FACE.
   It may happen Avhen the cephalic extremity presents at the superior  strait,
 that the head is not only extended, but also turned back toAvards the  poste-
 rior plane of the child, Avhich situation constitutes a face presentation,  Thii
 presentation is very rare ; thus, it has been ascertained, from the most numer-
 ous statistics, that  the foetus presents by the face, on an average, once in tAvo
 hundred and fifty to three hundred labors.
   We have admitted  tAvo fundamental  positions for this  presentation;  in
 one of which, the chin looked toAvards some point on the right lateral half
 of the pelvis, the right mento-iliac; and in  the  other, it Avas directed to one
 of the points on the left lateral half, the  left mento-iliac position; and Ave
 may repeat for  the face what Avas said concerning the vertex presentations,
 namely, that there is no portion of the circumference of the superior strait
 with which  the chin may not be in relation  at the commencement of the
 labor; nevertheless, we shall  include  all these shades  of position in the
 three principal varieties  for each side ; that is, for each fundamental one,
 we have the anterior, the transverse, and the posterior varieties,
   The right mento-iliac positions are somewhat mo^e frequent than the left;
 about in the proportion of thirty-one to forty-one, if we may judge from the
 statements of Madame Lachapelle.   The transverse variety is rather  more
 frequent than the right posterior one, Avhich  has  been considered erroneously
 as the most common.
   The face presentations are either classed as primitive or secondary, accord-
 ing to Avhether they existed before the commencement of labor, or Avere the
 result of ill-directed contractions.  In fact, the latter have generally been
 considered as the  more frequent of the two; but Ave shall have occasion  to
 sIioav the value of this supposition hereafter.

   § 1. Causes.
   The obliquity of the Avomb, according to most authors, is the cause of face
 presentations, though all of them do not interpret its influence in the same
 manner.   According to Deventer, if the Avomb be inclined to the right side,
 and the vertex be  placed in the left occipito-iliac position, the contractions,
 taking place in the direction  of the uterine axis  after the membranes are
 ruptured, will force the foetus  from  above doAvmvards, and from right  to
left, so that the vertex Avill  strike against the  left border of the superior
strait, and the  head, being  thus arrested, will  be  thrown back  upon the
posterior plane  of the  child.   Baudelocque,  though admitting the  right 
336
LABOR.
 uterine obliquity, supposes that a right occipito-ilial position of the vertex
 exists at the same  time;  for, says  he, a face presentation  is scarcely ever
 observed, without the obliquity of the womb being on the side Avhich corre-
 sponds to the occiput.   In  this instance, the foetus  is lying on the right
 lateral wall of the Avomb before the labor sets in, and the head, obedient to
 its own specific weight, departs slightly from the  chest; but when the con-
 tractions manifest themselves after the rupture of the membranes and the
 discharge of the waters, the direction of the forces transmitted to the head
 is such that, instead of falling on the occiput, as  they would Avere the head
 flexed, they are spent on  the forehead, and tend to force  it down; but a
 depression of the latter compels the occiput to ascend:  that is, causes an
 extension of the  head.
  The reader will perceive that all these explanations suppose that the face
 presentations are uniformly  the consequence of  de\Tiations from a vertex
 position; but this, hoAvever, is not ahvays the case, for the face may often
 present directly at the superior strait, even before the  commencement of
 the  labor  or the rupture of the amniotic sac.   For instance, Madame
 Lachapelle, Avhen making an autopsical examination of tAvo Avomen  who
 died at full term, found the foetus presenting by the face; moreover, of the
 eighty-five face presentations collected by  the authors of the Dictionnaire
 de Medecine, forty-nine had been clearly made out, and announced as such
 before the membranes Avere  ruptured ;  and  further, of those eighty-five
 women,  there Avere but  three in Avhom the  uterus was in a  state of well-
 marked obliquity, and only one Avhere the quantity of the amniotic liquid
 Avas so great as to attract attention.  Whence the conclusion is evident from
 these and many other facts, that the face presentations, in the great majority
 of cases,  are not determined by a previous inclination of the foetus, nor by a
 Avrong direction of the uterine contractions, but that they are primitive, and
 produced by causes Avhich  are beyond our knoAvledge.
  The reason for the greater frequency of the right mento-iliac position
 must evidently be OAving, Avhen secondary, to the  greater frequency of the
 right lateral  obliquity that produces it.  There are several causes, according
 to Madame Lachapelle, which contribute to render the transverse positions
more common than the others: as 1, the form of the superior strait and the
length of its diameters,  Avhich correspond better in this direction with those
 of the face; 2, the frequency of oblique or transverse positions, which, Avhen
the head falls back, evidently give rise to transverse positions of the face;
 3, the frequency  of lateral obliquities of the uterus, or partial  ones of the
child, if,  as Gardien admits, the foetus can be oblique independently of the
Avomb.

  § 2. Diagnosis.
  [Palpation of the abdomen affords very little  assistance in the diagnosis of face
presentations.  It will inform us, indeed,  that the greater axis of the foetus is in a
longitudinal direction, and we may, perhaps, feel the head to be in relation with the
pelvic opening; but how can  we knoAv whether it be flexed or extended?
  The results of auscultation in face presentations are also less precise than  in
those of the vertex, so much so indeed that M. Depaul *ays it were too much to ask
 that it should enable us to distinguish between them.   It is, however, well enough 
MECHANICAL  PHENOMENA  OF  LABOR.
337
to ben in mind M. Devillier's observation, that as the face engages less easily than
the vertex, the maximum intensity of the cardiac pulsations may be heard atone
of those points of the abdomen where they are commonly discovered in vertex pre-
sentations  Avith obstruction at the superior  strait.  It may, therefore,  lead to a
mistake of which it is well to be forewarned.
  Having determined that  the face presents, if we  resort to auscultation in order
to diagnose the position, the folloAving facts should  be borne in mind:  When the
head is so forcibly  thrown  back that  the occiput touches the upper part of the
back, the entire trunk of the  foetus inclines towards its anterior plane, whilst the
vertebral column has a strong backward direction.  The sternum of the child,
therefore, approaches the uterine Avail Avhilst the back recedes from it, so that the
maximum of the pulsations  of the heart is no longer  transmitted to the stethoscope
through the vertebral but through the sternal region; in a right mento-iliac posi-
tion, therefore, the maximum  sounds of the heart will be heard toward  the right
side. |
  By the touch  only, can the diagnosis be made Avith certainty. Before the
membranes are ruptured, the head in  general is  high, and difficult of access,
so that it  is almost impossible to reach the presenting portion,  provided the
membranes are the least tense.   Again, the reversion of the head not being
yet completed,  the forehead is the  lowest  part, and the  one the finger
encounters in performing the  touch ; Avhence, by feeling  a hard, rounded
body  furroAved  by  a  membranous  interval (the coronal suture), Ave might
very  readily mistake it  for  a vertex presentation.   But if the  flaccid
and  folded  membranes  can  be   depressed without  difficulty,  or, still
better, if  they have been recently ruptured, the diagnosis becomes easier.
Then Ave  find towards one side of  the pehds a rounded, solid surface, the
forehead,  traversed  by a  suture leading to a transverse  depression ;  next a
triangular elevation Avhose base, looking  in  an  opposite direction from the
forehead,  exhibits tAvo  openings, the  nares, and beyond this, a transverse
fissure bounded  by the superior and inferior maxillary arches.   Sometimes,
the finger, Avhen introduced  into the  mouth of  the child, has  been, clearly
sensible of an effort at suction.   On the sides of the median protuberance,
two little  soft tumors (the eyes) are felt, surrounded by an osseous  circle;
and lastly, Avhen the head is low doAvn, an ear may be detected behind the
pubis.  AVhen  the presentation is  once  determined, the position  is  easily
made out, for the opening of the nostrils  must evidently look  toAvards that
part of the pelvis Avhich corresponds with the chin.  When a long time has
elapsed after the rupture  of the membranes, neAV causes of difficulty are met
with.   Thus, the face,  Avhich  noAV  corresponds  to the open space  in the
pelvis, becomes  the seat of a  considerable  tumefaction, due  to  the same
cause  which produces the tumor of  the scalp in  vertex  presentations.  The
checks, being greatly swollen, and at the same time compressed on the sides,
project, and  lie  close  to  each other in front, thus  leaving a deep fissure
betAveen therein the bottom of Avhich the distincth'e characters of the face
are entirely concealed; this fissure  might verv  readily be mistaken for the
one between the nates, which are then confounded Aviththe tumefied cheeks.
Further, the lips are also swollen, Avrinkled, and everted, in such a  manner
as to offer a rounded orifice instead of the usual transverse fissure, and this
orifice has been mistaken, in some  instances, for the anus; hence, in such
       22 
338                             LABOR.
cases, a careful examination seems to be necessary to avoid an error Avhich,
according to authors, has not unfrequently been committed.

  § 3.  Mechanism.
  We  shall follow the example of Nsegele, Dubois,  and Lachapelle,  by
taking one of those varieties, in Avhich the chin looks toAvards one extremity
of the  transverse diameter, as the type in our description of the mechanism
of natural labor by the face, and shall commence Avith the right mento-iliac
  1. Mechanism of Natural Labor  in the right  Transverse  Mento-iliac Posi-
tion.— Before the  membranes are ruptured, the head, as a general rule, is
but moderately extended,  Avhence  the  forehead is nearly always placed at
the centre of the superior  strait; the chin  corresponding to the right, and
the bregma to the left extremity of the transverse diameter.   The diameters
of the  head hold the following relations to those of the pelvis:  the mento-
bregmatic  corresponds to  the transverse  diameter of the pelvis; the  bi-
temporal to the antero-posterior one, and the mento-bregmatic circumference
is parallel to the periphery of the superior strait; and, therefore, the pelvic
axis traverses the head in the direction of the occipito-frontal diameter.
  The  posterior plane of the foetus looks directly to the mother's left, and
its anterior plane to her right; its right  side is in front, and the  left one
behind.
  Early in the labor, the bag of waters projects into the upper part of the
excavation, to an extent proportionate  to the dilatation of  the orifice; and
its rupture generally takes place suddenly during a contraction, Avith con-
siderable noise.  The  rupture  is folloAved by the escape of a large amount
of amniotic fluid, and the  foetus, which \vas before so high as to  be felt Avith
great difficulty, descends, and renders the diagnosis more easy.
  As soon  as the membranes are ruptured, the mechanism  of the expulsion
begins, and here, as in the case of the vertex,  it is composed of six stages:
i. e., the forced extension, the descent, the,rotation, the  flexion or disengage-
ment, the external  rotation, and the expulsion of the body; these comprise
the movements Avhich  the head undergoes in face positions.
Fig. 79.                                         Fig. 80.
Fig. 79 The face in the right transverse mento-iliac position, after the forced extension.
Flo. 80 The face in the same position, though more fully engaged. 
               MECHANICAL  PHENOMENA OF  LABOR.            339

   A. First Stage.   Forced Extension. — The head being already moderately
 extended on the back, its extension will be completed during the first uterine
 contractions that take place after the  discharge of the Avaters,  OAving to the
 resistance it will then  meet Avith.  This forced extension of the head changes
 but very little the  relations  of its diameters to those of the pelvis (Fig. 80);
 for instance, the fronto-mental has taken the  place of the mento-bregmatic,
 and is noAV parallel to the transverse diameter of the strait; the bi-temporal
 has not changed at all;  the facial, or fronto-mental circumference corre-
 sponds with the periphery of the superior strait,1 and the pelvic axis traverses
 the head in the direction of  a line passing from the posterior fontanelle to
 the child's upper lip.
   B.  Second Stage.   Descent. — As  soon as the  head is freely  extended, it
 engages in the excavation, and descends as far as the length of the neck will
 permit.  This  last sentence requires a  short explanation.   In- the vertex
 positions, we have  already seen that the head descended to the floor of the
 pelvis in such a Avay as to traverse  all  the space betAveen the superior  and
 inferior  straits, Avithout changing its position.  But in the transverse  posi-
 tion before us, it is clearly evident that the  face can only reach the pelvic
 floor under one of the folloAving conditions: that is, either  the  chest  will
 engage along Avith  the head  in the excavation, or else it will  remain above
 the superior strait; the  face descending alone  as far as the inferior  one;
 that is to say, the forehead reaching the level of the left, and the chin that
 of the right tuber ischii; but then the neck must necessarily elongate enough
 to measure the Avhole  length of the pelvis at its lateral  portion, which is
 three inches and three-quarters.   But as neither of these two  conditions can
 be  realized, the head Avill  not be able to reach the pelvic floor; and it is for
 this reason that Ave say the face only descends as far as the length of the neck
 will permit; whereby the descent is interrupted.
   c. Third Stage.   Rotation.  —The head then undergoes a movement of rota-
 tion, during Avhich the chin  rolls from  right to left, so as to get behind the
 symphysis pubis, Avhile the  forehead  rotates from  left to right, and from
 before backwards, in order to place itself in  the  concavity of  the  sacrum.
 When this movement is effected, the descent  becomes completed; for the
 shortness of the neck,  or the too great extent of the ischium, formed hereto-
 fore the sole obstacle; if, therefore, by the process of  rotation, the neck,
 which can  be  no further stretched, is brought into apposition Avith a part
 of the pelvic Avail short enough for it  to span its  Avhole  length, the descent
 may evidently  be completed: that is, the breast  still  remaining  above the
 superior strait, the  chin may descend as Ioav as the inferior one, and this is
 precisely Avhat does take place;  for, as  the trunk participates in the rotation
 of the head, the neck gets  behind the symphysis  pubis at  the same time
 that the chin reaches the loAver edge of this symphysis, which is short enough
 to allow  the A*eck to subtend its whole length.

  1 M. Niegele further supposes that the face is inclined  relatively  to the superior
strait, and that the  anterior cheek is the most dependent part, &c. The reasons upon
which our objections were founded to such an inclination in the  vertex presentations,
oblige us also to reject it in the positions of the face, for we believe that the facial
Rircuniferenj i is most usually parallel to the plane, as stated in the text. 
340
LABOR.
  D. Fourth Stage.  Flexion. — The process of flexion begins as soon as tne
descent is achieved; indeed, we may remark that, Avhen the  chin passes
behind the symphysis pubis, the forehead goes into the holloAV of the sacrum,
and  it therefore has to traverse, in order to arrive at the inferior strait
simultaneously Avith the chin, the Avhole anterior face of the sacrum, that
is, about five and a quarter inches, Avhilst the chin only descends the length
of the symphysis, or one and a half inches; in a Avord, this is found just in
the same condition as the posterior extremity of the bi-parietal  diameter in
vertex presentations; and, like it, the  forehead  has to describe an arc of a
circle around the chin  as  a centre.   Now, this arc  cannot be described
without a certain  degree of flexion of the  head.  Whence it appears that,
in this transverse position  of the face, the descent is completed  at the same
time  that the rotation is taking place, and the process of flexion beginning.
  If the relations of the diameters of the head to the inferior strait  be then
examined, we shall find  that the same ones are  concerned as  at the begin-
ning of the labor, before the complete extension had occurred ; thus, the
mento-bregmatic corresponds to  the antero-posterior  diameter, the bi-tem-
poral to the transverse, and  the axis of this strait passes through the occi-
pito-frontal diameter: and  thus  it should be; since, by the commencement
of flexion, the head is replaced in the  state of semi-extension it had when
the labor began.
  The chin, under the influence of the uterine  contractions, next engages
beneath, and continues passing under the  inferior  part  of the symphysis,
until the fore part of the neck comes into apposition with the posterior sur-
face  of the pubis; then the upper part of the thorax engages in the  cavity,
and the upper portion of the back presses strongly against the occiput: the
occiput is depressed, and the head thereby compelled to complete its flexion
or disengagement.  Of course, the perineum becomes greatly distended, and
                            the forehead, the bregma, the vertex, and the
            FlG-81-            occiput, successively appear before its anterior
                            commissure.
                              During the process  of flexion, the prse-tra-
                            chelo-frontal, the prae-trachelo-bregmatic, and
                            the prse-trachelo-occipital diameters, clear in
                            turn the  antero-posterior one of the  inferior
                            strait.
                              e. Fifth Stage.  Restitution.—This differs in
                            no wise from the external rotation described by
                            the head in the vertex presentations; for here,
                            also, it is  a consequence of the movement exe-
                            cuted by the shoulders, in order to place them-
                            selves in  the direction of the antero-posterior
                            diameter of the strait.
 Various degrees of the disengagement
jf the head (in the same position), the
occiput departing more and more from
the shoulders.
                              [f. Sixth Stage.  Expulsion of the Body.— This
                            occurs as in cases of vertex presentation.]

  In addition to the  above, the  mechanism  of face labors sometimes  pre-
sents  a variety, which Ave purposely omitted  for fear of  interrupting the 
MECHANICAL PHENOMENA OF  LABOR.
341
tegular description ;  thus, Ave stated, that the head completed  its extension
and descended, but that this movement  of descent was  interrupted by the
rotation ; ».fter which the descent Avas completed, and at the same time the
flexion begun.   Noav all the difference rests on this last point; for in prac-
tice a considerable number of cases, more  particularly of  the  mento-poste-
rior positions, are met with, in AA'hich the following phenomena are observed:
the second movement, or the descent, actually commences, but  is checked
by the shortness of the child's neck.   Then a certain degree of flexion takes
place before the rotation occurs,  in consequence  of which  the  forehead de-
scends to the pelvic  floor, and the  mento-bregmatic diameter  places itself
aneAv parallel  to the transverse  diameter of the excavation; then the pro-
cess of rotation occurs, Avhich carries the  chin behind the symphysis, and
the labor terminates in the manner just indicated.
  2. Mechanism of Natural Labor in the  left Transverse  Mento-iliac Posi-
tion.— In this position, the expulsion of  the foetus takes  place  in. absolutely
the same manner as in the preceding case.  Only the chin, as well as the
anterior plane of the child,  is to the left; and hence  the movement of rota-
tion occurs from left to right instead of right to left,  but all the  rest is pre-
cisely similar.
  The same is  also true of the tAvo varieties denominated the right and the
left anterior mento-iliac positions.   The tAvo  other varieties (the right pos-
terior, and the  left  posterior  mento-sacro-iliac) exhibit an identity of
mechanism in  a Arast majority of cases: that is to say, the  head,  having
reached a certain  depth in  the  excavation, then undergoes the  process of
rotation, Avhich converts the position into  a mento-pubic  one; indeed, the
necessity for this movement is far more evident here than in the mento-trans-
verse positions, since the depth  of the pehds is much greater behind than
on the sides.
  It may, therefore,  be laid doAvn as a general, nay, as an almost absolute
rule, that, in the face positions, Avhatever may have been the relations of the
3hin with the circumference of the superior strait at  the commencement of
the labor, there must be a process of rotation, whereby the chin is brought
under the symphysis pubis, before the labor can  terminate  spontaneously.
The necessity for this rotary movement may be readily  understood.  In
order that delivery may be accomplished Avith  the face presenting, it is abso-
lutely necessary that the chin should reach the inferior strait; noAV, in the
extended condition of the head, the chin  cannot reach this  strait, except the
neck be capable of measuring the depth of that  portion of the Avail of the
pelvis  to which it corresponds.   If, therefore, the symphysis  pubis be the
only part of the pelvis which is  short enough to alloAV the  neck to measure
its depth, it becomes indispensable that  the chin should  be turned forward.
  In the numerous A'arieties of this position before admitted, the mechanism
of the labor only differs in the greater or the less extent of the  process of
rotation ; an extent evidently varying according to the point with which the
chin was primitively in relation  to the upper  strait.
  Remarks.— Nevertheless, the mechanism of the face positions occasionally
offers some  anomalies, that require a more special  notice.
  1.  The rotation just described, whose object is to bring the chin constantly 
342
LABOR.
towards the symphysis pubis, and which has been spokei  tif as absolutely
essential to the spontaneous termination of the labor, may  not be executed.
But such very rare exceptions do not in the least discredit  the general prin-
ciple before laid down, for they may all be referred to those instances Avhere
the dimensions of the head are small relatively to  those of the pelvis;  or
else to those cases in AA'hich the position of the face has been spontaneously
converted into one  of the vertex.  True, Madame  Lachapelle has  known
the face to escape from the vulva  in a transverse direction, or nearly so, in
two or  three  instances;  but she  carefully adds that they were very rare
exceptions.
  Now, to understand this movement of rotation, it is only necessary to
recall our remarks  concerning the mechanism of labor; thus, it  has been
shown that the descent could not be completed  in the transverse positions,
until the chin has turned toAvards the  pubic symphysis; and further, that
when the head is extended, the resultant of the forces transmitted by the
spine falls very nearly on the chin, and tends to engage it still more.  Well,
in this situation, the  expulsive force is either perpendicular or oblique to
the plane of the resistance; if the former, the uterine efforts are lost, since
they do not contribute in any Avise to the progress of the labor; but, if the
force is oblique to  the resistance, it is so  either from before backAvards, or
from behind forwards.  In the former case, it will have  a tendency to carry
the chin  backAvards; but a movement of this  kind will not  aid in the
engagement of the  chin, since the  pelvic wall is much higher nearer the
median line; and hence  the efforts are still lost.
  In the latter, on the contrary, the oblique force, by operating from behind
forwards,  tends to carry  the chin in front: that is, towards a portion of the
pelvic wall, Avhich becomes shorter and  shorter as  it advances anteriorly,
and thus facilitates the descent.
  But, after all, Avhat is the direction of the uterine force?   Everybody
knoAvs that it  changes at each instant; according to the Avoman's position,
or the poAver of the contractions, the womb may be  successively found in all
three of the directions above indicated, relatively to the resistant plane.  If
it is perpendicular to that plane, the efforts  are lost;  or, if oblique, from
before backAvards, the contractions are useless ; they can only be fully effica-
cious Avhen acting on  the chin from above dowmvards, and from behind for-
wards.  But far be  it  from me to attribute an intelligent force to the uterus;
for it is only by groping along, so to speak, that the womb finally acquires
a proper  direction, though, when the impulsion  is once  given, the force
becomes more and more oblique, and consequently more active.  And it is
those gropings (excuse the term) which at times render the rotation so diffi-
cult and so tedious.
   It has been asserted, of late, that the process of rotation is quite as easy
in the mento-posterior as in the mento-anterior positions.   Now, if I have
succeeded in making my vieAvs of  the cause  and mechanism  of this move-
ment understood, the reader Avill readily comprehend that, in proportion as
the chin is turned  backAvard, and more especially if towards  the right at
the same  time, the  greater Avill be the difficulty of its accomplishment, since
the resultant of the uterine forces becomes nearly perpendicular to the plane
Df resistance. 
MECHANICAL PHENOMENA OF LABOR.           3<i3
  2.  As regards those varieties in which the chin looks backwards, we have
already stated that it  is necessary this part  should come round in front,
though some cases of mento-posterior positions, that terminated  spontane-
ously, are found in the books, where the chin did not  get under  the pubic
arch; Avriters differ in their explanations of this anomaly.  M. Velpeau takes
as an illustration the mento-sacral variety, or the second position of Baude-
locque, in Avhich the chin is turned toward the anterior face of the sacrum
(though Ave  may observe, in  passing, that this  position  is scarcely admis-
sible) ; and  he remarks that, as the chin does not rotate in front, the folloAV-
ing phenomena may then take place:  the forehead engages behind the body
or  the  symphysis  of  the pubis,  while  at the same time  the chin gets
below the sacro-vertebral  angle.  The Avhole head descends into the excava-
tion beyond the anterior fontanelle for the anterior plane, and the face drags
after it the  front surface of the neck, and even the upper part of the chest
behind. The occipito-mental diameter, Avhich still represents the axis of the
strait very nearly, now begins to  perform a see-saAv  movement from above
downwards, and from behind  forwards.  The chin, penetrating further and
further  towards  the bottom of the excavation, though at the  same time
retained by  the thorax, Avhich cannot advance, forces the sagittal suture to
slip  down behind the pubis, and the forehead to gain the upper part of the
inferior strait.   The frontal protuberances soon find a point of resistance
on the perineum, and  the posterior fontanelle descends  in  turn, and ulti-
mately appears at the summit of the  arch, Avhen the  head finally escapes
from the vulva as it would in an  occipitoanterior position:  Avhence  it fol-
lows, adds M. Velpeau, that the occipito-frontal is the greatest diameter Avhich
can present  at the planes of the straits.  But Ave cannot  admit the truth of
this  last proposition ; for if, as he says, the chin is in relation with the ante-
rior  surface  of the sacrum, and it descends more and  more, while the occiput
slips behind the pubis, it is evident that  the occipito-mental diameter must,
at a given  moment, traverse the antero-posterior one  of the excavation.
Now, as this is clearly impossible, Ave have to reject  M. Velpeau's explana-
tion altogether.   Besides, the cases observed by Smellie and  Delamotte,
which he  cites in support of his theory, prove nothing at all, for, in both of
those instances, the foetuses Avere small and dead, and the woman had, on for-
mer  occasions,  been  delivered of voluminous children.
   M. Guillemot has explained the spontaneous termination of the labor in
these cases someAvhat differently; forAvhen the chin does not rotate in front,
the labor, according to his idea,  may terminate in  tAvo  ways, namely:  1st.
The forehead continues to descend and to engage under the branch of the
pubis until the anterior fontanelle appears at  the vulva,  Avhich progression
permits the  chin to advance forward and reach the border of the  perineum;
then the  process of flexion commences, &c.  But Ave cannot conceive hoAv,
in the forced extension of the head on the thorax, it is possible for the chin
to arrive at  the anterior perineal commissure by traversing  the whole pos-
terior plane of the  excavation, because, from  all evidence, the breast must
engage extensively along  with the head, which  is Avholly impossible, unless
it be a case  of abortion.
   2d. The labor by the face may be converted into one by the vertex  and 
344
LABOR.
this  ahvays takes place, he continues, in the following mannei : the face
being forcibly pressed on, and unable to escape through the perineal strait,
has a natural tendency to pass towards  those points that offer the least
resistance.   Here, this condition is found above and behind, Avhence the chin
leaves the perineum and  approaches the foetal chest by ascending along  the
hollow of the sacrum towards the  sacro-vertebral angle, and the forehead
following this movement corresponds  to the sacrum in turn; the vertex is
depressed and slips behind the pubis, and, just at the moment when the chin
applies  itself to the child's breast, the occiput  engages under  the pubic
arch.  He further supposes the face to be sufficiently engaged for the chin
to come in contact Avith the perineum; but, as  Ave have already stated, this
is impossible, on account of the extent of the conjoint diameters of the head
and breast, both of Avhich would be deeply engaged in the excavation.
  But, even admitting the chin should descend so Ioav, Avhere is the poAver
to make it subsequently rise up  in  the IioIIoav  of the sacrum, the cavity of
which is occupied, whatever M. Guillemot may say  to the contrary, by the
deeply engaged breast?  For the uterine contraction, Avhich is always trans-
mitted by the spine, acts at first on the chin  as a consequence of the reverted
position  of the head (as M. Velpeau clearly  recognized), and  it is only
because its power is inadequate to make the latter descend any further, that
its action is transferred to the other extremity of the fronto-mental diameter,
that is, to  the forehead, which it then  depresses, according to the theory of
Guillemot.  Again, even supposing that the chin may remount, it is scarcely
possible  to believe that  it gets above the  sacro-vertebral  angle;  it must
therefore constantly remain in contact Avith  the  anterior  surface of the
sacrum; and, consequently, at a given moment, the occipito-mental diameter
must traverse the antero-posterior one  of the excavation.
  In my estimation, therefore, Ave are not to understand this as the true
mode by which the mento-posterior positions of the face are converted into
occipito-pubic ones; indeed, among all the  cases I have  been able to con-
sult, I have only found three in  Avhich the chin Avas in direct relation Avith
the anterior face of the sacrum,  viz., those of Smellie, Delamotte, and Meza
(reported by Guillemot).
  Now, in the one furnished by Smellie, it is positively stated that the child
Avas  small, that the woman had a large  pelvis, and that she Avas  usually
delivered very promptly;  Delamotte says nothing about the head and the
dimensions of the pelvis, in his case; and lastly, Meza Avas obliged to apply
the forceps, in the one reported by him;  so of course, that was no longer a
spontaneous termination, for it would be an  easy matter to demonstrate that
the application of the forceps may act in an altogether  different manner
and even more advantageously, than the uterine contraction in this instance;
besides, the reader will not forget that, in  the first two cases, the children
came away dead.
   All the  other observations may be referred either to the right or the left
mento-sacro-iliac positions; and, in these latter,  it appears to me that a
spontaneous termination of the labor might occur without a simultaneous
engagement of the chest and  head;  for  instance, let us suppose that the
child is in a right mento-sacro-iliac position; then, after the complete extern 
              MECHANICAL  PHENOMENA OF LABOR.           345

sion of the head, the face  will descend  into the excavation  as far as the
length of the neck  permits, and consequently the chin will reach the level
of the great sciatic notch, the  more so, as the  form of  this portion of the
ilium, Avhich is shaped like a cone, Avill favor the movement of doAvnward
progression.  Having arrived at this notch, the chin will  there encounter
soft parts, which it  can  very readily depress, and this  depression  will be
quite  sufficient to augment the length of the oblique diameter of the excava-
tion from a quarter to half an inch, thereby permitting  the occipito-mental
diameter to  clear it, and  the head to undergo  the process of flexion, that
will gradually bring the  occiput under the pubic  symphysis.

  § 4. Inclined or Irregular Face Presentations.
  The face does not always present so regularly at the superior strait, as to
have  its fronto-mental  circumference  parallel to  the opening in the pelvis,
since  the same causes that determine the inclination in vertex presentations,
may also render those of the face irregular; and here, likewise, Ave  may
invoke the  uterine  obliquities, the partial obliquity of the  child, or an
incomplete or an exaggerated extension of its  head, to explain how Ave
sometimes find one of the cheeks, and at others the forehead or the chin, at
the centre of the upper strait.
  But still, these are  not to be considered as distinct presentations, but
rather as varieties or shades of the  face  presentations, Avhich  scarcely ever
render the labor more difficult.  In fact, the folloAving is the only modifica-
tion they are likely to cause in the mechanism of parturition; in the malar
positions of  Baudelocque, or those  inclined tOAvards the  side, Avhere one
cheek is at the centre, the head undergoes a movement  of correction Avhilst
engaging, similar to what it does in the parietal  inclinations of the  vertex,
Avhereby the face gradually regains its normal horizontal direction.   In the
so-called presentations of the forehead  or  chin, the most  elevated  part
becomes depressed, and ultimately gains the same level as  the other.

  § 5. Prognosis.
  It Avas  for a long time thought, and still  is, by some persons, that  a
delivery by the face cannot take place by the powers of nature alone, and
it is only since the labors  of Boer, of Chevreul,  and Madame Lachapelle,
that the expulsion of the child  in the  face positions has  been admitted to be
spontaneous nearly as often as it is in the vertex  positions.
  Nevertheless, Ave must remark that, as a general  rule, the  labor  is  more
tedious, more painful, and more dangerous, both to the  mother and the
child, and that it much oftener demands  the intervention  of art.   Besides,
the reflections  above presented would naturally lead us to anticipate that
the mento-posterior positions are much more unfavorable than the anterior
ones.   NOav, this unusual delay is not because the greatest  diameters of the
head  then present to those of the pelvis, as Capuron  and many others sup-
posed : for it is only necessary to bear in mind the relations  before indicated,
to understand that it is the mento-bregmatic, and the bi-temporal diameters
(the  one three  inches,  and  the other three inches and three-quarters in
lengih),  which  are  then found to correspond with  the diameters of the 
346
LABOR,
straits; but because the dilatation of the os uteri takes place more slowly,
and because the expulsive forces, especially in the process of flexion and of
disengagement, act, like the arm of a lever which is bent, nearly at a right
angle.  Moreover, it has already been  stated that, in all other than vertex
positions, a very large quantity of the amniotic liquid usually existed betAveen
the presenting part and the inferior 'segment of the uterus.   We have also
remarked (see the Physiological Phenomena of Labor), that this circumstance
singularly influenced the rapidity of the dilatation of the os uteri.   On the
other hand, it is also evident that, Avhen the chin is actually engaged under
the symphysis, and the process of flexion has already commenced, the force
of the contraction transmitted through  the spine can  only determine the
successive disengagement of the  forehead, the bregma, and the occiput, by
describing a well-marked flexure, and,  consequently, thereby losing a large
proportion of its  force.1
  Certain authors, says Gardien, have incorrectly supposed  that  those
labors in which  the child  presents by  the forehead are more unfavorable
than  those where it offers  by the face;  for, if attention  be directed to this
point, the head will then  he found  to present in reality by its favorable
diameters ; and  further, as M.  Stoltz  remarks,  in the  face positions, the
forehead is already the lowest  part, and, the  more  it  descends Avhen the
head  engages, the more easy Avill  be  the labor.  Again, the chin presenta-
tions  are less favorable than those of the forehead, because the child's head
is then in the most perfect state  of reversion,  and, if the shoulders engage
at the same time  Avith  the  vertical diameter of the cranium, a Avedging in
must inevitably take place in the excavation.   But even these, also, soon
transform themselves into true face presentations.
  As  regards  the  foetus, the labor,  if tedious, may prove very disastrous;
since apoplexy, or at least  a cerebral plethora, and a disposition to convul-
sions, are but too often, says Madame Lachapelle, its  unfortunate result.
The repeated and prolonged compression of the child's neck, a compression
which occurs just at the moment Avhen  the head is clearing the cervix uteri,
or the superior strait, or, still more probably,  Avhen the front of  the neck is
placed under the symphysis pubis, satisfactorily accounts for the difficulty
in  the return of the venous blood, and the  cerebral congestion which it
occasions.  Consequently, particular attention should  be  given to  the con-
strained position-; for  a case  that might be abandoned to nature, Avere the
  1 This is so true,  that, during the process of extension, the uterine contraction is  not
transmitted by the  spine alone ; for I believe that, in certain cases at least, the thorax,
by being subjected  to forcible.pressure, and therefore  flexed on itself, just above  the
head, rests by its  posterior-superior part directly upon the occiput, and hence may
immediately transmit the  uterine force to  the latter,  as I believed occurred in  the
following case.  In August, 18^9. I  was summoned  to  a grocer's  wife, in the Rue du
Bac, in whom the child presented in the left transverse mento-iliac position ;  tlie mem-
branes had been ruptured at eight o'clock in the  morning; it was then five in the
afternoon, and an application  of the forceps had already been attempted.   However,
in about  three-quarters of an  hour  after my arrival, the labor terminated  spontane-
ously. The  infant soon  revived; but, in examining  its head, 1 detected, near the
posterior fontanelle, \fhat appeared to be  small splinters of bone,  which crepitated
under the finger, and there were  also evident traces of a cons"Jerable deiression on
its  dorsal region. 
              MECHANICAL  PHENOMENA OF  LABOR           347

mother alone regarded, AArould require the intervention of our art, to relieve
the foetus from its painful situation.   In cases of this  kind, where the face
had descended enough to be in  full vieAv at the vulva, Madame Lachapelle
was in the habit of judging by the movements of the infant's tongue and
lips; though it must not be forgotten that these  motions are  not constant/;
but, when they do exist, and are found to groAV Aveaker, and  finally to dis-
appear,  they constitute  a bad  sign, and claim  our  immediate  attention.
Furthermore, the child often exhibits certain peculiarities in face deliveries,
which ought to be knoAvn, in order that the family may be advised of them
beforehand.   The face corresponds to the open space in the excavation, as
also for  a long time to the \Toid under the pubic arch; and hence, it becomes
affected  Avith the ecchymosis and the  sero-sanguineous  infiltration before
spoken of as happening in vertex presentations.   Consequently,  when the
labor has been somewhat tedious, the infant's face at birth is  nearly black,
its  cheeks  SAvollen, its  lips turned  in, and the  nose scarcely visible, and
nothing frightens  the parents so much as  such an object, if they are not
previously advised of the possibility  of  such an occurrence.  HoAvever, this
condition is  generally dissipated in the  course of  a feAV days, and its resolu-
tion may be hastened by. lotions composed of a little Avine, or vegeto-mineral
water, or brandy, freely diluted Aviih Avater.  No alarm need  be felt  about
the tendency observed in the head to fall backAvards,  as soon as the support
is Avithdrawn ; for, it only regains the  attitude  it had temporarily in the
pelvis.  This feebleness of the muscles of the neck is evidently due to the
prolonged extension  they  have  undergone,  and Avhich  has  momentarily
paralyzed a part of their contractile force:  it ordinarily disappears  in the
course of tAvo or three days.  ,


                           ARTICLE IV.

              PRESENTATION OF THE  PELVIC EXTREMITY.

  We have  already had occasion to state that  most  accoucheurs describe
three distinct presentations of the pelvic extremity of the foetus, to wit, the
presentations of  the breech, of  the feet, and of the knees, according  as the
breech,  the feet,  or the knees, are the first to engage in the excavation and
clear the external  parts of generation.   We have  also explained  Avhy (fol-
loAving  the  example of Madame Lachapelle, Ant. Dubois, P. Dubois, and
others) Ave  consider  these  three  as  being only  slight modifications of the
true pelvic  presentation;  for modifications that do not in any Avise change
the mechanism of  the natural  labor ought certainly to be included  under
one and the same title.
  Thus, it may happen, in  presentations of the  pelvic extremity, that this
extremity, composed of all its elements, that is to say, of the  thighs  flexed
on the abdomen, and  the legs on the thighs, may engage in the excavation
and inferior strait;  or that  the lower extremities, carried along when the
membranes  are  ruptured, by the gush of the  waters, may be  completely or
partially unfolded ; the feet in  the former case, and the knees in the  latter,
appearing first externally ;  or that, the inferior members being stretched out 
348                             LABOR.
and applied to the child's anterior plane, the breech alone may descend ;' or,
lastly, that one of the lower limbs may be extended up along the abdomen,
while  the  other remains down, and then  one foot or one knee, as the case
may be, Avill  present at  the vulva.   We  shall include all these varieties
under the general name of the presentation of the pelvic extremity; and we
again  repeat  that,  in  the presentations  of  this extremity, the  points of
departure, taken on the foetus, are, the  posterior face of the sacrum for the
breech;  the anterior face of the  tibias for the knees ; and the  heels in the
footling  cases.  With regard to the pelvis, the sacrum, or the  back of the
child,  may be found in  relation with  any7 one of  the various  parts of its
superior strait; but still, all these shades of position  are included in two
principal ones, namely, a first, or left sacro-iliac, and  a  second, or right
sacro-iliac  position; and, further, each of these exhibits its anterior, trans-
verse,  and  posterior varieties.
  The presentations of  the pelvic extremity  are less frequent than those of
the vertex, though much  more common than  those of the face.   Thus, in
thirty-seven  thousand  eight  hundred  and  ninety-five  labors, Madame
Lachapelle has noted one thousand three hundred and ninety of this class;
in tAventy thousand  five hundred and seventeen, Madame Boivin observed
six hundred and  eleven;  and in  two thousand and  twenty, M. P. Dubois
met Avith eighty-five.  In order to give an  idea of the relative frequency of
the cases in Avhich the nates, the knees, or the feet are first expelled, Ave Avill
add that, in those eighty-five labors, the  nates appeared  first at the vulva
fifty-four times,  and the feet  twentyr-six  times.  The presentation  of the
knees, so called, Avas not observed in a single instance.   In fact, this is a
very uncommon variety ; for in the thirty-seven thousand  eight hundred and
ninety-five cases of Madame Lachapelle, the knees came  doAvn  first only
eleven times, or one in three thousand four hundred and forty-five.
  In a sum total of sixteen thousand six hundred and fifty-four labors, Dr.
Collins has observed the pelvic extremity to  offer once in thirty times; and
Ramsbotham, Jr., from  calculations founded on  twenty-seven  thousand
seven hundred and^ thirty-nine labors, and tAventy-eight thousand and forty-
three births, occurring  at the Maternity Hospital  of  London,  has arrived
at the conclusion that breech presentations are to the others as one to thirtyr-
five.2   The left  sacro-iliac positions  are far  more frequent than the right;
thus, in  thirteen hundred and ninety instances, the back looked toAvards
the left side seven hundred  and  fifty-six times, and to the right, four hun-
dred and ninety-four times; but  thirteen times in  front, and twenty-six
times directly backAvards (Lachapelle).  In  the eighty-five positions of M.
  1 This position of the lower extremities may be primitive: that is, it may exist before
the rupture of the membranes, (indeed, according to M. P. Dubois, this most frequently
occurs,) or may be consecutive to the engagement of the breech.  In this  latter case,
the feet may have been arrested either by the periphery of the cervix uteri, or by the
superior strait at the time when the breech was passiug into the  excavation, and henee
the inferior members would be necessarily pressed up along the child's anterior plan*.
  2 By a table in the revised edition,  Dr. Ramsbotham furnishes  a record of 35,743
delivei'ies that occurred between January 1st, 1828, and December 31st, 1843, in which
there were 930  presentations of the breech, or lower extremities, thus showing tha
proportion to be 2*6 pe." cent, or 1 in 38-8.— Translator. 
MECHANICAL  PHENOMENA OF  LABOR.           349
P. Dubois, the back was forty-one  times tOAvards the mother's left, and
forty-four times to her right.  As to the varieties exhibited by these two posi-
tions, the left anterior is a little more frequent than the right posterior one,
but each of them is far more common than all the  others put together.
For instance, in one hundred and sixty-three pelvic presentations, says M.
Nai»ele, the back Avas in front and to the left one hundred and twenty-one
times, Avhilst it was only forty times behind and to the right.
  § 1.  Causes.
  It is Avholly impossible, in the present state of the science, to say why the
breech should  sometimes present at  the superior strait;  true, numerous
explanations have been offered, and the  following, proposed  by Madame
Lachapelle and  reiterated by Velpeau, is perhaps the least  objectionable
of any.  The child, they say, floats comparatively free in  the uterus, until
near the eighth month ;  then its  head, during certain movements on the
part of the mother,  the  act of lying doAvn in particular, is carried towards
the fundus uteri; and, if the  infant has then  acquired a considerable vol-
ume, perhaps its great  occipito-coccygeal diameter cannot repass through
the small diameters of the uterine ovoid, without undergoing as forcible  a
movement as that which' changed  its  position;  and if this latter does not
occur, the foetus  will retain its  new attitude, and at the time of the  labor
the  pelvic extremity will present  at  the passage.   This explanation,  I
repeat, although liable to many objections, still appears the most probable.

   §  2. Diagnosis.
   [Breech presentations may be recognized by the successive employment of pal-
pation, auscultation, and the touch.
  Palpation, in  accordance with the rules  given, will enable us  to feel the head at
the upper part of the uterus; and, if it can be clearly made out,  leaves little doubt
as regards the diagnosis.   If, however, the Avails of the abdomen be thick, or thoso
of the  uterus rigid, the cephalic and pelvic extremities may be mistaken for each
other, especially if Ave  should happen to feel the latter by its posterior or  sacral
surface.  But moderate importance ought, therefore, to be attached to this kind of
exploration, though it is nevertheless true that it has its advantages.   We remem-
ber a case in which both  auscultation  and the  touch  seemed to indicate a  vertex
presentation, whilst palpation enabled us to feel the head at the  fundus  of the
uterus, and the child  was born by the breech.
  Auscultation  may also enable us to recognize breech presentations, for in this
ease the dorsal region of the foetus is pretty high up, and, in consequence, the
maximum of the pulsations of  the  heart  are higher than  in head  presentations.
The  loudest sound will generally be heard on or above a  horizontal line passing
through the umbilicus, and the side of the abdomen at which it is perceived will
also indicate the point toward which  the back is directed.  The diagnoses of both
presentation and position are thus made at the same time.]
   To the foregoing  signs  may be added  the following as distinguishable
during labor.  The bag of Avaters is very large, and  projects  considerably
into the upper part  of the vagina ; sometimes assuming the form of an elon-
gated  tumor,1  which may descend,  even to within a  short distance of the
vulva.
  1 Certain writers have evidently been in error in giving this particular form of the
amniotic sac as a positive sign of a presentation of the pelvic  extremity, since it may 
350
LABOR.
  When  the membranes are  ruptured, a  very considerable  quantity of
Avater escapes, for the presenting part fills up the neck but very imperfectly,
and  hence, all the amniotic  liquid  Aoavs out; and if the  rupture  should
occur during a strong pain, it Avould  probably be accompanied by a loud
report.
  Stein described the uterine orifice  as being oval  after the  rupture, and
Madame Lachapelle confirmed  this sign; but I must confess  that  I have
found great difficulty in verifying it.
  A momentary suspension or  a diminution of the pains often  results from
a too copious or a too rapid discharge of the Avaters; and, further, a flow of
meconium most  generally takes place  soon after the membranes give Avay.1
  But the only characteristic signs are those furnished  by  the touch;  and
theyT Avill  vary Avith the presenting  part.   Therefore,  although Ave have in-
cluded, so far as the mechanism is concerned, all the  cases in Avhich either
the nates, the feet, or the knees present, under one general term ; yet, in the
diagnosis, we must carefully distinguish them from each other.
  1. When  the  breech alone  presents, the  finger first encounters  a soft,
rounded tumor, upon some portion of  Avhose anterior surface a hard, resist-
ant  part, formed by the  great trochanter of  the .thigh-bone,  is  detected.
Thus far,  it might be mistaken for a vertex  presentation ; but if the finger
be next carried upwards  and  backAvards, so  as  tb  reach, as it Avere, the
sagittal suture, it Avill penetrate into  the fissure between the  nates, at the
bottom of which  the most  important  diagnostic signs  are discovered; for
the point  of the coccyx is felt towards one side, surmounted By an irregular
osseous surface, constituted by the  posterior face of the sacrum ; then the
anus, a small, rounded, and Avrinkled  orifice, into Avhich the finger  cannot
be introduced Avithout resorting to considerable force, Avhatever  authors may
say to  the contrary ; lastly, the external genital organs can be easily distin-
guished, and thereby the sex of the child may be announced in advance.2
  The prominence of the coccyx is not only a certain sign of the presenta-
tion, but  it  may also serve  to  determine the position ;  because its point is
ahvays directed toAvards the side not corresponding Avith the child's back.
be met with in other cases.  I have twice observed it myself in  clear vertex presenta-
tions that were engaged, even then,  as far as the middle of the excavation.   I can only
explain this last circumstance by supposing  an extreme laxity of the membranes.
  1 However, a discharge of meconium may take place in other than pelvic presenta-
tions ; but then it is an alarming sign, and  one that should  receive the accoucheur's
immediate  attention.  In fact, it always indicates  the death,  or at  least a suffering
condition, of the child ;  and. therefore, Avill most generally require the intervention of
art,  since it is particularly apt to  come on  when the labor has continued a long time
after the rupture, and the foetus is  suffering from the protracted delay ; or possibly it
may announce the compression of the umbilical cord (see Prolapsus of the Cord).
  2 The  accoucheur ought to be exceedingly careful not to  deceive himself  on this
point; and, in case  of any doubt, it would be much better to  abstain from all  predic-
tions, than to expose himself to an  error that would most certainly be  retorted upon
him afterwards.  It is  also prudent, where the child is  ascertained, by the touch,  to
be of a sex different from what the family, and more especially from what the mother
desires, not to communicate the result of  his diagnosis,  lest the disappointment she
would experience might, like any other acute moral emotion, exercise an unfavorable
influence over the progress of her labor. 
MECHANICAL  PHENOMENA  OF  LABOR.           351
  2. Where the two feet present together  in the vagina, it is impossible to
confound  them with  any other part, and  the  direction of the heels then
clearly  indicates the child's position.   But  where  a single foot  only is
detected, and that very high up, it might be mistaken for a hand.  Hoav-
ever, a  little attention will  serve to distinguish them ; thus the toes  are
arranged in the same line, are shorter, and less movable;  while the fingers
are longer and the thumbs separated from the others ;  the internal border
of the foot is much thicker than the external; but the tAvo margins of  the
hand  are very nearly  of the same  thickness ; again,  the foot articulates
with the  leg at  a  right  angle, Avhile the hand continues out the line of
the arm.
  The diagnosis is very difficult when the feet present along  with  the nates,
and they alone  are accessible.   Sometimes even only one foot can be felt,
which renders the case still  more obscure; then Ave have  first to ascertain
which is the foot touched; though, for that purpose, it is only necessary to
pay attention  to  the  relation existing between  its internal border and  the
heel.  For instance,  let us suppose  that the  latter  is turned  toAvards  the
svmphysis pubis, and its internal border to the right side  of the mother;
this is  evidently the right foot;  if,  on  the contrary7, the  heel be directed
toAvards the sacro-vertebral angle, and the internal  border to the right, this
Avould  be  the left  foot, &c.; iioav, the right foot being once distinguished
from the left, it only remains to determine tOAvards Avhat part  of the superior
strait the points  of the toes  are directed (bearing in  mind that Ave ahvays
suppose the inferior extremities to be flexed  on the abdomen, and the feet
crossed  and turned imvard).   In this position of the child, if the toes of the
right foot  are turned towards any point of the anterior half of the pelvis,
the back will  be directed to some part  of the  left  lateral half; but if the
toes on  the left foot point toAvards the anterior part of the pelvis, the child's
back Avill look to some point on the right  lateral half, and vice versa.
  [We think the following the easiest Avay of distinguishing the  right foot from the
left one : First, make sure of the position of the toes, heel, and inner edge of the
foot in question.  Then let the observer  imagine his OAvn foot in precisely the same
position, with the heel, inner edge, and toes superposed, as it AArere, upon it.  Should
his right foot correspond, he Avill diagnose a right foot, but a  left one, should it
require the left foot to satisfy the conditions.]
  3.  The knees very rarely present first;  besides, they have such Avell-
marked characteristics in their form, their roundness, their hardness, the
size of the limbs attached, and the fold  of the  ham Avhich surmounts them,
a fold presenting a transverse concavity instead of  the convexity exhibited
at the elboAV and instep, that Ave  consider it useless to dilate further upon
their diagnosis.

  § 3. Mkciianism.
  As the left anterior and the right  posterior  are the most frequent of the
three varieties admitted for both the left and the right sacro-iliac positions,
we  shall select them as the type of our description.
  1. Mechanism  of Natural Labor in the Left Anterior Sacro-iliac Position.
\ The. first,  of authors.) 
352
LABOR.
     Before the rupture of the membranes, all the parts of the child are folded
  up along its anterior  plane; the head is slightly flexed on the chest, the
  arms are applied to the sides of the thorax, the fore-arms are bent on the
v breast,  and the inferior members flexed on the front of  the  abdomen.  In
  the position before  us,  the back of the foetus  looks forward  and to the
  mother's left; its anterior plane behind and to her right;  its left side is in
  front and to the right, and the right side behind and towards the left; the
  greater or bis-iliac diameter of its hips corresponds to the right oblique, and
  its sacro-pubic or antero-posterior one to the left oblique  diameter.
     [a. First Stage.  Moulding of the Breech.—The first effect of the contractions  is
                                   to  curve  the  foetus upon its  anterior plane,
                                   and compress the lowrer extremities upon the
                                   breech, so as to mould these parts into a mass
                                   small  enough to engage in the  cavity of the
                                   pelvis.  The pressure really lessens the size of
                                   the breech, and, at the same time, adapts it
                                   better to the opening of the superior  strait.
                                   Although the diminution of bulk is  greatest
                                   after the  membranes are  ruptured, the escape
                                   of  the Avaters is  also liable to be  accompanied
                                   by an extension of the lower limbs, giving rise
                                   to  the varieties knoAvn as foot and knee pre-
                                   sentations,  the only  effect,  howeArer, being to
                                   facilitate  the descent.
                                     This stage  is analogous to  the first one  in
                                   vertex presentations ;_ only  the diminution  of
                                   size, in this case, is real and sufficient to allow
                                   the breech  to descend into the pelvis,  whilst
     The presentation of the breech in the left   in  vertex presentations, the slightly compress-
          anterior sacro-iliac position.       ible head is only enabled  to do so by a sort of
                                   mechanical artifice, whereby the  act of flexion
   causes it to present the diameters most favorable to its engagement.]
      B. Second Stage.   Engagement.— If the os uteri be freely dilated when
   the rupture takes  place, the nates immediately engage by traversing the
   cervix, and descend  rapidly into the excavation; though, in  the contrary
   case, they  remain high up for a long time.   In proportion  as the contrac-
   tions acquire more force and energy, the buttocks  gradually descend; the
   left sliding on the  internal surface of the obturator foramen and the obtu-
   rator internus muscle,  and the right along  in front of the parts that are
   situated in the left posterior quarter of the pelvis.
      c Third Stage.  Rotation of the Bretell.—Having arrived at the inferior
   strait,  the  child's pelvis undergoes  a movement of rotation that carries the
   left hip behind  the right ischio-pubic ramus, and the right hip in front of
   the inner half of the sacro-sciatic ligament.   The left or anterior hip next
   engages under the aforesaid  ramus, and  is the  first to shoAV itself  through
   the vulva; but it is generally  the  right or posterior hip, which, advancing
   step by step, and describing an arc of a circle around the anterior one as a
   centre, and traversing the  Avhole anterior surface of the perineum, first suc-
   ceeds  in disengaging itself at the  anterior commissure, while the other
   remains nearly immovable at the summit of the arch.  During the  delivery
Fig. 82.
 
               MECHANICAL  PHENOMENA OF LABOR.           353

or" the breech, the bodyr of the child, by becoming strongly engaged in the
excavation, is flexed laterally on its anterior  (left) side in such a way as to
accommodate itself to the curvature of the pelvis.  (Fig. 84.)
  D.  Fourth Stage.   Disengagement of the Breech.—As the right buttock
approaches the posterior commissure of the labia externa, and  engages in
               Fig. 83.                                Fig. 84.
       The same position after the internal                The delivery of the breech.
          rotation is accomplished.

this opening, the breech, or rather the bis-iliac line of the foetus, which had
already cleared the  loAver strait in  a somewhat  diagonal position, now
assumes an exactly antero-posterior  direction, so as to correspond with that
of the longitudinal diameter of the  vulva.   However, this is  not constant,
as the breech sometimes retains its diagonal position throughout; the thighs
closely applied on the belly already begin to appear, and, pending the dis-
engagement, the foetal trunk, by accommodating itself, as above stated, to
the direction of the pelvic axis, is strongly flexed on its anterior (left) side.
The rotation executed by the hips, Avhen they reach the inferior strait, may
either be a partial movement, or else one in which the Avhole trunk partici-
pates.
  In the former case, it can only take place by the aid of a certain degree
of torsion in the lumbar vertebral column, and then the pelvis, immediately
after its delivery, undergoes the process of restitution, Avhereby it once more
regains its primitive diagonal position.
  As  soon  as the hips  are  clear, the breast engages in  the  excavation, the
arms  always remaining applied against the anterior lateral  parts of the
thorax, and the shoulders soon arrive at the inferior strait in an  oblique
position, supposing  they have not previously participated in the rotation
performed by the pelvis of  the child.
  The shoulders observe the  same mechanism in disengaging as  the hips;
that is, they turn in such a manner as to place the anterior  one, here the
left, behind the right ischio-pubic  ramus, and the posterior  one just  in
advance  of the left  sacro-sciatic ligament, whence  they both clear this
strait  diagonally; but Avhen this is passed, and there  is no other  resistance
than that of the soft parts to overcome, they  complete  the rotation and
     23
 
354                             LABOR.
                                                   0
become placed, the one  directly in  front, the other behind.   As  to the
other parts, the sub-pubic shoulder and elbow are the first to  at pear exter-
nally ; but it is still the posterior ones that are first delivered.1
  Prof. Dubois contends that, in breech deliveries, the anterior hip and the
front shoulder, in the disengagement  of the  upper part of the trunk, are
expelled before the corresponding part in the rear; but I may be permitted
to repeat again, that, although matters often do occur in the Avay described
by the professor, still it has seemed to me that the view above given holds
true in the majority of cases.
  E.  Fifth Stage.  Rotation of the Head.—Whilst the shoulders are travers-
ing the pelvis  in the manner just indicated, the head, being flexed on the
breast, clears  the upper strait in the direction of its left oblique diameter;
that is, the forehead is turned towards the right sacro-iliac symphysis, and
it retains that  position  until it reaches the  inferior strait.
  The diameters of the head, which  are then found in  relation  with those
of the inferior strait, will necessarily vary according to the greater  or less
degree of the flexion of the head.  For instance, when it is only moderately
flexed, Avhich is generally the case, the occipito-frontal diameter corresponds
to the left oblique one, the bi-parietal to the right oblique, and the axis of
the  inferior strait traverses  the  head very  nearly  in the direction of its
trachelo-bregmatic diameter.
  If Ave suppose  the  head  to be more  strongly flexed on the chest, the
sub-occipito-bregmatic diameter takes the place of the occipito-frontal, and

                                 Fig. 85.
Delivery by the breech.  Disengagement of the head with the chin behind.
the occipito-mental corresponds very nearly to the axis of the inferior strait.
In a Avord, Ave find  the same  relations as in a vertex presentation, only the
head presents by its base instead of its summit.
  It then performs a movement of rotation,  whereby the face is carried into
the holloAV of the sacrum, while the occiput gets behind, and the neck under
the symphysis pubis ; Avhence the sub-occipito-bregmatic diameter approaches
the antero-posterior  one very  closely, still retaining, hoAvever,  a certain
obliquity.
  F. Sixth Stage. Expmlsion of the  Head.—At that time, the Avomb can act
but very feebly on the head (see Prognosis),  which is altogether down in the
vagina, or nearly so ; but the tenesmus, says Velpeau, occasioned by its pres-
  1 Many books, on the subject of shoulder-delivery, assert that the arms are retained
f)V "he Girders of the excavation, and thereby get up alongside of the  head; though, 
Missing Page
  355-356 
 
MECHANICAL  PHENOMENA OF  LABOR.
357
Fig. 87.
 the folloAving parts  are found to appear in succession below the symphysis
 and through the vulva ; first the whole face, then the forehead, the bregma,
 the vertex, and  last of all  the occiput.   The head  is  therefore  delivered
 by a process of flexion, having the neck, as a centre,  resting against the
 anterior commissure of the  perineum.  (Fig. 86.)
   Finally, it may happen  that, instead of remaining applied on the chest
 the chin is arrested, and  continues above the pubis, while the occiput is
 carried  more and  more backwards
 by a Avell-marked movement of exten-
 sion.  The head engages in the strait
 by its occipital extremity, Avhich then
 traverses the whole  posterior  part of
 the excavation  byr  a see-saw move-
 ment, and is born first at the perineal
 commissure;  after  it come,   succes-
 sively,  the vertex,  the anterior fon-
 tanelle, the  forehead, and  the entire
 face.  Consequently, the head disen-
 gages by a process of extension, hav-
 ing the  prsetracheloid  region as  a
 centre, which is placed at first behind,
 and then under  the symphysis pubis.
 Cases of this kind  are reported by
 Leroux,  Michaelis,  and Asdrubali,
 but they are very rare (Fiu.  87).—
 The mechanism  of  labor in the left
 transverse, and in the right anterior,
 and right transverse sacro-iliac posi-
 tions,  is  analogous to  that just de-
 scribed for the left  anterior, and of
 the right posterior iliac position.
   [We would observe, however, that the left hip, which in all left sacro-iliac posi-
 tions ought  to appear under  the arch of the pubis, turns from right to left in the
 left anterior sacro-iliac position,  and from  left to right in the left posterior sacro-
 iliac-position.  The right  hip  will, in like manner, be found to disengage the first
 in the right sacro-iliac-position, by turning from left to right in the anterior variety
 and from right to left in the posterior one.]
   § 4. Prognosis.
   Breech presentations are not, usually, much more dangerous than those
 of the head ; still, in order to arrive at an intelligent prognosis, the labor
 should be studied in reference to its effect upon the mother and upon the
 child respectively.  Though, from the manner of its  expulsion alone, the
 life of the  child is  seriously  endangered, the  parturition is  certainly less
 exhausting and less  painful  for the  mother.
  1. As regards the Mother. — As a Avhole, the labor is  somewhat longer  in
 breech presentations; though, fortunately, the delay is experienced almost
exclusively during the first  stage, and  is the cause of but little additional
suffering to the mother.   The slowness of the process of dilatation is readily
explained by the conditions  which have been  already  pointed out.   Before
  Delivery by the breech;  the occiput behind, and
disengaging at the posterior commissure of the
vulva, whilst the chin remains behind the pubis. 
358
LABOR.
the membranes are ruptured, the presenting part, having neither the ft mi,
roundness, nor regularity of the top of the head, cannot adapt  itself to the
regular concavity of the inferior segment  of the uterus, and being separated
from  the  neck by a considerable amount of amniotic fluid, is therefore in-
capable of hastening its dilatation.  Should the membranes happen to rup-
ture long  before the dilatation  is completed, the size or irregularity of the
breech prevents its engaging readily, and the neck, not being supported as
it is by the top of the head in vertex presentations, collapses, and contracts,
so to  speak, the opening Avhich it had just  before  presented.  In cephalic
presentations, on the contrary, the  head engages like a Avedge,  and  each
expulsive effort tends to increase the dilatation.
  When  the  neck is once thoroughly dilated, the expulsion has ahvavs
seemed to me to be effected more  rapidly than  in vertex presentations.
The breech, the trunk, and the shoulders  are generally delivered with ease,
but the head sometimes meets with obstruction, and may be arrested at the
superior strait.  Generally, hoAvever, it is detained for but a short time; for
if the efforts of the female are not capable of expelling it, it  becomes the
duty of the accoucheur to interfere promptly, in order to remove the child
from the danger which  threatens it.   The course to be pursued under these
circumstances, exposes  the mother to  no danger whatever, the entire  risk
falling upon the foetus.
  As  regards  the mother, therefore, the breech  presentation is perhaps even
more  favorable than that of  the vertex;  I Avould add, that  it is certainly
more  so for her than a face presentation.
  It is important to observe, that all  the varieties of breech  presentation
are not equally favorable.  Some authors think  that  the labor  is usually
longer when the foetus presents by the breech  than when the  feet are the
first to descend into the excavation.
  The size of the parts that constitute the  pelvic extremity,  it has  been
said, do not permit it to engage so readily;  and hence, the uterine contrac-
tions must operate a longer time in order  to adapt those parts to  the diame-
ter  of the  pelvis.  This is true; but, as Madame Lachapelle has observed,
their softness  is  such that,  Avhen  once engaged, they easily conform to the
passage; and besides, as M.  P. Dubois declares, the greater their volume
is, the more will the labor resemble that of the vertex presentations.   Con-
sequently, the professor teaches, contrary to the opinion generally adopted,
that a delivery by the  breech ■ is  far  preferable to that in Avhich the feet
come  down first:  the truth of Avhich proposition  will  be better understood
when  we shall have pointed out the inconveniences attending this latter cir-
cumstance.
  As  the footling presentation does not exhibit the same  unfavorable ap-
pearances  in  respect to volume, it is preferred by some persons; for then
the foetus, presenting by its smallest extremity, will,  in their estimation, be
more  easily expelled, since  the  dilatation of the parts, from being slow and
gradual, Avill be much  shorter and less painful.   If  you Avish, they say, to
drive  a cork into the neck of a bottle, you Avould present its  smallest ex-
tremity, and then it would  enter more readily, and the same is true of the
child  in the foot presentations; for the foetal ovoid may7 be considered as a
cone,  whose base is at  the cephalic, and  Avhose summit is  at the pelvic ex- 
MECHANICAL  PHENOMENA  OF  LABOR.            359
 treinity.   In the case of the bottle  this is true, but  only so, because  the
 efforts you use to make it penetrate, will be redoubled as the larger extrem-
 ity approaches  the neck of the bottle; that is, the force Avill increase Avith
 the difficulties to be overcome ; but this last condition does not  hold good
 in the delivery  by the feet.   Because, as the inferior parts of the  child be-
 come  successwely disengaged,  there is less left remaining in  the uterine
 cavity, and there is even a period Avhen the head, having reached the exca-
 vation, is  almost entirely out of  the cavity of the cervix; but  the uterus,
 during its evacuation, retracts, and, like all contractile muscles, loses a great
 portion of its power by this retraction ;  and it is therefore just  at the mo-
 ment Avhen the  great extremity of the cone, represented by the foetus, has
 to overcome the resistance of the soft  parts, that the uterine contractions
 are the most enfeebled, and often, indeed, they cannot aid at all in the ex-
 pulsion of the fcetal head:  consequently,  the poAvers here diminish in an
 inverse ratio to the obstacles in  the delivery.  If the  reader now recalls
 Avhat takes place  in vertex  presentations, he will readily comprehend the
 difference  between  the two; no  doubt, the largest part of the  child then
 presents the  first, and  its expulsion requires violent and long-continued
 efforts; but remark that, up to  the moment when the head clears the vulva,
 the  uterus yet  contains  in its cavity a considerable  quantity of amniotic
 liquid, and also the largest  part of the  foetal trunk; Avherefore, it is still
 sufficiently distended not to have lost its power of contracting, a  poAver that
 can be exercised over  a large surface, and  upon which it is forcibly applied
 until the end of labor.  Again, the  head having  once  reached the exterior,
 the parts Avhich  have been freely dilated by its passage offer but a feeble resist-
 ance to the expulsion  of the  trunk and  loAver extremities; and  hence, the
 retraction of the womb may diminish its expulsive forces without this diminu-
 tion having any unfavorable influence over the termination of the  labor.
   2. As regards the Child. — The delivery by the pelvic extremity is very
 dangerous to the child; thus, the statistical results  furnished by Madame
 Lachapelle prove  that, in eight  hundred  and  four presentations  of this
 class, one hundred  and tAvo children are born feeble, and one  hundred and
 fifteen are still-born:  the proportion of deaths to the Avhole  being rather
 more than one-seventh;  whilst, in twenty-six thousand six  hundred and
 ninety-eight vertex  positions, there Avere only six hundred and  sixty-eight
 still-born children, Avhich gives one  in thirty, or about one-thirtieth.  As
 to the  particular prognosis in each of the- three varieties of this presenta-
 tion, it has been remarked that, Avhen the buttocks advance first, the num-
 ber of deaths is about  one  in eight and a  half, or  a little less  than an
 eighth; for footling presentations, one in  six and a  half, rather less than
 one-sixth ;  and for the  knees, one in four and a half, or not quite one-fourth.
 But M. P.  Dubois has justly remarked that this proportion is not perfectly
 correct, since all the children born by the pelvic extremity are included in
 the registers of the Maternity, without making  any alloAvance for circum-
 stances foreign to the position, but Avhich  nevertheless may have produced
 the child's  death.   Therefore, by laying aside all the cases Avhere the chil-
dren seemed to have been lost under  the influence of causes that evidently
did not attach to the presentation itself, he has arrived at the conclusion
that, in  delivery by the pelvic extremity,  about one  child  in  ele ren dies;, 
360
LABOR.
whilst in vertex presentations, only one  in  every fifty proved fatal.  The
difference still, as here shown, is frightful.
  Other things being equal, the labor is much more dangerous for the fcetua
in primiparae, than in those Avho  have previously borne  children ;  because
the resistance of the  perineum Avhich is sometimes  sufficient in the former
to arrest the labor, even in vertex  presentations, has here .a  still greater
tendency to arrest the head, the uterine contractions, as just  demonstrated,
being weaker.
  But Avhat is the cause of the child's death?  For a long time it was sup-
posed that, Avhen the foetus  presented its smallest extremity, each part, as it
came down, being more voluminous than  the one Avhich preceded it, had to
overcome new resistances;  that  it  underwent,  in  consequence, a certain
amount of compression, and this  compression, being exercised  from below
upwards, would necessarily drive back the fluids, and thus  give  rise to a
cerebral congestion,  the anatomical  signs of which are  detected at  the
autopsy of the little corpse.  But this supposed pressing back of the fluids
is altogether inadmissible:  1st. Because the uterine  neck is alternately in a
state of relaxation and constriction,  Avhilst such  an explanation Avould
require it to be  permanently contracted; 2d.  Because, hoAvever great the
contraction, it would not be sufficient to compress the large vessels  situated
deep in the extremities, and in the centre of the great cavities ;  3d.  Besides,
by recalling Avhat takes place in the vertex and face presentations, Ave shall
see that it is not in the parts Avhich are still contained in, and  compressed
by, the uterine  cavity, that a  more considerable afflux of fluid Avould be
likely to occur, but  rather in those Avhich, from  being already free,  are
thereby relieved from all further compression.   We think this mortal con-
gestion can be explained in a much more satisfactory manner by a com-
pression  of the  cord; for, after the  breech  is  disengaged,  the  cord is
stretched from the umbilicus to its placental insertion, and is placed, both
in the excavation and uterine cavity, betAveen the pelvic Avail and the trunk,
or even,  a little later, betwixt  this Avail and  the child's  head.   Hence, we
can easily understand hoAv liable it is to be compressed ;  and as the delivery
of the upper parts, and more especially of the head, often takes place Avith
difficulty, how this pressure may  exist for a long time, and thus necessarily
interrupt the circulation in the cord.  Indeed, it is noAV generally admitted
that the  placenta is the seat of the child's respiration ; or, rather, that  the
blood of the foetus comes there directly into contact Avith that  of the mother,
Avhereby it experiences certain modifications closely analogous to those Avhich
the blood of the adult undergoes in the lungs, by its contact with the atmo-
spheric air;  the circulation being interrupted in the cord, the foetus then
finds itself in the condition of  an adult deprived of respirable air, and it
dies asphyxiated ; noAV it is Avell known that cerebral congestion is one of
the most constant anatomical phenomena of this state.1  I am of the opinion
  1 Most of the older writers have explained the child's  death somewhat differently, in
these cases; thus, according to some, the pressure interrupts the circulation in the
umbilical arteries, but leaves the  calibre of the vein entirely free, whence  the foetus
continues to receive blood through the latter, without being able to send it back again
by the former; and it then dies from a superabundance of this fluid, from apoplexy.
Others, on the contrary, supposed  that the stricture acted  more particularly upon the
?ein, leaving the arteries free, and therefore that the infant died of anaemia or syncope. 
MECHANICAL  PHENOMENA  OF  LABOR.
361
  that asphyxia of the foetus  might take  place in still another mannei, and
  yet Avithout  the cord being necessarily compressed.  It Avas stated above,
  that, when the head gets doAvn into the  excavation, no portion of the  child
  is left in the uterine cavity, and the empty Avomb then retracts of its  oavh
  accord ;  which retraction determines, as is well known, the separation of the
  placenta, whereby the  utero-placental vessels are inevitably torn, and the
  foetus  placed in the same  condition as if the  cord Avas compressed/and,
  should the expulsion of the head be at all delayed, it might die asphyxiated.
    It  is  not necessary, hoAVever, that the  placenta  should be separated in
  order  to produce  this effect; for, as Van-Huevel remarks,  if the head be
  retained for some time in the cavity of the pelvis, the retraction of the womb
  would of itself obstruct, or even stop the utero-placental  circulation, and
  destroy the foetus by asphyxia.

                             ARTICLE V.
                      PRESENTATION OF THE TRUNK.
    At the commencement of this chapter, Ave ga\^e the reasons that induced
  us, like  Madame Lachapelle, Naegele, and Dubois, to admit but  two  pre-
  sentations  for  the trunk,  and therefore  shall not  uoav  repeat  them;  for,
  doubtless, the reader will bear in mind  that all  the varieties of the trunk
  presentations may be referred to the two folloAving, namely, one of the right
  and one  of the left lateral  plane.
    When the former presents at the superior strait, the child's head,  Avhich,
  in these  cases, is taken  as  the point of recognition, may be found  placed
  over some portion of the left lateral  half of the pelvis, and this  constitutes
  the first position  of the right lateral plane (or of the right shoulder, Lacha-
  pelle) ; or, the head may be situated over some  point of the right lateral
  half, and this is the second position.  We have,  therefore, tAvo positions of
 the right shoulder, or right  lateral plane;  and, in the same  Avay, there  are
 tAvo for the left shoulder, or left lateral plane ; in  the one, the head is to the
 mother's  left (the left cephalo-iliac), and in the other it is at her right  (the
 right cephalo-iliac).
   It is a  very common circumstance  in trunk presentations, to find the  arm
 and hand hanging doAvn in the vagina, or even the latter appearing at the
 vulva.  This, although  regarded  for a long Avhile as a much more serious
 affair  than a proper shoulder presentation, should  be considered as very
 nearly  similar in  its character to the deflexion of the loAver  extremities in
 certain cases of pelvic presentation;  the  older accoucheurs'  have therefore
 erred in describing it as a distinct variety, under  the title of the  presenta-
 tion of the  arm and hand, it being merely an additional phenomenon asso-
 ciated  with  the  presentation of the child's lateral region, and scarcely
 deserving consideration as a variety of these positions; Ave shall see, further
 on, wherein they were mistaken on this point of doctrine.
 Neither of  these theories will bear the slightest  examination, since it is all-suflicient to
 examine the cord,  and the intertwining of  its vessels, to be convinced  that this partial
 compression cannot exist, except under peculiar circumstance-;  that such pressure
 must interrupt the circulation, both in the  arteries and veins, and that it neither aug-
ments nor diminishes the quantity of the child's blood.  Death by asphyxia, therefore,
is the only  possible mode. 
362
LABOR.
  The tr ink presentations are comparatively rare, being a little less so, Iioav-
ever, than those of the face ; thus, Madame Lachapelle met with sixty-eight
cases  in fifteen thousand six hundred and-fifty two labors, or one in  about
two hundred and thirty;  and, in the two thousand two hundred deliveries
reported  by M. P: Dubois,  there were  thirteen trunk presentations.   Dr.
Bland observed it in the proportion of one to tAvo hundred  and ten;  Dr.
Joseph Clark, one in tAvo hundred and twelve ; Merriman, one in two hun-
dred and fifty-five, in his private practice;  M. Naegele, one in one hundred
and eighty ; and Dr. Collins, one in four hundred and sixteen.
  As  to the relati\re frequency of the presentations and positions, it Avould
appear, from the  statistical  tables  of Madame Lachapelle, that the right
shoulder, or the right lateral plane, presents a little  more frequently than
the left;  and  that the dorso-anterior positions, that  is, the first one of the
right  shoulder, and the second of the left, in Avhich the back corresponds to
the anterior part of the uterus,  are more frequent than the dorso-posterior
positions, or the first one of the left and the second one of the right shoulder,
where the  child's back is directed tOAvards the mother's loins.  (Naegele.)

  § 1. Causes.
  We have but little to  say concerning the cause of trunk  presentations,
excepting that the smallness and mobility of the child, a rounded form of
the uterus  produced by a large  amount of  amniotic  fluid, obliquity of the
womb, or of the straits of the pelvis, and distortions of the superior strait,
are generally regarded as predisposing thereto. We can readily understand
that, in the latter case, the contraction of the pelvic entrance might render
the engagement of the head impossible, and by causing it to glide toward
one of the iliac fossse, favor a presentation  of the shoulder.   The insertion
of the placenta upon the neck  of the  uterus, also, seems to  predispose to
presentations of the trunk, inasmuch as out of ninety cases of this character
there  were twenty-one in Avhich the shoulder presented. M. Danyau thinks
that a more plausible explanation may be found in the shape  of the uterus,
whose transverse diameters he supposes to  be greater under  those circum-
stances than usual.  In  support of his vieAV, he  alleges the folloAving case
of Dr. Lecluyse.   A Avoman had her children to present  the shoulder in
three  successive labors, and on the  third occasion, the latter  physician  dis-
covered that the womb, so far from  being pyriform in the vertical direction,
was shaped, so to speak,  like an ellipsoid, Avhose major axis Avas transverse.
whilst the fundus of the  organ Avas but  slightly elevated above the pubis.
  The same explanation  Avas proposed long  ago by Wigand.  Hoav is it pos-
sible,  says  he, for  a well-formed child, whose body represents  an  oval, to
assume, Avithout being compressed or incommoded, an oblique or transverse
position, in a Avomb of an ovoid shape?   Supposing that, impelled by  cer-
tain causes, it should assume these  defective positions for a  moment, Avhat
magical power could keep there  a foetus, Avhose mobility is so highly favored
both by the fluid in Avhich it SAvims, and  the polish of the  internal surface
of the ovum ?  What is there to prevent it, in obedience to physical laAvs,
from  changing its inconvenient position by bringing its long  diameter to
coincide with  the longitudinal one of the uterus ?  No better reply, he adds, 
               MECHANICAL  PHENOMENA  OF  LABOR.          363

can be given to these questions, than by admitting that these defective posi-
tions are due to an irregular shape of the Avomb, rather than to the  move-
ments  which it may have performed.
   Remembering the unfortunate perseverance Avith AA'hich defective positions
recur in the cases  of certain females, there is a strong disposition to seek for
the cause in a peculiar shape of the uterus;  and had a peculiar conforma-
tion of the organ  been discovered before the first  gestation, it might, per-
haps, be admitted, that notwithstanding the development undergone during
pregnancy, the irregularity of shape Avould be preserved.
   Still, Ave may be alloAved to ask Avhether the increase in size  transversely,
near the end of gestation and at the beginning of labor,  may not  be the
effect rather than  the cause of the unfavorable position of the  foetus.
   As to the determining causes, the only ones recognizable are fortuitous and
accidental;  thus, any violent commotion, any trifling shocks, kept up for a
long time, such as those produced by carriage riding, or by exercise  on
horseback, the perturbation from' the upsetting of a coach, and  even sud-
den fright, may change, according to authors, the child's position in certain
cases,  and convert  spontaneously a vertex presentation  into one  of the
shoulder.   Indeed, many accoucheurs have supposed that irregular or par-
tial  contractions might convert, during labor, a favorable position in one of
the trunk; this is  barely  possible.  But I cannot as readily admit the sup-
posed  influence Avhich, according  to some others, those uterine contractions
may have, that torment  the Avoman during the last feAV days, or sometimes
even Aveeks of her gestation, and Avhich  havre before been considered  as the
preludes of labor.    The folloAving is a  case  in  point:  A patient, in  Avhom
the  foetus presented by the shoulder  five times successively, had ahvavs
suffered from these pains during the last feAV  days of her pregnancies; Pro-
fessor Na'gele, under Avhose care she came on the sixth accasion, endeavored
this time to calm the pains, which again appeared with the  same energy
as in  the preceding gestations.   After the ineffectual administration  of
various remedies,  he finally ordered opiate injections, Avhen,  to his  great
satisfaction, the spasms  ceased almost  immediately,  and  were  not  again
renewed, and the Avoman was delivered at full term of a living child,  which
presented in a favorable position.  But what does this prove?  simply that,
whatever may be the child's position, these pains, the preludes of labor, may
appear, and that vicious  positions may be reproduced  in the same woman
with a most deplorable perseverance.  It must be evident that such contrac-
tions are  too feeble to change the child's position in  any Avay, especially
when we remember that the integrity of the amniotic sac, and the presence
of the  waters, likewise protect it from any influence they might have.

  § 2.  Diagnosis.
  There is sometimes reason  to suspect  a trunk presentation, even before
the commencement of labor, from the folloAving signs :  the abdomen is much
larger  in its transverse diameter than usual, and Avhen its Avails  are soft and
flabby, they can often be depressed enough to detect the foetal  head  in one
of the  iliac fossae, presenting there as a hard,  rounded, and resistant tumor;
then by placing the hands opposite each other in the lumbar regions, a 
364
LABOR.
greater and firmer resistance  offered by  the  tAvo extremities of the foetal
ovoid will be felt at these points, and the solid body, formed by the child,
may be readily moved from side to side, thus proving that its long axis lies
transversely above the superior strait.   Finally, the tumor formed by the
head, in the vertex presentations, is no longer detected by the vaginal touch,
and  it  is almost  impossible  to reach the presenting part;  in  some rare
instances, the elboAV, or the little hand of the  child, may be recognized and
ballotted, and this sign, accompanied by the first two, renders the diagnosis
quite probable.
  The form of the  abdomen is then very irregular, especially if  the  uterus
should  contain  but a small quantity of amniotic  fluid.  It has, hoAvever,
been  observed,  that  after the  discharge of the waters, the  longitudinal
diameter gradually becomes greater than the other; because, as M. Hergott
remarks, the transverse position has no longer a real existence, for the body
of the foetus is so curved upon itself  that one of its extremities is lodged in
the fundus  of the  uterus, although  the  other does not correspond to  its
orifice.
  [Although the  use of auscultation in breech presentations is but of doubtful
advantage, M. Depaul thinks that it may enable one to arrive at a correct diagnosis
when the back of the foetus is directed forward.  In this case, he says, everything
is arranged  favorably for the recognition of the  maximum intensity of the sound,
which Avill be found at the anterior part of the lower segment of the uterus as in
head presentations.   In proportion, howeArer, as the position  assumes a transverse
direction, the difference becomes much more decided, inasmuch as the sound, instead
of being heard in a lessening degree toward the fundus of the womb, then extends
in an almost horizontal direction, from one iliac fossa to the other, for example, and
Avill be absent from a large portion of the upper region of the organ.]

  Though *M. Depaul's  opinion is rational and founded on fact, it is none
the less true that  trunk presentations would  almost ahvays remain unde-
tected if Ave had to depend upon auscultation for their recognition.
  Sometimes, however, it may prove a useful auxiliary.   If, for example, a
small member of the foetus be detected by the touch, and the pulsations of
the heart are heard in the hypogastric region, Ave may conclude almost cer-
tainly that the member  belongs to the upper  extremity.  Should the heart
be  heard on a level  with the  umbilicus, it would  most probably prove a
pelvic extremity.
   Before the membranes are ruptured, the elevation of the part renders  the
vaginal touch very difficult;  and  so, of course, the form  of the  bag of
waters, or that of the uterine orifice, can be of but little service.  Accord-
ing to Madame Bohdn, the os uteri dilates more sloAvly, but as this sloAvness
of dilatation is met with in all presentations, excepting those of  the vertex,
it forms a sign of minor  importance; the touch, therefore, can only give  a
positive certainty after the rupture  of the  membranes.  When  the side is
the  presenting  part, the shoulder (Lachapelle) is very frequently found at
 Dhe  centre of the  superior strait, as  also  the elbow, or the side of the chest
 (P. Dubois), and hence will be the first encountered by the finger in making
 an examination;  and Ave therefore  have to point  out  the characters, suc-
 cessively, whereby these several parts may be recognized. 
               MECHANICAL  PHENOMENA OF LABOR.           865

   1. When the shoulder presents, the finger first detects the rounded tumor
 formed by its summit, upon the surface of which a small osseous projection,
 constituted by  the acromion, is  distinguished;  then,  behind or in front,
 according to the position, the clavicle and the spine of the scapula are felt,
 and below the clavicle  the intercostal spaces are easily  made  out, Avhilst
 under tlie spine of the  scapula  there  is only a plane  surface, terminated
 by the ticute inferior angle of this bone, Avhich is  movable and permits
 the finger to  slip  under it; lastly, on  the  sides of the tumor formed by
 the shoulder, the  axillary space can  ahvays be distinguished,  and some-
 times also (though on  the opposite side) the depression  in the neck can
 be felt.
   The shoulder being once recognized, we must  next determine Avhich one
 it is, and Avhat is  its position.   I will remark, in advance, that Ave have
 admitted but four  positions of the trunk, namely, two for the right shoulder
 and tAvo for the left, and that the relation existing betAveen the situation of
 the head and that  of the child's posterior plane is different in each of these
 four.  Thus, there are tAvo positions Avhere  the  head is to the left, namely,
 the first position of the  right and the first of the left shoulder; and remark
 that, in the latter,  the child's back is turned toAvards the mother's loins; in
 the former, on the  contrary, it is in front;  and; therefore, Avhenever the head
 is to the  left  and  the child's  back is behind, Ave have to  treat Avith a first
 position of the left shoulder.
   In the same way, there are tAvo  positions  in Avhich the  head is  to the
 right, to wit, the second of the right  and the second of the left shoulder;
 but again observe,  that  in the  latter the back looks forwards, Avhile in the
 former, on tl>e contrary, it is  directed posteriorly.   Hence, to recognize a
 second position of  the left shoulder, it Avill only be necessary to ascertain
 that the child's head is turned tOAvards the mother's right  side, a*nd that its
 back looks anteriorly.   In a word, to satisfy ourselves Avhich is the present-
 ing shoulder, and Avhat  is its position, Ave only have to find out Avhere the^
 head lies, and the position of the  posterior plane of the child.
   The shoulder  presenting and being  recognized, it is evident that  if the
 axillary space  looks toAvards the mother's  right, the head will be to her
 left, and vice versa; consequently, the situation of the head  is readily knoAvn
 by the direction of this  space,  and, as regards the child's  dorsal plane, the
 omoplate Avill clearly indicate  its  position.
   2. When the elboAv alone is  accessible to the finger, it may be recognized
 by the three osseous projections (the olecranon and the tAvo condyles), Avhich
 it presents by the transverse concavity in the bend of the elbow, and by the
 vicinity of the chest and  intercostal  spaces.  The elboAv having been  dis-
 tinguished, it Avill be necessary to make out  the  position to ascertain  where
 the foetal head and its dorsal plane lie, but this is noAV comparatively easy,
 since the elboAv is ahvays directed toAvards the side opposite to that  Avhere
 the head is found, and the forearm is ahvays placed on the anterior plane.
  Again, as above stated, it happens at times that the forearm is not doubled
 up, but that, on the contrary, the  hand  hangs doAvn in the vagina, or even
appears at the vulva.  Noav, to determine which is the  presenting hand in
those cases, it is necessary to turn it in such a Avay as to place its palmai 
366                             LABOR.
 surface in front and above, for, in this position, if the thumb be directed to
 the mother's right thigh, it is the right hand, but if to  the left thigh, it is
 the left hand ;  and then, to find out where the head is, the  accoucheur must
 slip his finger up to the axillary space.
   [The advice just given would enable us to recognize with certainty the projecting
 hand; the misfortune is that it is so easily forgotten.  Therefore we think it better
 that the operator should simply observe which of his  oavh hands would fulfil pre-
 cisely the conditions of that of the foetus as to position, for then the diagnosis would
 be just as certain, inasmuch as, Avith the exception of the size, the right hand of an
 adult is formed precisely like the right hand of the child, and so Avith the left hands
 of both, whilst marked differences exist in the reciprocal arrangement of the parts
 composing a right hand and a left one.]

   When  the hand comes out at the Vulva, a careful inspection of it will
 most generally be sufficient to establish  the diagnosis.   Thus, if its  dorsal
 surface is turned tOAvards the patient's right thigh,  the head is at the right,
 and if to the left thigh, the head is at the left.   The little finger, directed
 towards the  coccyx,  indicates that  the  child's dorsal plane corresponds to
 the mother's loins, and the same finger pointing to the pubis, is an evidence
 of this plane being in front.
   We have been thus particular in the diagnosis,  because it is all-important
 in trunk presentations  to  understand clearly Avhich side presents at the
 strait, since the  accoucheur must ahvays endeavor  to turn; and if the details
 just given prove difficult of comprehension from a  single reading, we hope
 they Avill become clearer by practising on a mannikin.

   §  3. Mechanism.
   When  the trunk  presents at the superior strait, the labor nearly ahvays
 requires the intervention of art; though, in some rare cases, Avhich may be
 considered as altogether exceptional,  nature alone is  adequate to accom-
 plish the delivery, which  may then take place  in  one or two Avavs; for
 either the presenting shoulder is driven from the superior strait under the
 influence  of the uterine contractions  alone, to make room for one of the
 child's extremities, thereby producing  a  change in position, and giving rise
 to what is designated as spontaneous version, or else  the presenting shoulder
 descends  into the excavation and  engages at the inferior strait; notAvith-
 standing Avhich, the  breech SAveeps along the Avhole anterior surface of the
 sacrum and  of the perineum,  and  is  delivered  the first  at the  posterior
 vulvar commissure;  this latter mechanism is called  spontaneous evolution.
   1. Spontaneous Version.—-Where the membranes are not ruptured, though
 the labor has actually commenced, the foetus sometimes enjoys a great lati-
 tude  of motion  in the amniotic  cavity, in  consequence of Avhich  it might,
 in such cases, readily change its position before the discharge of the Avaters
 took place;  and it has been knoAvn  to present, in this Avay, different points
of its surface during the first period of the labor.  Sometimes the head
 ascends in the Avomb Avhile the breech descends; at  others,  on the contrary,
 the nates  mount up towards the fundus uteri, and  the head  becomes located
at the superior  strait.  Consequently, two varieties of spontaneous version
have been admitted, i. e., the cephalic and the pelvic. 
               MECHANICAL  PHENOMENA OF  LABOR.           367

  This phenomenon usually occurs either just before or else soon after the
membranes  are ruptured;  in some instances, however, it takes place a long
time after the waters  are  discharged.  The following case, reported by M.
Velpeau, Avill give a very correct idea of Avhat  occurs  under such circum-
stances :  ;'A young woman, pregnant for the second time, came into the
hospital at ten o'clock in the morning.  The os uteri Avas very little dilated;
nevertheless, I could recognize a second position of the  left shoulder.  The
waters did not escape until three in the afternoon, and I did not wish to go
after the  feet, as the pains were neither very strong nor very7 frequent, and
I had  some  confidence  in the  assertions  of Denman on this subject.  At
eight o'clock  in  the evening, the shoulder had sensibly moved toAvards the
left iliac  fossa, and I could then readily detect the ear at the right.  At
eleven, the temple had almost gained the centre of the orifice;  the contrac-
tions were  augmented in energy ;  and the cervix  Avas entirely effaced.  At
midnight, the  vertex  had become  lower;  the head engaged;  and, in the
course of an hour, the vertex Avas  delivered in the right occipito-cotyloid
position."1
  This  case,  in  Avhich the progress of the labor has  been followed and
described, step by step, is Avell suited for explaining the  mechanism of spon-
taneous cephalic version.  The reader Avill easily comprehend that the same
phenomena Avould take place, if the breech, instead of the head, descended
towards the  superior  strait; and, in the above  instance, for  example, the
shoulder, instead  of being driven toAvards the left iliac fossa, Avould be forced
to the mother's right, and then the side of the chest, the loins, the left hip
and  thigh, Avould successively appear at the  upper strait, and the breech
finally engage in the excavation.
  In  a shoulder presentation, the  arm and hand may hang doAvn in the
vagina, or even protrude beyond the vulva; but this last circumstance does
not preclude the  possibility of  a spontaneous version, only it is Avell to bear
in mind that the arm may then  ascend again into  the uterine cavity, and
this will  almost certainly happen  if the pelvic extremity descends into the
excavation, but it may also lodge  on one side of the pelvis, and thus permit
the head  to  descend  alongside of it;  the presentation of  the cephalic
extremity being then  complicated by a procidentia of  the arm and hand.
In the present state of  our science, it Avould be a very difficult matter
indeed to point out the various causes, under the influence of Avhich it is
sometimes the head, and sometimes the breech, Avhich thus, in cases of spon-
taneous \rersion, take the place previously occupied by  the shoulder, at the
superior strait.   Nevertheless,! am inclined to believe  that irregularity of
the uterine  contractions is not Avholly foreign to  such  an effect.   In fact,
Avhen  Ave  shall speak hereafter of what the German accoucheurs have

  1 With regard to the case in the text, I may say briefly, that the course of M. Velpeau
was legitimized by the desire he had of "testing the opinions at that time (182o) in dis-
pute ; but young practitioners should  be very cautions  how they make such experi-
ments :  for although, in the  hands of a man like Velpeau, the version, at an advanced
period of labor, would have been comparatively easy, yet it must never be forgotten
that,  in trunk presentations,  the  soonest  possible  period after the rupture of the
membranes is the most favoraMi- for  the artificial version. 
368
LABOR.
described under  the name of Partial Contraction  of the Womb, it Avill be
seen that, in some cases, the organ appears to contract in but a limited part
of its extent,  the remainder contracting with much less force, or even per-
haps  remaining  entirely inert.   Now, Avithout being able to cite a single
instance in support of my opinion, I am strongly  inclined to belieAre, that
it is in such a condition of the uterine walls that spontaneous version would
be  the  most  likely to take place.  Let  us suppose, for example,  that
when the child  is placed in a left cephalo-iliac position of the right shoul-
der, the left side  of the uterus alone contracts, the right remaining passive;
it is manifest  that the whole expulsory effort, being then  exercised on the
head, would necessarily depress it towards the centre of the superior strait;
and this movement of the cephalic  extremity will be easy, in proportion as
the inertia of the fight lateral Avail of the womb shall oppose no obstacle to
the elevation of the pelvic extremity.   But if, on  the contrary, (in the same
position of the child),  the  right  side of the Avomb only contracted,  it is
evident the breech alone would receive the impulse from the uterine efforts,
and then a spontaneous podalic version would be observed to take place.1
  2. Spontaneous Evolution.—The mechanism of spontaneous evolution is
much better understood, and Ave shall find embraced in its descriptions all
the divisions of the mechanism of natural labor in the vertex and face pre-
sentations.  Here,  also, M. Velpeau has admitted  two varieties, that  is, a
spontaneous cephalic, and a spontaneous  pelvic evolution.   But Ave cannot
conceive hoAv a spontaneous  cephalic  one can take place, unless it be in
cases of abortion, or in those Avhere the child is completely putrefied ; hence
we shall treat of the pelvic variety alone,  taking, as an example, the first
or left cephalo-iliac position of the right shoulder, in Avhich the child's head
is placed in the left iliac fossa, the breech  in the right iliac fossa ; the dorsal
plane being in front, and  the sternal one behind, and the long axis situated
very nearly in the direction of the transverse diameter of the upper strait.
   Under such circumstances nearly all the Avaters escape immediately after
the membranes are ruptured; then  the  uterus  contracts forcibly,  and by
compressing the foetal  trunk on  all  sides, has  a tendency to make the pre-
senting part engage in the excavation.
   A. First Stage.  Doubling up of the Child.—Under the  influence of the
uterine  contractions, the child is strongly bent in the  direction  of its  long
axis tOAvards the side opposite  to  the presenting one; for instance, in the
case before us, the head is bent to the left side, and the breech toAvards the
hip of the same side.
   b. Second Stage.  Engagement. — A second stage, the period of descent,
then sets in;  that is to say, in proportion as the contractions are renewed,
the shoulder approaches more and more toAvards the inferior strait,  and the
fcetal trunk, being bent double,  engages deeply in the excavation.  But
the same difficulty is  here  met Avith as in the face  presentations (see Posi-
tions  of the Face); that is, the body being thus placed transversely, it is
impossible for the shoulder to reach the lower strait unless the head engages
simultaneously with it in the excavation ; or, indeed, unless the neck should

  1 It is proper for  me to acknowledge that Wigand had already given a similar oxpla-
aation. 
MECHANICAL  PHENOMENA  OF  LABOR.           369
be long enough to subtend the height of the lateral Avail of the latter, which
we have already seen is impossible (see Mechanism of Face Positions).   The
descent of the shoulder is therefore limited to the length of the neck.
  c Third  Stage.  Rotation. — A  movement  of rotation next occurs, by
Fio- 88.                                   Fig. 89.
First position of the right shoulder with                 The same position (luring the descent.
     the arm hanging down.
 which the long axis of the child, that was  originally placed transversely,
 is brought very nearly into an antero-posterior direction, so that its cephalic
 extremity is placed above the horizontal branch of the pubis close to the
 spine of that bone, and the breech  above, or rather in  front of the sacro-
 iliac symphysis.   This process of rotation being  once effected, the descent
 may noAV be completed, since the side of the neck is  placed  behind the
 symphysis pubis,  whose  Avhole length  it can  subtend; consequently, the
 forearm  and arm are found to appear at the vulva, and  the shoulder to get
 under the arch of the pubis.
   D. Fourth Stage.  Disengagement of the Trunk. — The trunk, being now
 bent double, is forced en  masse into the excavation, under the influence of
 the poAverful uterine contractions, but the shoulder can descend no further,
 because  it is arrested  by the shortness of the neck;  hence, the expulsive
 force acts on the pelvic extremity, Avhich is pressed more and more towards
 the floor of the pelvis, and traverses the whole anterior face of the sacrum.
 It then rests against,  depresses, and forcibly distends the perineum; the
 vulva soon dilates, and the acromion  remaining always fixed under the sym-
 physis, the following parts are observed to appear successively at the ante-
 rior  perineal commissure: first, the  superior lateral  parts of the chest;
 next, its  inferior  part, the loins, the hip, the thighs ;  and lastly7, the whole
 length of the inferior extremities ; and  there remain only the head and the
 left shoulder in the excavation.  This last movement may be considered as
 the fourth stage of the labor, and it is therefore named the period of deflexion
 or disengagement.   It takes place around the shoulder, situated under the
 symphysis as a centre, and therefore, if lines be draAvn from this centre, ter-
 minating  at  the various points on the child's side, Ave shall have all the
radii, or  the foetal diameters, which  clear the  antero-posterior  one of tho
inferior strait.
       24 
370                              LABOR.

  [e. Fifth Stage.  Rotation of the  Head. — When  by spontaneous  evolution  the
body has been disengaged, the conditions have become the same as in breech presen-
tations  In the fifth  stage, therefore, the head  rotates so as to bring the occiput
behind the symphysis pubis.
  f.  Sixth Stage.  Expulsion of the Head.— In the last stage the head is deli\'ere<l
as in breech cases.]
  Such is the exact mechanism of the spontaneous evolution  in those casea
where the child's posterior plane was originally in front; or, in other words,

 Fig. 90. Position of the child after the rotation, and just at the moment when th>j process of disengagement
begins.
 Fio. 91. The same position with the delivery more advanced.

in  a first position of the  right or a second of the left shoulder, for there is
no difference in this last, excepting that the movement of rotation must
take place in the opposite direction, that is, the head must pass from right
to left and from behind fonvard, and the breech from left to right and from
before backAvards.   But when the sternal plane of the  foetus is  primitively
directed toAvards the mother's front, as  in the first position of the left,  and
the second one of the right shoulder, the process takes  place somewhat dif-
ferently.  M.  P. Dubois, who  had  an  opportunity of  seeing  two cases of
this nature, informed me that, at  the  moment Avhen the breech disengaged
at  the anterior  perineal  commissure, the child's Avhole trunk undenvent a
movement of  torsion that again brought its dorsal plane forwards  and up-
wards, Avhich  plane, without this process of torsion, Avould  still have been
directed tOAvards the anus; Avhence Ave  find, even here, remarkable as it
may seem, the influence of that general laAV which Avas observed to regulate;
ail  natural labors, namely, that, whatever may have been  the original rela-
tions of the child's posterior plane, it ultimately comes into correspondence  with
the anterior parts of the pelvis.
  As observed in the commencement of this article, the mechanism of spon-
taneous evolution may be subjected Avithout impropriety to the same divi-
sions as the deliveiy by the face.   In fact, we have a first  period of flexion
cf the child's trunk toAvards the side opposite to the presenting one; a second,
of descent,  irterrupted  by  the third movement, or period  of rotation; a
Fig. 90.
 
MECHANICAL PHENOMENA  OF  LABOR.
371
fourth, of deflexion, or disengagement, and  a fifth  and sixth, during which
the head rotates, and is finally expelled.

  § 4.  Pk<h;xosis.
  We again repeat, for it seems highly important that this should be firmly
impressed on the mind, that in trunk presentations a spontaneous expulsion
of the child is Avholly an exception to the general rule, and one upon which
no reliance can be placed, unless in a case of abortion; and that the resources
ff our art are demanded in every case just as soon as the necessary condi-
tions exist for such intervention.   (See Version.)
  In fact, by consulting the published cases, or indeed by simply reflecting
on the  mechanism by Avhich the  delivery is effected, Ave realize hoAv this
must expose the Avoman to a very long and painful labor, and  the foetus to
so violent a compression  that its death  must often result in consequence.
According to the statistics furnished by  M. Velpeau, one hundred and
tAventy-five children, in one hundred and  thirty-seven, Avere still-born.  It
must not be supposed, hoAvever, as some persons appear to have done, that
this mode  of delivery is only possible in  cases of abortion; for facts too
numerous militate against this opinion for  it to be any longer tenable.
   Burns justly remarks, in endeavoring  to demonstrate the  physical  possi-
bility, that the greatest diameter measures five inches and a half; sometimes
the distance  is barely five  inches, and continued  force may make it less;
hence, provided the dimensions of the pelvis are slightly greater than in
their normal condition, there is nothing here physically impossible,  as has
been affirmed and reaffirmed, doubtless Avithout mature  reflection.  The
favoring circumstances Avhich  render  a spontaneous evolution easier  and
more likely to take place are : a premature labor, the smallness of the child,
a large pelvis, strong  contractions, diminished resistance from the soft parts,
numerous antecedent labors, and  the readiness  with Avhich  the Avoman has
heretofore  been delivered of large-sized children.  The opposite circum-
stances Avould render  it exceedingly difficult, if  not wholly impossible.


                          ARTICLE  VI.
         REVIEW OF THE MECHANISM  OF LABOR IN  GENERAL.
   A curious fact  in  the mechanism of labor, and one Avhich  has claimed
the attention  of all modern accoucheurs,  amongst whom Ave may mention
especially MM. Dubois and Jacquemier, is, that whatever the  presentation
may be, the movements undergone by the foetus during its expulsion are
always the same.   Finally, Professor Pajot  made a clear statement of this
single mechanical laAV, and applied it to all the presentations.  " We main-
tain," he says, "that all labors, so far  as the mechanical phenomena Avhich
they present are concerned, are governed by the same law.   There is, in fact,
but one mechanism of labor, whatever the presentation and position may be, pro-
vided the expulsion takes  place spontaneously, that  is to say, Avithout the
intervention of art and at term, for in cases of abortion the  expulsion is not
of the  regular character."  (Pajot, Dictionnaire Encyclopedique des Science.
Medicales.) 
B72
LABOR.
  We accept fully this vieAV of the subject, and repeat that all spontaneous
labors obey the same lasv as respects their mechanism. The presenting part
of the foetus is first modified, as to its size or direction, in order to adopt it
to the opening of the superior strait;  then  it descends into the cavity of the
pelvis,  and having reached the  inferior strait turns, so as to present  its
longer diameters to the longer diameters of the pelvis, and not until  it has
undergone this series of movements is the vulva cleared and the expulsion
complete.
  We have thought that the transition would be easier from this simplicity
of facts to the region of  theory, if the classification of the different  stages
of labor were  someAvhat modified. Although the most recent classifications
are wonderfully simplified, they still fall short of entire uniformity, present-
ing here and there some omissions and a feAV  contradictions.   For instance,
in deliveries by the vertex or face five stages are described, the first four of
which are really executed by the  head, then the rotation of the body is
described  as the fifth and last time, without  considering its final expulsion,
which is merely^  mentioned.   The disengagement of the body being thus
disregarded, students are liable  to forget  an  important cause of  dystocia
described  by Jacquemier, viz., the large size of the shoulders.   In  cases of
delivery by the head, a fifth stage, that of rotation of  the body, is described,
why, therefore, not be logical  throughout and admit a  sixth stage for its
expulsion ?
  In breech labors, four  or even five stages are commonly described.  It is
well, indeed, to recognize, as do MM.  Dubois and Pajot, a first stage for the
diminution in size and modelling of the presenting part; then  the engage-
ment, rotation, and expulsion of  the body will correspond with the second,
third, and fourth stages.  Up to this point there is entire uniformity between
labors by the  head and  breech, but for the  fifth stage  in breech  cases we
have a  confused account of the  internal rotation of  the head  and. its final
expulsion.  The fifth stage,  which in a  uniform nomenclature ought to
recall similar  things, Avould, in this case, seem to imply a notable difference
betAveen the  various kinds of delivery;  for, in the same stage in  vertex
presentations,  the body rotates Avithout being expelled, Avhilst in breech cases
the head rotates and is expelled at the same time.  In order, therefore, to
remove  this apparent difference, it Avere better  to divide the fifth  stage of
delivery by the pelvis into two stages, the fifth  for the internal rotation of
the head, and the sixth for its final expulsion.   The throwing of these tAvo
stages into one, is essentially the same as confounding the third and fourth
stages of  delivery by the vertex.
  In order to  remove these imperfections and contradictions we have, there-
fore, described six stages in the mechanism of labor in each of the presenta-
tions ;  an innovation Avhich has the advantage of showing clearly that this
mechanism is uniform throughout.  These views have been taught in  our
lectures, in  the  text of  the Atlas Complementaire de tous  les  Traites d'Ac-
couchements, by Lenoir, and one of our students has made it the subject of
his inaugural  thesis.  (Granier.  Theses de Paris, 1863, No. 98.)
  For the clear understanding of this uniformity of  the general laws of the
mechanism of labor, we should  observe in  the first place  that the foetus, 
MECHANICAL  PHENOMENA  OF  LABOR.
373
doubled up as it is in the cavity of the uterus, with its limbs pressed closely
against the chest, and the neck concealed betAveen the base of the head and
the upper part of the  chest, forms really but tAvo distinct parts, the  head
and the body. Noav let us for a moment imagine these tAvo parts to be  sepa-
rate and  independent, and that they presented* themselves one after the
other;  then Ave should have four stages for  the  expulsion of each.  The
head Avould be flexed, engage, rotate, and be delivered ;  nor Avould this suc-
cession of phenomena be in any respect altered whether the engagement of
the head should precede or folloAv that of the body.   The delivery of each
of these  tAvo parts of the foetus Avould then present  similar phenomena to
the observer; nor Avill  there be the least  occasion for surprise, Avhen we con-
sider that the section of each presentation  gives an almost oval figure, the
longer  and shorter diameters of Avhich are adapted in the same way to the
curvature and form of the genital passages.
  Setting hypotheses aside, if Ave examine a  foetus closely, we shall be at
once struck Avith the fact that it represents two superposed masses, the head
and the body so united by the  neck that one cannot progress Avithout the
other;  and that Avhilst the presenting part undergoes its four movements
of compression,  engagement, rotation, and disengagement, the remaining
part has  also become flexed and engaged, in other words,  has performed its
two first  movements.
  On the other hand, Ave observe, whilst examining a foetus, that the long
diameters of  its two superposed  parts (head and body)  have opposite direc-
tions, from before backAvard for the  head,  and  transverse for  the body.
These  two diameters  are  also  at right angles  to  each other,  whence it
happens that Avhen one of the two parts has a  direction adapted to its ready
exit from the pelvis, the other will have an opposite direction.  For example,
when the head disengages from  before backward at the vulva, the shoulders
are situated transversely at the inferior  strait; Avhich  renders it necessary
that the head and body should  perform  successively the  same mechanical
movements of rotation and disengagement.
  If Ave note, therefore, such mechanical phenomena only as are apparent
and palpable, such, in fact, as the accoucheur is expected to detect at any
moment, Ave shall hav-e in the  first place to  observe successively the four
motions performed by the part Avhich engages  first, and next the final move-
ments of rotation and expulsion of the second part of the foetus.
  We have thus to describe six  stages in the delivery:
        1st Stage..................Compression  ")
        'Id Stage..................Engagement   J-of the first foetal part.
        3d Stage..................Rotation      J
        4th Stage..................Disengagement ~|
        5th Stage..................Rotation      lof the second  foetal part.
        6th Stage..................Expulsion     J
  In the  following table are recapitulated the six stages  in the mechanism
of labor  for all the presentations.

        TABLE of the six Stages of Labor in all the  Presentations.
                              (of the vertex.........by flexion.
                              of the face............by extension.
                              of the breech.........by folding.
                              of the body...........by folding.
   1st Stage.
 Adaptation of  J
the presentation 
374                                 LABOR.
  2d Stage.
Engagement.
/ Taking place in
\  presentations
   3d Stage.
Rotation of the-. ^^^
 presentation.   I pubi
  Bringing under
i the  arch oft the
  4th Stage.    j Taking place in
Disengagement. \ presentations

  5th Stage.     rT}  .         ,
o * *•     e a   I Bringing under
Rotation of the  .,    °  °  „ ,,
 second fcetal  J thl arch  of theH
part.
\ pubis
   6th Stage.   f
Final expulsion. \
By disengage-
    ment
'of the vertex.........by sliding.
 of the face...........by sliding.
 of the breech........ by sliding.
 of the body........ ...by sliding.
 the occiput............for the vertex.
 the chin................for the face.
 a hip....................for the breech.
 a shoulder.............for the body.
'of the vertex.........by extension.
 of the face............by flexion.
 of the breech..........by progression.
 of the body............by lateral flexion.
'a shoulder.............in casesof vertex presentation
 a shoulder.............in cases of face  presentation.
 the occiput............in cases of breech presentation.
 the occiput.............in  cases of body presentation
                      (spontaneous  evolution).
 of the body ..........in cases of vertex presentation.
 of the body...........in cases of face  presentation.
 of the head............in casesof breech presentation.
 of the head............in  cases of body presentation
                      (spontaneous  evolution).
  By applying  this  general  classification to each  presentation  separately,
v»e obtain entire uniformity for the mechanism of every k.'nd of labor.

                                   VERTEX.
               1st Stage..................Flexion of the head.
               2d Stage...................Engagement of the head.
               3d Stage...................Rotation of the head.
               4th Stage...................Disengagement of the head.
               5th Stage..................Internal rotation of the body.
               6th Stage..................Expulsion of the body.

                                    FACE.
               1st Stage..................Extension of the head.
               2d Stage...................Engagement of the head.
               3d Stage...................Rotation of the head.
               4th Stage..................Disengagement of the  head.
               5th Stage..................Internal rotation  of the body.
               6th Stage..................Expulsion of the  body.

                                   BREECH.
               1st Stage..................Folding of the breech.
               2d Stage...................Engagement of the breech.
               3d Stage...................Rotation of the breech.
               4th Stage..................Disengagement of the breech.
               5th Stage..................Internal rotation  of the head.
               6th Stage..................Expulsion of the head.

                         BODY.  (Spontaneous evolution.)
               1st Stage..................Folding of the body.
               2d Stage...................Engagement of the body.
               3d Stage...................Rotation of the body.
               4th Stage..................Disengagement of the body.
               5th  Stage..................Internal rotation of the head.
               6th Stage..................Expulsion of the head. 
TWIN   LABORS.
375
                         CHAPTER  IV.
                            TWIN  LABORS.
  Although the expulsion of the child often takes place in twin pregnancies
with as much facility or sometimes even with greater rapidity than in ordi-
nary labors, yet it must not be supposed that the whole duration of the
labor is ahvays shorter; for very often, on the contrary, the parturition will
be found to drag along, and become tedious.   Indeed, by reflecting on the
circumstances Avhich then  complicate the process, it Avill not be a difficult
matter to explain this  unusual delay, since it is well known that  an exces-
sive distention of the Avomb greatly diminishes both the force and frequency
of its contractions; and, as the labor often comes  on before the end of the
ninth month, the  cervix uteri  has not yet undergone those modifications
which usually render its dilatation at term quite easy; besides Avhich, the
elevation of the presenting part, Avhose engagement is impeded by the pre-
sence of  the  second foetus, also assists in retarding this  dilatation.  The
stage of expulsion, Avhich  the small size of the twins Avould at first sight
seem to facilitate, is often delayed  by the feebleness of the contractions, and
also by the decomposition and considerable loss of the force occasioned  by
the presence  of an ovum, still remaining intact  Avithin  the cavity of the
womb; and such  is  the unfavorable influence of this latter circumstance,
that  it  is only through  the thickness of the second  ovum that the contrac-
tions of the greater  part of the uterine fibres  can possibly reach the body
of the  child  that  first  presented  at  the upper strait.  But  Avhen the first
child presents  by  the  pelvic extremity, the escape of the head is particu-
larly apt to be  attended Avith difficulties; for, if the perineum be resistant,
even in a slight degree, as in primiparse, for example, the intervention of
art will nearly  ahvays be  indispensable, because  the  uterus, being Avholly
occupied  by the other ovum, can  have no further  influence on the head of
the first.
  The  folloAving table, Avhich gives the presentation of both children in
three hundred  and twenty-nine cases of twin pregnancy, will serve, as a
matter of curiosity, to sIioav the relative frequency of the positions.
I.N 329 TWIN PItEGNANCIES, THE TWO CHILDRKX PRESENTED AS FOLLOWS:			
Both by the head. 134 times.	The 1st by the head ; the 2d by the breech. 55 times.	Both by the breech. 12 times.	The 1st by the brect-h; the 2d by the head. 31 times.
The 1st by the breech; the 2d by one foot. 11 times.	Both by the feet. 8 times.	The 1st by the feet; the 2d by the head. 29 times.	The 1st by the breech ; the 2d by the elbow. once.
The 1st by the head; the 2d by the shoulder. 7 times.	The 1st by the face; the 2d by the head. once.	The 1st by the feet; the 2d by one hand. once.	The 1st by the feet; the 2d by the breech. once.
  Nearly ahvays the twins present one after the other at the superior strait,
and  the  expulsion of the first is  promptly folloAved by the birth of the 
376
LABOR.
 second; and  the same is true of the others Avhen there  are more than tAvo
 But it occasionally happens that the labor does not progress so regularly
 and that the children may be born  at  a considerable interval  from each
 other, and their expulsion rendered  difficult by the attendant  delavs and
 dangers.   It most  generally happens  that the womb, being fatigued bv the
 efforts necessary for the expulsion of the first-born, retracts a little after this
 partial depletion, and remains in a  state of rest for some minutes, in conse-
 quence of having  lost a part of its contractile  properties;  still retaining,
 however, a greater volume than  usual.   By placing the hand on the  ante-
 rior abdominal  region, the accoucheur will  be able to verify the abnormal
 size of the organ, and to  detect, through this Avail, the inequalities apper-
 taining to the  foetus; besides, another  amniotic pouch, or the  presenting.
 part of a  second child, can readily be detected at the upper part of the
 uterine neck by the vaginal  touch.   In general,  the repose of the womb is
 but momentary, and  in about a quarter  of an hour, sometimes  at the end
 of five or ten minutes, though  rarely later than twenty or thirty minutes,
 the  patient feels the  pains coming on again;  at first feeble and sIoav, but
 soon becoming stronger and more energetic.   Care should  be taken to rup-
 ture the membranes, if this had not  already occurred, and  then to abandon
 the rest of the labor to the powers of nature.   This second delivery is soon
 over, as a general rule, Avhen  the foetus  presents in a natural position, for
 the parts have been so enlarged by  the passage of the first child, that they
 offer but  little  resistance to the escape of the  second.   But in some cases,
 the pains Avhich have been suspended after the  birth  of one of  the tAvins,
 do not reappear for some hours, and sometimes even not for several days.1
  Noav, what is  to be done in  cases of this kind ?
  "When  the two children present well, and the expulsion of the first is
 effected naturally,  and Avithout  great fatigue to the Avoman, I wait," says
 Merriman, " until the pains of the  second childbirth come on;  ordinarily,
 this happens shortly after the escape of the first-born.   If efficacious pains
 do not occur in the course of a quarter or half an hour, I provoke the con-
 traction by rubbing the abdominal tumor gently with  the  hand, and by
 titillating the os  uteri Avith the finger; if these irritations, made simul-
 taneously  on the body and neck, are  ineffectual, and several hours elapse
 without the womb contracting, I deem it advisable to excite the contractions,
 by rupturing the membranes, after having previously administered the ergot.
 This course is based on the two folloAving reasons: where we have delayed
 too long a time,  the pains  have  ahvays  appeared to me more severe  than
 they would have been if the action of the uterus  had been solicited sooner;
 and the expulsion of  the  second child has  commonly seemed to me more
 easy through the parts recently dilated by the first delivery."
  1 Four Avomen, registered in the Dublin Hospital, were delayed ten hours in the
 delivery of their second child. The reader will also find, in the Medical  and Physical
 Journal (April, 1811, the details of a case in which the second child was not born until
 fourteen days after the first; and the author of that communication states, that another
 case had come to his knowledge, in which six weeks had elapsed between  the birth of
 the  twins.  A woman was delivered on the 4th of March, 1814,  of two children; she
 found herself so well on the second day that she rose to attend to  her affairs, but, on
'the  sixth, she was again delivered of tvo more. (Gentleman's Magazine, 1814.) 
PREMATURE  AND RETARDED  LABORS.
377
   Iii all such cases, our rules of conduct  should be based on the condition
 of the Avomb itself, rather than on the length of time that may have elapsed
 since the birth  of the first child; because it must be evident that relaxation
 and inertia of this organ  Avould forbid all attempts at extraction, and that
 Ave should never endeavor to deliver the second child before having excited
 the organic contractility of the uterus, by all the available means.  If, by
 chance, these measures prove inadequate, it will be better to wait several
 hours, or, if necessary, even for several  days, rather than  expose her to the
 terrible consequences resulting from inertia.

   [The presentation and position of each child in twin labors are  detected by the
 same signs as when one child only is present, observing, however, that it is neces-
•sary to be careful in respect to the data supplied  by palpation and percussion, for
 the presence of tAvo children in the womb alters greatly the results afforded by the
 former; so that although these  measures may sometimes prove helpful, they  may
 also very easily lead into error.
   That auscultation is equally unreliable and  may be deceptive,  will be understood
 from the fact that the idea of the position of the first child may be formed  from the
 maximum intensity of the cardiac pulsation of the one which is born last.
   What has been already said  in regard to  the touch, will  suffice for twin cases
 also, although difliculty may arise from the simultaneous  engagement of both chil-
 dren— for which case we refer to the subject of dystocia.   (See  Dystocia.)
   The  expulsion  of each child  is subject  to the  usual laws  which  govern the
 mechanism of labor as already described, so that we have  only to add that  as twins
 are often small and born prematurely, the inequalities in the mechanism  of labor
 are more common, especially as regards the second child, which traverses the genital
 passages which have been enlarged  by the first one.  In short, we have only tc
 regard  a twin labor as two successive deliveries.]
                            CHAPTER  V.

                OF PREMATURE AND RETARDED LABORS.

                             ARTICLE  I.
                          OF PREMATURE LABOR.
   When a Avoman is delivered in the seventh or eighth month of her gesta-
 tion, the labor is said to be premature.  Now a great number of causes may
 determine the expulsion of the child, before  the ordinary term of its intra-
 uterine life; such, for instance, as an excessive distention of the Avomb, Avhether
 this be occasioned by too great a quantity of the amniotic liquid, by hydror-
 rhoea, or by the presence of tAvo or more infants in the uterine cavity; the
 accidental death of the foetus;  the artificial evacuation  of the liquor amnii;
 any Ariolent muscular effort; the abuse of strong purgath'es ; various acute
 diseases, more especially  those of the skin;  and  certain  conditions of the
 animal economy, as plethora, great debility, or an excessive irritability and
 sensibility.  Finally, in a singular case already mentioned, premature labor
 occurred eight times  consecutively, in consequence of extreme itching of the
eirface. 
378
LABOR.
   Delivery before term  is said to be  often  preceded by  a severe chill
 Burns supposes that this  chill occurs immediately before or after the death
 of the foetus.  I have no recollection of having observed anything of the kind.
   In some cases, the uterus is fully developed prior to the ordinary term of
 gestation, and  then'the contraction commences and goes on as regularly as
 usual; but in  most instances, the organ has not as yet undergone  all the
 necessary modifications for the  proper  accomplishment of labor, and  the
 latter, consequently, exhibits  numerous  irregularities  in  its course.   The
 uterine neck  and orifice  are  not yet properly  effaced  and  softened.  For
 example, it is  not at  all  uncommon to find the neck sufficiently dilated,
 during the primary pains, to permit the introduction of the finger, and this
 notAvithstanding the lips are still thick and of a considerable length.  This
 length of neck  must greatly retard the dilatation, for the latter cannot really'
 commence until  after the  effacement is completed, which  often  proves a
 tedious process.
   This first, or preparatory, stage is marked by pains that are very irregular
 both in their duration and intensity, accompanied by  a feverish state;  the
 patient experiences a very distressing sensation of weight about the belly,
 and she is  usually restless and agitated.   When the cervix is once effaced,
 the os uteri begins to dilate; but this dilatation is much sloAver than at term,
 because  the neck has not yet  attained  the same  degree of softening, and
 therefore offers more resistance to the contractions of the body.
   But, although the first stage is  somewhat  longer,  the second, or that
 Avherein  the expulsion  occurs, is generally shorter than in labor at term,
 OAving to the small size of the child;  nevertheless, this advantage is often
 counterbalanced  by the irregularity and  the spasmodic nature of the con-
 tractions, which are then more apt to assume this form  than under ordinary
 conditions.  For, as the muscular organization of the uterus is not yet com-
 plete, Ave can  understand Avhy  its contractile poAvers are less  perfect; and
 also, on  the other hand,  how the morbid  cause  Avhich has developed a
 premature  action in  it must  necessarily influence  the regularity of their
 contractions.
  The vertex  presentations are far  from  being so frequent  here as in  the
 natural labor at term, and  those of the breech, according to M. P. Dubois,
 are proportionably more  common as the  labor is  more premature.  For
 instance, in ninety-six  still-born children, delivered during the last two
 months of  gestation at the hospital of La Maternite, seventy-tAVO presented
 by the head, twenty-two by the pelvic extremity, and two by the shoulder;
 whilst in seventy-three living children, who had only reached the seventh
 month of intra-uterine life, sixty-one presented the head, ten only the breech,
and two  the shoulder.  Hence, it is evident that the number of pelvic pre-
sentations  in premature parturitions is  comparatively greater where  the
children  are born  dead,  and  also  that, Avhen  the foetuses  are living,  the
podalic extremity7 presents first much oftener than in ordinary labors.
  Finally, according  to Burns, Avomen who are taken  in labor before term
are more exposed than others  to  hemorrhages during its progress, and  the
delivery  of the after-birth is both more difficult and more liable to accident
than usual. 
              PREMATURE AND  RETARDED  LABORS.           379

  " When a  Avoman  is threatened with premature labor," continues  the
author just named, " Ave ought, unless we are sure of the death of the child,
to endeavor to check the process, Avhich is done by keeping the patient cool
and tranquil in the horizontal position, bleeding her in the arm if she  be
plethoric, or the pulse be throbbing; but above all, by administering opiate
injections  immediately (forty to  sixty  drops of Sydenham's laudanum, in
tAvo or three doses, in the course of a couple of hours)."
  When the  labor  is once  established, it  is to be conducted much in the
Bame way with parturition at the full  time;  nevertheless, says Burns, the
following observations should be carefully attended to:  1. The patient must
avoid much motion, lest a hemorrhage be excited; 2. Frequent examina-
tions  are  hurtful by retarding the process, and tending to produce spas-
modic contraction;  and, if  this  takes place, a full dose of the tincture of
opium should be given at  once;  3.  A rigid  state of the os uteri requires
venesection to a moderate extent; 4.  The delivery of the child is to be re-
tarded rather  than  accelerated in  the last stage, in order that the  uterus
may have time to contract on the placenta; 5. This is to be further assisted
by rubbing and gently pressing  on the uterine region  after the child is
born; 6. The delivery of the after-birth requires  more than ordinary care
(see Delivery of the After-birth):  thus,  we are not to pull on the cord, for it
is easily broken; besides, it is often necessary to introduce the hand in the
uterus to aid the detachment of the placenta artificially, and to prevent its
being retained by the irregular contractions;  and lastly, great attention is
to be paid to the patient herself for some days after the delivery, for it has
justly been observed that she is, from the mere fact of having had a prema-
ture labor, more exposed than others to those inflammatory affections Avhich
so often complicate  the  parturient state.  With regard to the premature
labors brought on by the accoucheur Ave shall say nothing at present, as
Ave shall have to treat of them more particularly under the head of Opera-
tions.

                          ARTICLE  II.
                        OF RETARDED LABOR.
  As  an ordinary rule, the pregnancy terminates about the tAvo hundred
and seventieth day after conception.   However, labor  often occurs at  an
earlier period than this, and, on  the other hand,  it  may not  appear until
some time in the course of the tenth month, or even at the termination of
this period, although the latter is a much more unusual circumstance.   Jn
making this statement, Ave decide a question  in advance that gave rise to
some very sharp and  animated discussions  during the  last century;  and,
still more recently, the tribunals of England  have summoned to their bar
the most celebrated physicians of Great Britain, and have listened to nume-
rous and  protracted  pleadings for and against the legitimacy of retarded
labors.
  But this question no longer presents to the  medical jurist the same diffi-
culty  that it did in the past century, for the French law has noAV declared
every child to be legitimate that is born after the one hundred and eightieth 
380
LABOR.
or before the three hundredth day of marriage; and, as if it Avere possible,
in the eye of the laAV, for a pregnancy to continue more than ten months,
it further adds that the legitimacy of a child born three hundred days after
the dissolution of the marriage contract niay be contested.
  Although a legal  decision  has thus deprived  the question  of  retarded
labors of its greatest interest, yet we, as practitioners, may  be permitted to
recall briefly the principal reasons that militate in their favor.
  At first, it Avas very natural to study the process in those animals Avhich
approach the  nearest to man in this respect, in order to judge of the possi-
bility of a retarded birth in the human species.
  Among the  numerous observations  made on this subject, those submitted
by M. Tessier, in 1819, to the Academy of Sciences at Paris, of Avhich the
following is a summary, are probably the most exact, namely: out of one
hundred and seventy-one coavs, fourteen calved  from the two hundred  and
forty-first to the  two hundred and sixty-sixth day : three on the tAvo "hun-
dred and seventieth; fifty, from the two hundred and seventieth to the tAvo
hundred and eightieth; sixty-eight, from the two hundred  and eightieth to
the two  hundred and ninetieth; and five, on the three hundred  and eighth
day, which  gives a difference of sixty-seven days betAveen the births, if we
compare the shortest with the longest  period.  Of one hundred  and two
mares:
3 foaled on the		311th day.
1 «	"	314th "
1 '<	a	325th "
1	!<	326th "
2 "	'<	330th "
47 <<	from the	340th to the 350th day.
25 "	a	350th •< 360th "
21 "	a	360th " 377th "
1 "	on the	394th day.
                102
Making a difference of eighty-three days between the two extremes.  Nine
months and ten days being the average term for cows, and eleven months
and ten days for mares.
  These well-ascertained variations in the terms of gestation in animals,
certainly afforded a strong presumption of  their existence  in the human
species also ; for if  cows and  mares, Avhose  gestations are not disturbed by
the various  causes  that  may  lead to changes in a woman, may thus defer
for some time the ordinary period, hoAv much more would human females,
who are subject to so many diseases, and upon whom the moral  and  social
relations exert so powerful an influence,—how much more likely  Avould
they be to exhibit numerous varieties  in the duration  of their pregnancies?
   But all this was a mere probability; and  the question would still remain
undetermined, if  careful observations directly made, and well made  on the
human species, had not removed all doubts on that point; for several cases
bearing on this subject noAV enrich our science, where a  single well-estab-
lished instance would suffice to produce conviction.  Take, for example, the
folloAving  case, reported by Desormeaux:  A lady, the mother of three chil
dren, became  affected  Avith insanity, for which all the resources of thera- 
DELIVERY  OF  THE  AFTER-BIRTH.             381
peutics were  tried in vain.   As her physician thought that another  preg-
nancv  might possibly re-establish  her intellectual  faculties, the  husband
consented to  note on a register the time of each  sexual union, Avhich only
took place every three months, lest a previous conception (then uncertain)
should be disturbed.  Noav, this lady, Avho Avas closely  Avatched by her
domestics, and Avas besides endoAved Avith the most rigid principles of reli-
gion and morality, Avas not delivered before the expiration of nine months
and a half.
  Merriman furnishes a summary of  one  hundred  and fifty gestations, in
each of Avhich he has noted  the precise day of the last appearance of the
menses.  From this table it appears that—

       5 women were delivered in the 37th week — i. e. from 252 to 259 days.
      16          "         "    38th  »       «    262 to 266
      21   "       •'         "    39th  "       "    267 to 273
      46   "       "         "    40th  "       "    274 to 280
      28  "       "         "    41st   "       "    281 to 287
      18  "       "         "    42d   "       "    288 to 294
      11  "       "         "    43d   "       "    295 to 301
       5  "       "         "    44th  "       "    303 to 306

     150
  The foregoing statement exhibits the great variety in the length  of gesta-
tion.  There  is, in fact, a difference  of  fifty-six days between  the two
extremes; and, supposing that each  Avoman  became  pregnant five  days
before the return of her  courses, five  of them, at  least,  would overrun the
average term of nine months by ten or tAvelve days.
                         CHAPTER  VI.

              OF THE  DELIVERY OF THE AFTER-BIRTH.

  This comprises  the natural or artificial expulsion of the fcetal append-
ages from the mother's Avomb, and is the complement of the labor.  Like
the latter, it is  generally accomplished by the unaided powers of nature,
though in certain cases, Avhich are fortunately very rare (about one in tAvo
hundred), it is attended by difficulties or complicated by accidents that may
require the  intervention of art.  We shall, therefore, have  to  treat of the
natural and the artificial delivery of the after-birth, the former of which,
only Avill be described in  this  place  and the latter included in the article
Dystocio.
  Whilst the expulsion of the foetus is being completed by the spontaneous
exit of the breech and loAver extremities, or immediately after the expulsion,
the Avails of the uterus retract in virtue of their  inherent  contractility of
tissue, and its cavity diminishes ;  but the placenta, being a spongy and non-
contractile mass, does not follow this action of the organ.  Consequently,
it becomes puckered up, and the cellular and vascular tissues, that  connect
it to the internal  uterine surface, are rendered tense and then  torn, as the 
382
LABOR.
 difference in the respective size of the tAvo bodies becomes greater under the
 force of the repeated contractions.  A rupture of all these bonds of union
 is soon effected, the placenta is completely detached and forced doAvn upon
 the os uteri; the  latter, being irritated by its  presence, reacts on the body
 of the  organ Avhich is immediately throAvn into contraction;  the internal
 orifice, Avhich Avas closed after the delivery of the child, again dilates, and
 the placenta, being driven from  the uterine cavity, passes into the vagina,
 Avhence it is forced outAvards by the contraction of the  vaginal Avails aided
 by the abdominal muscles.
   Hence there are three distinct  stages in the delivery of the  after-birth;
 which Ave may divide, like Desormeaux, into the detachment of the placenta,
 its expulsion from the uterus, and its expulsion from the vagina.
   The detachment of the placenta is not always accomplished in the same
 way; the process varying with the part of the uterus to Avhich it is united.
 For  instance, when attached to the fundus, the separation first begins near
 the  centre of the mass,  because this  is the  thickest part,  and can  least
 accommodate itself to  the retraction of the uterine Avails ; whilst its thinner
 margins, being more easily wrinkled, are less liable to rupture  the  tissue
 connecting  them Avith  the  womb; a lenticular cavity is thereby created,
 Avhich is bounded externally by the still  adherent borders of the placenta.
 A quantity of blood is gradually effused into this cavity, which contributes,
 with  the uterine  contractions, to  effect the separation; thus, in this  case,
 the detachment is effected from the centre towards the circumference.  The
 placenta, being Avholly detached, then descends to the orifice, its foetal sur-
 face  corresponding to the latter, and becoming the external face, AA'hilst the
 uterine surface is the internal face, Avhich, together with the inverted  mem-
 branes, constitutes a pouch, Avherein such a quantity of fluid or coagulated
 blood is occasionally collected, as«to seriously  impede its delivery.
   When it is attached to the  anterior, the posterior, or the  lateral portion
 of the Avomb, the separation commences at one of the margins; or, if at the
 centre,  it is soon propagated towards one border, generally the superior,
 though, in some instances, the inferior one.  In the former case, the process
 advances in the avay just described, and the placenta again presents,  by its
 foetal surface, at the cervix  uteri; but, in the latter, being suspended on the
 uterine Avail until the detachment  is completed, it presents at the neck by
 its inferior margin.  It is then generally folded upon itself, and engages in
 the orifice rolled up  in a conical form.
  When  the placenta presents its foetal surface at  the os uteri, it plugs up
the orifice by its  bulk, and  prevents the blood from escaping; wherefore,
 its delivery in such cases is usually followed by the expulsion of numerous
large coagula.   But Avhere only one border engages, there is no obstacle to
the issue of the blood, and hence the discharge of this fluid commences with
the detachment of the after-birth, is increased at every pain,  and persists
throughout the Avhole process.
  From the description just given, the reader would naturally suppose that
the detachment of the  placenta only begins  after  the  child is born ; this,
hoAvever, is not ahvays the case.  In fact, the following phenomena are more
 usually observed to take  place: as  soon  as the labor-pains  are  developed 
DELIVERY OF THE  AFTER-BIRTH.              383
 and the dilatation of the os uteri  has commenced, the separation of the
 ovum begins in the neighborhood of the uterine orifice, and then gradually
 progresses over all parts of its surface, although not in a perfect and  com-
 plete manner.  After  the membranes are ruptured, and  the Avaters are
 partially  discharged, the  uterine cavity diminishes;  the  ovum becomes
 wrinkled,  and its detachment  is carried to a  still greater extent;  even
 involving the after-birth, as proved  by the fact that the fluid or coagulated
 blood is frequently expelled simultaneously Avith the foetus,  in cases of pro-
 tracted labor; which blood must evidently come from  that portion of the
 uterine surface in contact  Avith  the  placenta.  A separation of the greater
 part of the placental  mass is particularly apt to occur in the breech pre-
 sentations in  consequence of the  gradual contraction  of the  AA'omb, as the
 lower parts of the foetus are delivered.
   The interval betAveen the child's birth and the delivery of the secundines
 is very  variable.  Dr. Clarke, from a great  number of. observations, estab-
 lished its mean duration at twenty-five minutes; but if by  this a perfectly
 spontaneous delivery is to be understood, one in Avhich no traction is made on
 the cord, we believe he is in error, for this interval is generally much longer.
 At the  instance of M. P. Dubois, we made some experiments, in 1836, Avith
 a vieAV of determining this question ;  and those researches proved that, Avhen
 the delivery Avas left entirely to nature, the final expulsion  of the placenta
 ■did not usually occur under an  hour or an hour and a half after  the birth
 of the child.   It is true, the detachment of the after-birth, and its removal
 from the uterine cavity, is effected, as Clarke states, in the course of fifteen,
 twenty, or tAventy-five minutes ;  but, having passed into the vagina, it some-
 times remains there for se\reral hours Avithout causing the least irritation  by
 its presence, the least tenesmus,  or bearing-doAvn effort.  This circumstance
 is easily explained by the  fact that the sensibility of the vaginal Avails is
 blunted, as it Avere, by the  long  pressure they Avere subjected to from the
 head  and  other parts of the child.   Besides Avhich, as Levret long since
 remarked, the  after-birth will be  the  sooner  expelled  in proportion as the
 patient  is stronger, and the contractions more energetic; as the quantity of
 water in the womb Avas smaller, and as the period betAveen  the rupture  of
 the membranes and the delivery of the child Avas the longer.
  Although its delivery may generally be left to the poAvers  of nature with-
 out any serious inconvenience, yet it is equally true that it "will be delayed
 a long time  in a large  number of cases.  Noav, such a delay Avould  force
 the patient to remain on a bed, Avhich is poorly adapted for repose after all
 the fatigues of labor; and besides, so long as the delivery is not completed,
 she still considers  herself exposed to numerous dangers, and her fears  may
 have an unfavorable influence over her condition.   On this account, most
 of the accoucheurs of the present day believe it  advisable to accelerate the
 extraction a little, for the purpose of relieying the Avoman from her anxiety,
 and of  sparing her  unnecessary pain;  Avithout,  hoAvever, attempting  to
 deliver  the secundines immediately after the child's  birth.   But,  before
making  any traction on the umbilical  cord, it is necessary to ascertain the
situation of the placenta, and esjiecially the condition of the  uterus.  If the
latter is small,  hard, and contracted, and situated in the lowest part of the 
384
LABOR.
       abdomen, it is infinitely probable that the placenta is. in great part at least,
       expelled from the cavity of the womb into the vagina.   This, hoAvever, may
       be  easily ascertained,  for the  finger introduced  into  the vagina readily
       detects the mass, and even distinguishes the insertions of the  cord.  There
       is then, generally, nothing to prevent its being extracted at once, and simple
       tractions upon the external end of the cord  are all that  are required for
       this purpose.
         When, on the  contrary, the uterine tumor continues on a level with, or
       even above the umbilicus, and  has a soft doughy feel, due to its imperfect
       contraction, the placenta is  very probably still within the Avomb, and the
       first object should be to ascertain Avhether or not it is detached.  Noav we
       knoAV that the separation is usually accomplished by the fresh contractions
       that reappear after the apathy Avhich follows the expulsion of the child;
       and hence, there is every reason to suppose it is completed Avhen these con-
       tractions  have repeatedly occurred.   A little  blood usually escapes from
       the vulva during  the process.   Finally, if one or several fingers be passed
       up  to the uterine orifice, the after-birth  is found presenting there, and, if it
       should not be met with, the accoucheur  may rest satisfied  that the separa-
       tion is not  yet completed, and therefore he ought to wait.   Should  the
       detachment be delayed too long, frictions over the fundus uteri are resorted
       to,  for the purpose of rousing the  pains, or the same object is produced by
       titillating the cervix  uteri Avith  one or tAvo fingers.  Great care should be
       taken  not to make frequent tractions  upon the cord, for unpleasant conse-
       quences  might result.   Thus,  if the placenta is  completely adherent,  the
       tractions are liable to  detach  a part, and give rise to hemorrhage, or they
       might tear aAvay a portion of the after-birth and leave the remainder in the
       Avomb; again, the organ might be  inverted or the cord ruptured thereby.
         "Certain Avriters recommend  a ligature on the placental  extremity of the
it      covet after the child's birth, for the sole purpose of facilitating the detach-
       ment of the after-birth.  The easy  separation Avhen this has been done, says
       M.  Stoltz, is caused  by the  Aveight and turgescence of  this organ, which,
       when expelled, is found to be engorged with  blood; this practice is attended
       with no inconvenience,  and is at least beneficial by preventing the patient's
       bed from being soiled Avith the blood that ordinarily escapes from the cord.
         After  its entire separation, the  after-birth constitutes a foreign body in
       the uterine cavity, which the organ  endeavors to dislodge by contracting.
       These contractions, which are recognizable by the hardness of the uterine
       globe, and Avhich  are usually  perceptible to the patient, indicate  the  time
       for operating; the accoucheur then takes hold of the umbilical cord, after
       having enveloped it Avith a cloth  so  as to  prevent it  from slipping, and
       winds  its end around one or tAvo fingers; he next makes a moderate trac-
       tion Avith a vieAV of extracting it, but, as soon as any resistance is felt, he
       ought  to slip up two or even  three fingers of the other hand along the upper
       surface of the cord as far as the os uteri;  the points of these fingers, which
       are  intended to press the cord backAvards,  are brought together so as to
       receive the latter in the entering angle thereby formed, around Avhich it
       plays like a pulley.   To understand  the advantage of this manoeuvre, it is
       Dnly necessary to bear  in mind that  the tractions made by one hand alone 
DELIVERY  OF  THE AFTER BIRTH.
385
would correspond to the axis of the vagina, AA'hich forms an angle with that
of the uterus;  whence it happens that the placenta, instead of being draAvu
towards the centre of the orifice it has to traverse, would  abut against  its

                                  Fig. 92.
Mode of extracting the placenta.
 anterior border, and the corresponding parts of the cervix, upon Avhich all
 the tractive efforts are spent.  The patient should be directed to bear doAvn
 Avhile the tractions are made.  As the placenta clears the orifice, and gets
 into the excavation, the operator  changes the line of action, and gradually
 carries  the cord fonvard, so as to  make it always correspond Avith  the axis
 of the  pelvic canal.  Under the joint  influence of the  tractions and  the
 patient's bearing-dpAvn efforts, the placenta soon reaches the vulva, Avhere
 it is seized by the thumb and  fingers and tAvisted  round several  times, so
 as to complete the detachment of the membranes and form  them into  a
 solid cord, for the  double purpose of preventing their  laceration and of
 securing their entire removal.1
  It is  impossible to state precisely the amount of force which  may be used
 in these tractions upon the  cord, and it must be left to  the intelligence of
 the practitioner to  discover  Avhat is  proper to  be  done.  When,  hoAvever,
 the tractions have no effect, and the placenta seems to rise up and  draAV the
 cord after it, as soon as  they have ceased, all efforts should be suspended for
 the time being.
  " When the placenta  is partially engaged in the orifice by a portion of its
 periphery, this plan," says  M. Guillemot, " ought to be someAvhat modified;
 for  in this presentation, the root of the  umbilical cord, instead  of corre-
 sponding to the cervix, is higher up in the uterine cavity; and hence, if the
 operator resorts to traction, the centre of the placenta will have a tendency

  1 There certainly would be no very great danger in leaving a portion of  the mem-
 branes in the  uterine cavity; although, in addition to the accidents that  may arise
 from the presence of a foreign body there, the following phenomenon  might, possibly
 occur.  The membranes may inclose some  coagula, and thus form a mass whose expul-
 sion is often difficult.  In the course of a few days, the uterus, being irritated by the
 presence of this inconvenient lodger, begins to  contract, and the woman experiences
 some colicky pains, varying in intensity with the strength of the contractions; a little
 blood escapes from the vulva, and, after the pains have lasted for a longer or shorter
period, the patient is finally delivered of the foreign body, or, according to her expres-
sion, of a large piece  of flesh, the appearance of which causes great alarm.
        25 
386
LABOR.
to enter the orifice, and thus add its bulk to the disk already engaged there.
Such a disposition sometimes constitutes an obstacle to the further delivery
of this mass; but it  is surmounted  by making some moderate tractions, not
on the cord itself, but rather upon the part previously engaged, by applying
two fingers on its surfaces."  We have had  numerous opportunities of test-
ing the practical  utility of M. Guillemot's advice.
  " This seems,"  says  Merriman, "all that it is right to do, for a full hour
after the child is  born; but that time  being elapsed, and  there being no
reason to expect  that  uterine  contractions will  spontaneously arise,  the
accoucheur is to consider whether  it is prudent to wait longer, before he
proceeds to extract the placenta, by introducing his hand into the uterus.
  " If no bad symptoms are present,  there  can  be no danger in alloAving
more time to elapse before Ave  proceed to this operation;  especially, if there
be reason to think that the retention  arises  principally from the exhausted
state of the patient; because it is possible that a little more delay Avill
recruit her strength,  and that  aftenvards sufficient power may be imparted
to the uterus to expel the placenta.
  " Yet; generally speaking, we can  have  but  little expectation that  the
placenta Avill be  expelled by the natural powers, after it has been retained
much more than  an hour; Ave  may, therefore, consider ourselves justified in
interfering to extract it, at the end of  an hour or tAvo after the child is born.
  " It appears, then, to be a question  of prudence or discretion, Avhich every
accoucheur must  judge of in the individual  case he is attending, whether to
proceed to  delivery at  the end of the  hour,  or to wait another hour or two
before he  undertakes  this operation.  But, of  course, this  only applies to
cases Avhere there is no apparent danger."   (Synopsis, page 153.)
  " The  time for  interference of the accoucheur  for the delivery  of  the
placenta, should always be regulated  by the condition of the uterus itself,"
says DeAvees, " and that condition is whenever it is firmly contracted.   Time,
simply considered, can  never form a safe rule for the delivery of the placenta;
the degree of contraction of the uterus alone can point out the proper moment
to operate,  or teach us Avhen it would  be improper to attempt it.  This rule,
I believe, will never deceive,  or at least I have uniformly  acted upon this
principle;  and, so far, I think I am safe in  saying, I have not had cause to
believe it wrong."  (System of Midwifery, page 447.)
  As soon  as the  placenta is delivered, we must ascertain whether any por-
tion of it, or of the membranes, has been left behind in the Avomb; but this
is easily done by carefully examining the secundines.  Should it happen that
the membranes or after-birth are not  extracted entire, it Avould be proper to
pass the hand into the uterus,  for the  purpose of removing the remnants.
  If a large quantity of the coagula  that usually  accompany the placenta
remains in  the Avomb, they may subsequently become a source of the after-
pains  yet to be described.   Consequently, if there is reason to suspect the
presence of large  clots in  the womb, the latter  ought to be stimulated to
contraction by repeated frictions over  the hypogastrium.   Some authors
have  even  recommended the introduction of the  hand into the  uterine
cavity, so as to rid it completely of all  foreign bodies;  the  advice is good,
but to be folloAved cautiously, because, on  the one part, the uterus would 
DELIVERY OF  THE  AFTER-BIRTH.              387
be unnecessarily irritated, and on the other, it AA'Ould not prevent the subse-
quent formation of fresh coagula.
  We stated above, that usually in the course of fifteen, tAventy, or twenty-
five minutes after the birth of the child, the uterus,  by contracting,  notifies
the accoucheur, as it Avere, of the  proper moment for his intervention.  It
should ahvays  be remembered, hoAvever, that  moderate tractions  are all-
sufficient for the delivery of the after-birth; and, if much resistance is met
with, it Avould  be far better to Avait, and not make any neAV attempts, until
the contractions shall have  partly or completely overcome the obstacle.
  Where there is the least reason to suspect the existence of a second child,
after the birth of the first, the pliysician ought to  satisfy himself on that
point, both by an external and an internal exploration, before attempting
to remove the  placenta; and should a tAvin pregnancy  be recognized by the
great size of the womb, and more particularly by the vaginal examination,
a ligature is to be applied immediately on the  placental extremity of the
cord belonging  to  the first infant;  and the  secundines are  only to be
extracted after the  expulsion of both  children.  If, hoAvever, the placenta
Avere detached, and presented at the  orifice, he should attempt to extract
it, more especially Avhen it  seems  to  obstruct  the  passage  of the  second
foetus.   Nevertheless, such  tractions  ought to  be  exceedingly reserved;
because, in  compound pregnancies, there are frequent  adhesions between
the two placentas; and, if this were the case, it is evident that any forcible
traction might detach the after-birth of the second child long before its
expulsion;  and this premature separation would render the mother liable to
severe hemorrhage,  and the child to fatal asphyxia.
  After the birth of both children, so far from pulling on the two cords
simultaneously, and  moderately tAvisting them into  one, it is more prudent
to bring down the placentas, one  after the other, giving the priority to the
one Avhich offers the least resistance.  The mass of these conjoined bodies is
made to engage  in  this way  by one extremity; and it is thus enabled to
clear the uterine orifice more readily.
  In most cases of compound pregnancy the womb is excessively distended,
and this distention,  as Ave are all  aAvare, is* one  of the circumstances that is
most likely to  enfeeble the contractility of its tissue; therefore the removal
of the  after-birth, after  the  labor is over, should  not be accelerated too
much, and  the womb  must  be alloAved a longer time than  usual for its
retraction; Avhile moderate frictions are to be made over the fundus of the
organ for the purpose of stimulating its action.
  As regards  the removal of the secundines after a miscarriage, Ave have
nothing to add further than Avhat will be stated in the article on Abortion, 
388
LABOR.
                        CHAPTER  VII.

   OF THE NECESSARY ATTENTIONS TO THE WOMAN  AND CHILD
                           DURING LABOR.

                           ARTICLE I.

         OF THE ATTENTIONS TO  THE WOMAN  DURING  LABOR.
  When the  accoucheur is summoned to a woman in  labor, he should
always provide himself with lancets, a'female  catheter,  and the forceps;
and, if in the country, he should have besides some ergot,  either in grain or
else  freshly poAvdered, and  one or two drachms of Sydenham's laudanum.
His  arrival ought always  to be announced  before entering the patient's
chamber, for the emotion caused by  a sudden entrance often proves sufficient
to suspend the pains for a considerable time.  Then, after having made the
usual inquiries as to the time at  Avhich  the pains began, their frequency,
their duration and intensity, he might, if he supposes from this account the
labor to be somewhat advanced, proceed at once to the vaginal exploration;
in the contrary case, he may wait a few minutes, as Avell to satisfy himself
of the value of the communications made by the attendants, as to give the
Avoman time to prepare for the  examination.  When he finally judges this
is necessary, he is to  proceed with all possible decency, and always during
the  interval between the pains.  The object of this is to endeavor to ascer-
tain: 1, Avhether the woman is pregnant; -2, if she is in labor; 3, if she is
at full term ;  4, Avhether the membranes are ruptured; 5, whether the labor
is far advanced; 6, what is the condition of the cervix, vagina, and perineum,
and  their degree of suppleness or resistance ;  7, what is the conformation of
the  pelvis; 8,  lastly, Avhat part of the child presents.
  At first  sight, it may seem a ridiculous precaution to  attempt to verify
the  existence of the  pregnancy in  a Avoman avIio declares  she is actually
suffering from the pains of childbirth; but, to  say the  least, this is  not
altogether useless, since it has unfortunately happened that some over-con-
fident accoucheurs have been imposed upon by women who were themselves
deceived as to the nature of the pains they felt;  and we might quote many
instances AA'here, after having waited for the delivery to take place for
several days, they have ultimately been constrained to acknowledge their
mistake.   Besides, this error is easily avoided by bearing in  mind  the
diagnostic signs pointed out in the  article on Pregnancy.
  After observing the progress of the pains for some instants, he should
next endeavor to ascertain their cause and nature, in order to favor those
which have a bearing  on the labor, and  to  combat  any that are foreign
thereto.  Women are not unfrequently tormented by pains during the latter
stages of gestation, which are dependent on some sympathetic disorder of
the  intestines,  or abdominal organs, and which even a,physician might mis-
take  for the  commencement of labor; these have been denominated the
false pains, by way of distinguishing them from those produced by the con-
traction of the womb.  The true and the false pains may be recognized by 
            ATTENTIONS TO THE  WOMAN AND  CHILD.         389

the folloAving  characters:  the latter are ordinarily seated in the region
occupied by the  diseased organ, Avhile those occasioned by the commence-
ment of the travail  usually begin about the umbilicus and loins, and die
aAvay at the perineum, the  anus, or the  sexual parts;  the  false are almost
continuous, and  their intensity is  nearly uniform; the others, on the con-
trary, are intermittent.  If the irregularity in the return  and  progression
of the pains be such as to leave any doubt as to  their character, he should
interrogate the neighboring  organs, and by a little attention  he Avill suc-
ceed in determining their seat and  nature.   There are,  hoAvever,  certain
pains Avhich have their seat in the uterus itself, affect a certain degree of
regularity, and simulate a true labor, Avhich  are dependent on a plethoric
condition of the  organ, that may be calmed  by  rest, a restricted diet, and
blood-letting.  Further, the epoch at which they occur, and the absence of
the other phenomena of labor, will serve to lessen  the difficulties in deter-
mining the diagnosis; ne\Tertheless, it is the touch alone that can dispel all
doubts; for the hardness that comes on  in the uterine  globe, the rigidity in
the circumference of the os uteri, the tension and  protrusion of the mem-
branes during, the pain itself, together with the retreat and relaxation of all
these parts  in proportion as it diminishes, characterize the pains of child-
birth in an infallible manner.
   " By examining," says Wigand,' " the course of the true contractions, it
will be found that they commence at the cervix, and pass to the fibres of the
fundus, which  are then throAvn into action ;  and hence all  contractions that
begin in this latter part of the Avomb  are anomalous, and result either from
some disorder having occurred in the uterine forces,  or else they are pro-
duced by  an inflammation, or a disturbance in the functions of a neighbor-
ing organ." When  the true  pain is manifested, the  head, which reposed
during the interval  on the cervix, sometimes mounts up  even beyond the
reach of the finger, but the membranes engage  more or less in the orifice.
In the course of a feAV seconds, the contraction extends all over the uterus,
and more particularly to the fibres of the fundus; and the  head, Avhich was
at first elevated, is forcibly pressed doAvn on  the neck, thus assuming the
office of a Avedge for hastening its dilatation; and, as a general rule, it is
only Avhen the fundus contracts in this manner, that the Avoman complains
of pain.   We  may,  therefore, consider  the- true pain  as  constituted of a
series of phenomena, Avhich succeed each other in the following order: first,
the periphery of the cervix becomes tense; then, the presenting part ascends,
and the membranes bulge out; next, the  remainder of the uterus, the fundus
especially, becomes hard,  during Avhich the patient complains of a sharp
pain;  and, lastly, the part that presented endeavors anew  to engage.  It  is
unnecessary to add, that the rapidity  Avith which  these phenomena succeed
each other necessarily varies  according to the individual, to the irregulari-
ties to Avhich the process is subject, and  according to the stage of the labor.
Other things being equal, the contractions will effect the dilatation so much
the sooner, in proportion as the cervix shall correspond more directly to the
fundus of the organ, and the  uterine axis shall be the more parallel to that
of the pelvis.
  After having learned the true character of the pains, the  accoucheur next 
390
LABOR.
endeavors to ascertain whether the woman is  really at term, so as not to
encourage a premature labor, Avhich might  often be prevented if he knew
its cause.  He ought, therefore,  to' recall the various signs, by means of
which we have attempted to characterize the different periods of pregnancy.
Thus, should he find that the cervix is not yet  entirely effaced, that it still
retains a certain degree of  length, that it is hard and resistant even during
the interval of the  contractions ;  that the latter are much  less  regular in
their  course,  duration, and  return, than  in parturition at  full  term; and
the belly not yet sunk down; he  may justly conclude that the patient has
not yet reached  the end of the ninth month;  also, that such a premature
labor is  owing  either to some acute moral emotion, or some  antecedent
external  violence.  In  all  cases, he  ought to attempt the arrest of this
premature or false labor, by rest, both of body and mind,  by venesection,
if the woman's general condition  will admit of it, and,  more especially, by
the administration of laudanum  in full  doses, taking care to  empty the
bladder Avhen necessary, and to keep  the boAvels free by mild laxatives.
   The use of means to stop the premature labor ought not to be given up,
even though the cervix be entirely effaced, the orifice someAvhat  dilated, and
a certain amount of water discharged  ; inasmuch as the escaped fluid might
proceed from a hydrorrhoea and  not from Avithin the amnios, Avhilst prema-
ture pains can sometimes be calmed and  the pregnancy enabled to proceed
to full term.
   Very conclusive observations on this point Avere published in  1857 by Dr.
Charrier: he cited  cases in which the dilatation equalled a quarter of a
dollar in size, and in which the pains Avere  suspended notwithstanding the
membranes Avere engaged in and projecting from the orifice.  The cervix
afterwards closed in such a  way as to reproduce its external orifice, and to
present the conical shape Avhich it has in the eighth month of gestation.  This
phenomenon, styled by M. Charrier,  retrocession of labor, though doubtless
rare, need only be possible in order to encourage the practitioner to suspend
the labor Avhenever he is sure the  membranes are intact, the  child alive, and
the woman not at term.
   However, there is  one phenomenon, sometimes manifested in the latter
weeks of gestation, which may place  the most skilful practitioner at fault.
I allude  to Avhat has been  designated as the false labor, in which certain
women, after  having nearly reached  their full  term,  experience the true
contractions;  the  pains are regular, the  membranes bulge  out, and  the os
uteri dilates ;  at times, these pains last from four to six hours, but then they
disappear all at once, and everything goes on as usual.   In others, the false
labor is kept up at first during several hours, and then it passes off, return-
ing in this manner every day, particularly toAvards the  evening, and lasting
one or two Aveeks.  (See Uterine  Rlieumatism.)
   When the accoucheur is  very  sure that the  woman is really  in labor, his
attention must be directed to the frequency and the intensity of the pains,
and to the dilatation, the hardness, and  thinness of the cervix, in order to
judge of its  probable duration.   During the  same exploration, he should
ascertain the conformation of the pelvis, particularly if the Avoman happens
to  be in her first confinement, and if any apparent deformities  exist;  he 
             ATTENTIONS TO THE  WOMAN AND  CHILD.         391

 should also learn the situation of the orifice, the obliquity of the body and
 neck of the  womb,  and the child's presenting part.   (See Mechanism of
 Labor.)  If this  latter is so high up as to render the  diagnosis of  the  pre-
 sentation difficult, its examination should be deferred until a more advanced
 period  of the labor; but the  bag of Avaters is never to be ruptured, in  any
 case, for the mere purpose of  rendering this examination more easy, before
 the entire dilatation  of the  neck ; for such an untimely rupture of the mem-
 branes  Avould be attended by very great inconveniences, if the position Avere
 at all defective;  for, all  the Avaters escaping, the  foetus might suffer from
 the pressure exercised directly upon it by the uterine  Avails;  the umbilical
 cord would be compressed ; and the womb, irritated by the prolonged con-
 tact of the  foetal inequalities, might be  affected Avith spasmodic  contrac-
 tions ;  and, finally, the intervention of  art  becoming  necessary, long after
 the evacuation of the waters, the necessary manipulations Avould be attended
 with much greater difficulties.
   But  it is not always so easy  a matter  as one might imagine to ascertain
 whether the  membranes are ruptured or are still intact; for instance, Avhere
 the vaginal  examination is resorted to  betAveen the pains, in a vertex pre-
 sentation, they are often applied so directly to the scalp that it is impossible
 to distinguish them.  A pain should then be waited for, because, as soon as
 the uterus contracts,  it drives  the Avaters toAvards the loAver parts, and  the
 finger is observed to  be raised  up by a small  quantity of this fluid  that in-
 sinuates itself between the head and the amniotic sac, the integrity of Avhich
 latter is thereby easily verified ; but Avhere the head is more deeply engaged,
 this afflux of liquid is very inconsiderable, and the tension  of the  mem-
 branes  can  scarcely be  distinguished.  Consequently, attention should be
 given to  the state of the  tumor both  during and after  the contraction.
 Where the Avaters have  escaped,  and the  finger conies directly upon  the
 child's  cranium, it will detect  the hairy  scalp puckering up Avhile the pain
 lasts, and becoming smooth and even as soon as it shall  have ceased ; though
 the contrary will take place Avhen  the membranes  are intact, for they are
 never more smooth or more tense than during the contraction  itself.
   It is  difficult at times to reach the cervix uteri in the commencement of
 the labor, because it is then carried  so far backAvards that  the plane of its
 orifice actually looks  toAvards the anterior face of the sacrum.  I have often
 seen young practitioners  avIio were unable to get at it at all, and  others,
 who, not finding the os uteri, and distinctly feeling the child's head through
 the anterior inferior part  of the Avomb, which is then rendered very  thin by
 the distention it has undergone, have imagined that the dilatation  Avas  al-
 ready completed, Avhereas it had hardly commenced; the disastrous conse-
 quences to Avhich  such an error might  lead, can be readily imagined.  In
 fact, it  is very often  necessary  to pass the finger around the convex tumor
 Avhich fills the excavation, in order to get the index far  enough upAvards
 and backwards, Avhere the uterine orifice is to be found.
   All these questions being determined,  the accoucheur's  attention  should
 be directed early in  the  progress of the confinement to having the  woman
 moved into the most suitable place.  The chamber intended for her lying-in
should be spacious, airy, Avell lighted, and retired; the air she respires ought 
392
LABOR.
 to be pure and of a moderate  temperature, and  all  strong  odors, whether
 good or bad, should be excluded.  A temperature too elevated will predis
 pose her to nervous agitation, and  to hemorrhagic accidents;  and, on the
 other hand,  the impression of cold is  a very frequent  cause of acute inflam-
 mation, or of chronic engorgements,  such as those that often come on aftei
 delivery, which have for so long a  time  been attributed to lacteal metas-
 tasis.   But few persons are to be admitted in the chamber, and all those,
 especially, Avhose presence is at all unpleasant to her, ought to be rigidly
 excluded.   This  latter point demands the greatest care on the part of the
 physician, for it is he alone Avho has authority thus to  dismiss  such as  he
 may think useless or injurious,  and  he must judge, from the reception given
 to each, of the pleasure or  otherwise the  patient experiences from their pre-
 sence.  Some women are almost ashamed of being delivered in the presence
 of the  husband; with others, on the  contrary, it is one of the greatest con-
 solations to have him near them, and the accoucheur must endeavor to dis-
 cover all the little shades of delicacy  and feeling, to sound, by discreet and
 artful questions, a Avish that the woman  herself at times fears  to  express,
 and, after having once learned  it, he should religiously comply with it. As
 a general rule, the mother and sister,  or tAvo intimate friends of the patient,
 besides the nurse, are the only ones  that  are  to  be alloAved  to  stay in the
 room.  With  regard  to dress, her garments  should be full, sufficiently so,
 as neither to incommode her movements  nor her respiration.
   If some time has elapsed since she has  had a passage from  the bowels, a
 simple  injection must be given;  and Avhere this does not prove sufficient to
 procure a stool, a second is to be immediately administered with the addi-
 tion of one or two ounces of the miel mercuriale.1  The evacuation of the
 matters contained in the  rectum  is  the more  necessary, as its distention
 might subsequently retard the escape of the head, and likeAvise prevent that
 of the  intestinal gases, Avhose accumulation might bring on colic and grip-
 ings; besides, this precaution has the advantage  of sparing the woman the
 shame and disgust Avhich an involuntary  expulsion of the faeces during the
 last moments of labor Avould necessarily cause,  as also of preventing the
 accoucheur's hand from being soiled, Avhile it supports the perineum.
   The accumulation of urine in the  bladder ought likewise to be prevented,
 by persuading the patient to urinate in the very  commencement of her par-
 turition ; for, where she has not observed this precaution, or the physician
 arrives too late to insist upon it, the emission of  water  becomes more and
 more difficult, and  sometimes quite impossible, owing  to the compression
 which the head, engaged  at the superior strait, makes on the neck of the
 bladder.  In such cases, he should endeavor to push the head up someAvhat
 by two  fingers, so that she can urinate; and  if  this does not succeed, the
 catheter must be resorted to.  We have elsewhere stated that it Avas advis-
 able, under such  circumstances, to  use a male  catheter, the curvature of
 which is greater;  though,  even by taking this  precaution,  a considerable
 resistance is  occasionally experienced to its introduction.   This condition

   1 This preparation is only used as an injection; it is prepared by taking equal parts
 of clarified honey and the juice of the mercurialis annua, a plant belonging to the tribf
■of the Euphorbiaceie, ant reducing  hem to the consistency of a syrup.—Translator 
             ATTENTIONS  TO THE  WOMAN AND CHILD.         393

requires  the  most  careful manipulation ; the woman  must  lie flat on her
back, and then, with one  hand  the womb is pressed backAvards from the
strait, or Avhat is preferable, while the head, Avhich  by its presence in the
lesser pelvis  compresses the urethra, is raised by two fingers  in the vagina,
the other introduces the instrument into the  urethra.
  The accumulation of urine is attended with such grave consequences as
to Avarrant a persevering effort to  introduce  the  catheter.  The least of all
the accidents Avhich may result  therefrom, is a relaxation, or even the total
cessation of the pains; for the distressing sensation caused by a distention
of this  organ, which is  increased Avhen the abdominal muscles contract,
induces the Avoman to suspend the contractions as much as possible; besides
Avhich, the pain itself is  sometimes so acute as  to paralyze,  as  it were, the
action of these muscles ;  and again, as they are separated from the uterine''
Avails by the mass of urine shut  up in the  bladder, their action is trans-
mitted to the Avomb in but  a very feeble manner.  The paralysis of the
bladder, so often met Avith  after  labor, is a common consequence of pro-
longed  retention of the  urine; and finally, the Avails of this reservoir are
occasionally  ruptured just at the moment when the woman gives way to the
most violent bearing-doAvn.   Doubtless this  last accident is rare, but still it
is not Avithout example, since Ramsbotham,  Sen., has observed tAvo cases of
the kind.  (Obs. Praet., cases 89, 90.)v  The  tumor thus formed by the over-
distended organ may easily be recognized, more particularly after the rup-
ture of the membranes, by the soft, fluctuating tumefaction detected imme-
diately above the pubis, extending at  times nearly as high as the umbilicus,
at the side of, and behind which,  the hard resistant mass constituted by the
uterus can be distinguished, Avhose consistence varies according to Avhether
the examination is made  during or after pain.
   He should also attend early to  having everything prepared that may be
wanted  someAvhat later;  thus, the thread intended for the  ligature of the
cord is to be laid out, and the band and linen for covering the child's  navel
are to be cut;  for  the mother, he ought to procure some cold iced Avater,
vinegars, and smelling-salts, agents that will probably be unnecessary, but
Avhich, notAvithstanding, he ought ahvays to have at hand;  and, lastly, he
must direct  the preparation of the bed upon Avhich  the Avoman is  to be
delivered.   This bed (called the lying-in bed, the bed of misery, or the little
bed)  is arranged in the  folloAving manner: one Avith a  sacking-bottom is
procured, of a moderate height, and about tAvo feet to two and a- half in
 width, and one end of it  is  placed against the wall,  being careful to keep it
clear on both sides, so that one can pass freely  all around it.   A first mat-
tress  is placed on the bottom, and upon this  a second, which covers its  upper
part, and is folded double  towards its superior third, in such a Avay as to
leave the  first one uncovered  about  the foot.   An oil-cloth, then a sheet,

   1 The symptoms of  this accident are very similar to those of a rupture of the  womb,
excepting that the child remains in situ.  There is, besides, a sudden and sharp pain
in the AT'esical region,  and the patient complains of the sensation caused by the effusion
of the liquid into the  abdominal cavity, syncope, &c.  The signs peculiar to the vesical
rupture  are the collapse and disappearance of the tumor previously formed  by the
bladder (which could be felt above the pubis), and an obscure fluctuation in the belly 
394
LABOR.
 some  pilloAvs, and a coverlet, complete the furniture of the bed.   A s did
 bar is placed transversely across the foot of the  bed, so  as to  give the
 Avoman's feet a solid point of resistance in the last moments of her labor.
 In France, the patient is so placed that the upper part of her back rests on
 the inclined plane formed by the second  mattress, and her  breech at the
 margin of the same mattress ; the inferior extremities  are  slightly flexed,
 and the feet press against the transverse bar  placed at the foot of the bed.
 In England, women are delivered on the edge of their beds; they lie on the
 left side, having their  legs and thighs flexed, and their knees separated by
 pilloAA's.  In Germany, the lying-in chair of the ancients is used ; the patient
 is placed on an inclined plane, Avhich can  be modified  at will, by lowering
 or raising the back, by means of a rack ; the Avoman then draAvs on the arms
•"of the chair, and presses her feet against the rounds with  Avhich it is sup-
 plied, and, as she  gives Avay to the throes of labor, the sexual  parts are
 uncovered, and  correspond to the opening made  in  the edge of the seat.
 But, On the whole, the bed, furnished as Ave have described, appears prefer-
 able,  the more so, because it is ahvays at hand; and, as  suggested by Desor-
 meaux, it is particularly suitable Avhere the woman must remain recumbent
 during the Avhole progress of labor, as is necessary whenever she  is affected
 with hernia, or is threatened Avith hemorrhage, prolapsus, or a displacement
 of the Avomb.   In case of necessity,  its place  might be supplied by a table
 and a feAV chairs placed against the wall.  It Avould be much better, say
 Desormeaux and M. P. Dubois, Avhere the family are in easy circumstances,
 to make use of  an  ordinary bed, taking care, hoAvever, to supply it with  a
 rather hard mattress, and a hard cushion near the buttocks, to prevent the
 pelvic region from sinking doAvn  into the  substance of the mattress, and the
 borders of the hole thereby produced, from  forming  an  obstacle to the
 extension of the coccyx, or the escape of the child's head.  On this bed, the
 woman is more  at ease; she can lie on her side, or take the most convenient
 attitudes, and even sleep during the intervals of the pains; and then, after
 the delivery, she may remain  there some time before being transported
 to another.
    Ought the accoucheur to remain constantly with the patient ?   This is a
 question Avhose solution varies according to the character of the female her-
 self, and the greater or less intimacy  existing between her and  her physician,
 for there are  some timid Avomen who desire to  have <fcim  always close at
 hand, and others again, aa-Iio are impatient and annoyed by his continual
 presence. But in all  cases, he should bear in mind that, during parturition,
 the  patient very often Avishes to urinate  or to  empty her boAvels, and he
 ought, therefore, to go from time to time into an adjoining chamber, in order
 to give her the  desired opportunity.  Again, during the labor, a Avife is fre-
 quently cheered up by the caresses and consolations bestowed by her husband;
 the physician Avill understand that his presence at such times  must act as a
 restraint, and he should discreetly withdraAV, or, at least, not observe Avhat
 is going on.   Further, he may absent  himself more frequently during  the
 period of the dilatation; for instance, after having made the examination,
 and  ascertained that the child's presentation and position are both favor
 able, he might,  if the cervix Avas just beginning to dilate, attend to his other 
            ATTENTIONS  TO THE  WOMAN  AND  CHILD.        395

occupations, and return again in the course of a couple of hours; but if the
diagnosis of the position had  been impossible, or if the latter had proved to
be an unfavorable one, he must not quit her under  any  pretext, in order to
be ahvays ready to Avard off any accidents Avhich might subsequently demand
his intervention.   When the  stage of expulsion commences, the accoucheur
places himself at the right of the bed, on a chair of a suitable height.  The
part he  has to perform consists, in a natural labor, in ascertaining its pro-
gress, from time  to time, by the  touch,  in directing properly the bearing-
down efforts of the patient, and in sustaining the perineum with his hand
while the  child's head is passing through the vulva.
   During the first stage, the woman may lie doAvn, sit doAvn, or Avalk about,
at her pleasure; indeed, this  frequent change of position renders the sIoav-
ness and  fatigues of childbirth more supportable; but, at the end of this
stage, when  the  dilatation  is completed,  and  the amniotic sac projects
strongly, and is on the point of yielding, she must then resume her bed;
and this precaution is particularly indispensable in  those Avho  have already
borne several children; because, in them, the expulsion of the foetus some-
times folloAvs so  promptly after the rupture of the membranes, that  the
patient  has not ahvays the time to regain her bed, and is liable to be deliv-
ered standing.  But Avhen, after  the  rupture, the progress  of the labor is
slow, and  the head is more or less engaged in the excavation, or has already
descended as Ioav as the perineum, but does not advance, and the pains seem
to become more and  more feeble and distant, it is advisable to recommend
her to get up and Avalk about, having her supported  by assistants, if her OAvn
strength does not permit her to Avalk alone, for it is found byr experience
that bodily motion seems to give more activity to the uterine contractions.
In the contrary case, she must not leave the bed Avithout some special indica-
tion.  Where the patient is tormented by pains in the loins, Ave may relieve
them by stretching a folded napkin under the small of the back, and direct-
ing two persons, placed at the opposite sides of the bed, to pull on the ex-
tremities of the tOAvel during the  pain.   Attempts should be  also made to
assuage the cramps, so  often  experienced  in the thighs and  calves of the
legs, by voluntary contraction of the antagonist muscles  of  the suffering
ones, which will be far more effectual than frictions  over the suffering parts.
   Some nervous women are troubled Avith tremblings and chills, in the very
commencement of their  labor, Avhich  are  at  times sufficiently marked to
cause much disquietude.  Dewees  observed that they often coincide  with an
unusual rapidity in the dilatation of the  cervix, and he says : " A lady, Avho
every moment expected her labor to commence, Avas aAvakened suddenly in
the night by a violent chill.   The nurse  became alarmed, and I was imme-
diately sent for. When I arrived, I found her still trembling very severely,
but she  had not experienced any symptoms of labor; she assured me that
nothing was the matter Avith  her except  Avhat I Avas Avitnessing, namely, an
agitation of the Avhole body, which she could not, by any effort, control. In
about five minutes, she cried out she believed her labor was coming on ; and
this really Avas the case, and  so rapidly as not to give me time to place her
in a proper situation for delivery;  she Avas  delivered  in less  than five
minutes from die time she first called my attention to her.  These shiver- 
396
LABOR.
ings are sometimes reneAved during or immediately after the labor, but in
no case do they merit a serious attention."
  Patients are often frightened at the time the bag of waters is torn, and it
is therefore  a good plan to  advise them of it beforehand; and the precau-
tion should  also be taken  of  placing  a sponge or some old  linen near the
genital parts, so as to receive the liquids as they escape.  Immediately after
the discharge  of the Avaters, it is advisable  for the practitioner to  assure
himself aneAV  of the presentation and  position, lest he might  have been
deceived in the first examination.
  The rupture of the membranes generally takes place spontaneously, but
this is not always  the case, and  the accoucheur must sometimes interfere.
It is very certain that Avhen the uterine orifice is entirely dilated, Avhen the
membranes are forced into the vagina by a large quantity of fluid, and the
head  is movable, but still  the contractions  do  not produce  a spontaneous
rupture of the membranes,—it is  evident, we  repeat,  that  they, by their
resistance, prolong the labor.  Although this obstacle is never insurmount-
able, by the efforts of nature  alone, yet the  delay in the delivery and the
dragging on the membranes  may  be  attended Avith some inconveniences,
and it is therefore  better to lacerate them.   This is done by  taking advan-
tage of a strong contraction, and, Avhile they  are greatly distended, forcibly
pressing the index finger against the centre of the tumor.
  When this  rough pressure  is  not sufficient,  we scratch the membranes
with the finger-nail; and by gradually Aveakening the three tunics, succeed
in rupturing them.  Sometimes,  hoAvever, they  still resist, and  then some
instrument, such as a blunt probe, or, still  better, the end  of a quill cut
down, is directed up to them  along the finger.  M. Dubois made for the
same purpose a very convenient instrument, consisting merely of a piece of
Avhalebone sharpened at one end.   Where the Avaters zxe flat, that is, Avhen
but little liquid intervenes betAveen the membranes and  the head, some care
is requisite, in using the little  instrument, to direct it obliquely, so as not to
wound  the foetus with its point.   Rupturing the membranes is, therefore,
a trifling operation; still, excepting in some rather rare cases to be spoken of
hereafter, it ought not to be performed until after the orifice is thoroughly
dilated.  Whatever the presenting part  may be, there is   ahvays an ad-
vantage in retaining a large amount of fluid in the uterus.
  Some peculiar circumstances may, however, demand the artificial rupture
before the dilatation is completely effected.
  In a case reported by Baudelocque, the child Avas so movable, that it suc-
cessively presented every part of the surface  of its body at the os uteri. In
a Avoman Avhose belly Avas distended  by a great quantity of water, M. Martin,
of Lyons, had  recognized the feet and one  hand through the membranes.
"I  then felt  disposed," says  he, "to  terminate the labor, Avhen, at the
request of her husband, I called a friend in  consultation; but on touching
her again, before his'arrival,  I detected  the  head where I had previously
found  the  feet  and hand, when  I  immediately punctured the membranes,
Avhereby the head Avas fixed at the superior strait and the delivery rendered
natural."  (Comptes Rendus,  p. 155.)   Should a case of this nature be met
Avith,  the rule we have just given might be  laid  aside,  and the membranes 
           ATTENTIONS  TO  THE  WOMAN  AND  CHILD.        397

be ruptured, hoAvever inconsiderable the dilatation.  It is scarcely necessary
to add that an artificial rupture is only to be resorted to when the foetus
shall  be  detected presenting by its cephalic extremity; for then the dis-
charge of a certain quantity of the amniotic liquid, and the  retraction of
the uterus, will irrevocably fix this part at the upper strait.
   Again, according to the majority of writers, the membranes maybe lacer-
ated  before the  entire dilatation of the cervix, Avhere there is reason  to
suppose that the waters, from their too  great  abundance, distend beyond
measure, and thus weaken the contraction of the uterine Avails; but, even
here,  Gardien  recommends the greatest circumspection, and advises the
previous  employment of all the measures  calculated to stimulate the con-
traction of the Avomb.
   Finally, Ave shall learn hereafter that the puncture of the ovum  at an
early  period of labor, is one of the most effectual means of arresting certain
dangerous hemorrhages which may supervene during its progress.
   The finger ought to be introduced into the vagina several  times  in the
course of the last stage of labor, both during the pains and in the interval
betAveen  them, to ascertain the progress of the  head in the excavation.
Nevertheless, this exploration is to be resorted to as rarely as  possible, and
only Avhen the interest  of the mother seems to demand it.
   Most Avomen, supposing that they can  materially hasten the termination
of the labor by making the most of their pains, contract their  muscles, bear
down violently, and make extraordinary efforts at the beginning; but these
uselessly exhaust their  strength; for, so long as the neck is ineffaced, and
the bag  of waters  unbroken, all bearing-doAvn effort  is fruitless.   But in
the second stage, Avhere the head descends into the excavation and rests on
the perineum, she should be encouraged to aid the uterine forces  by a volun-
tary contraction of the  muscles of the trunk and limbs; though, as soon  as
the pain has passed off, all the auxiliary efforts should be at once suspended.
Again, in the latter moments of the travail, just when the head is about to
clear  the vulva, the pains are so sharp that the woman naturally gives Avay
to incredible exertions, Avhich  may possiblyr occasion serious  accidents ;
hence all the poAvers of persuasion should then  be employed to  induce her
to moderate her strainings.
   During the last moments of childbirth, the pressure of the head on the
loAver part  of the rectum creates an urgent desire  of emptying the boAvels ;
and many  Avomen, yielding  to a misunderstood  modesty, then wish to rise
and retire  to the closet; but it Avould be exceedingly imprudent to comply
with their demand,  and they must  not  leave the bed  under any  pretext
whatever.  In the first place, this desire  is often illusory,  more especially
where the  precaution has been taken to empty the intestine at the com-
mencement of labor; and then it may happen, as I once witnessed, that the
patient, surprised by a  violent pain, is delivered on the close stool, Avithout
the physician being able in any way to render her the necessary attentions.
  It is in these last moments that the accoucheur must give all his attention
to supporting the  perineum, which is done by pressing the whole perineal
surface equally, and with  a  moderate degree of force, by the  palmar face
of the hand.  The latter is  applied  in such a way as to make the radial 
398                             LABOR.
border of the index  finger cover the anterior  margin of the perineum, the
ends of the fingers corresponding to the left side, and the thenar eminence
of the palm  to the right side of this partition, Avhile the thumb is held to
the right of the labia externa.   The pressure  should be someAvhat greater
near the anus, so as  to give the foetal head a forward direction, and facili-
tate its movement of extension.
   Finally, Avhatever may be the child's position, Ave should, contrary to the
opinion of certain authors, abstain from introducing the fingers  into the
loAver part of the vagina, or making pressure on the perineum and coccyx;
in a Avord, from  performing what they  call their  little  labor.  There are,
however, a feAV measures Avhich may7 be useful; for  instance, Avhen the geni-
tal parts exhibit  great rigidity, heat, and  dryness,  the emollient  injections,
or frictions with  mild ointments, such as  cerate,  or cucumber ointment,
emollient fumigations, or  bathing in  lukewarm Avater, may be very advan-
tageous.   This last remedy, especially, is of marked utility where the abdo-
men is tender and painful, and the cervix  uteri is rigid and resistant.
   Within a few years, Professor Simpson has introduced into obstetric prac-
tice the use of those anaesthetic agents, which  are daily productive of  such
wonderful results in surgery.   The Edinburgh accoucheur does not,  how-
ever, reserve ether or chloroform for difficult cases, but advises their use in
the most  natural labors.   The importance of the subject  demands of us a
detailed examination; and a long article will  be found appended, in Avhich,
after  having stated  the known results, we  shall  give  frankly our OAvn
opinions.
   Regimen of Women in Labor. — Those women AA'hose labors are unusually
short, need not, as  a general  rule, take  any nourishment whatever; but
when the travail drags  along, it is necessary to sustain their strength by
articles of easy digestion;  thus, as  many are  in the  habit of taking  coffee
Avith milk every morning, this  may be alloAved  them without danger ; and
then,, during  the day, a feAV cupfuls of some broth  may  be given, though
ahvays  in  small  quantities  at  a time.   Where the stomach is  disordered
and vomiting takes  place,  as  very frequently happens, even  these liquid
aliments Avill have to be restricted.  This  plan, hoAvever, is  not  applicable
in all cases, since some must be allowed Avhat Ave should  refuse to others ;
for example,  there is no necessity for subjecting robust country-women to
the same severity of regimen  as the delicate ladies of large cities.   The
choice of  drinks  is  also a  matter of some  importance, and Ave may recom-
mend some pure  or  sugared water, or a weak infusion of lime, or orange-
leaves, of malloAvs, violets,  &c.   Lemonade, or Avine diluted with  water, will
be very agreeable to  most Avomen at first; but,  in general, they soon produce
a  sour stomach  and eructations;  all hot cordials  and fermented liquors
should be  positively prohibited.  In  the  country  districts,  there  is  often
much difficulty in overcoming the vulgar prejudices on  this subject; but
the physician must  insist  upon it, for he ought never to lose sight of the
distress and agitation that  folloAV the administration of spirituous beverages,
and which expose the patient  to  inflammations and active hemorrhages.
Should  it happen that her feeble condition requires any restoratives, then
some good broth, or  a little old Avine, or  a  feAV spoonfuls of sherry-wine, are
the only and the best means that can be employed. 
           ATTENTIONS  TO  THE  WOMAN  AND  CHILD.        399

                           ARTICLE II.
          OF THE  ATTENTIONS TO THE CHILD DURING LABOR.
   Having determined the presentation and position, the accoucheur should
next ascertain Avhether the child is living or dead, as it is highly important
to determine this point, in order to diminish his  OAvn  responsibility, by
advising the family of the fact.        /
   Before the  membranes are ruptured, the diagnosis  may be easily made
out by ascertaining through auscultation the  existence or absence of the
pulsations of the fcetal heart, as also the continuance or complete cessation
of the active movements, in regard  to Avhich  the Avoman can ahvays give
sufficiently accurate information.   After the rupture of the membranes, the
active movements are feeble, and sometimes entirely absent; in Avhich case,
however, the pulsations are still detected by auscultation.
   The touch  also reveals certain signs  which may shed still  further  light
upon  the question.  Thus, when the  child is alive and  the head  presenting,
it often becomes affected Avith a  sanguineous SAvelling, the size of Avhich
depends upon the length of time which has elapsed since the discharge of
the waters.  This tumor does not form  Avhen the child has ceased to live;
and if its death dates back for  several  days, the resisting  tumor formed by
the sero-sanguineous  infiltration  Avill be replaced by a  soft, flaccid, and
wrinkled condition of the  hairy  scalp.   Besides  this, the bones  of the
cranium%Avill be  more movable, and the overriding of their edges greater
than usual; a sort of crepitation is also produced by their rubbing against
each other.   A more embarrassing case is that in which the child dies some
time after the rupture of the membranes, but not before the sanguineous
tumor has had time to be developed.  Even here the uncertainty will be of
short  duration, for, provided the labor should continue beyond three or four
hours, the tumor will lose  its  consistency, and its softness and flaccidity
render a mistake a matter of difficulty.
   Finally, Avhen  the  pelvis is rather contracted, the Avrinkling of the scalp
may simulate a swelling, Avhose diagnostic importance it is well to appre-
ciate.   In this case, says Merriman, the best  means of judging of the life
or death of the child  by the tumor of the scalp is as follows: Avhen living,
it is observed that,  at the  moment Avhen the  head is strongly urged doAvn
by the contraction of the Avomb, the bones overlap each other, and, as  a
consequence, the  scalp becomes folded, and  thus constitutes  a temporary
tumor; but immediately after  the pain is over, the head regains its primi-
tive form, by the expansion of  the cranial bones, and  the folds and tume-
faction previously exhibited by the skin disappear, or, at least, considerably
diminish.  On the contrary, however, if it be dead, the expansibility of the
bones  is destroyed, and the head  does not reassume its primitive form and
volume after the contraction has passed  off; Avherefore the tumor formed by
the doubling of the hairy scalp still  persists, in  a great measure.  Now, in
this condition of affairs, the SAvelling  is sometimes greatly augmented by the
liquids forced  in  by the  pressure from above,  and Avhenever, in  such cases,
a perforation  of the cranium has to be  resorted to, practitioners Avell knoAV
there is half an inch at least of soft  parts to be traversed before reaching
the bone.  (Mcrriman's Synopsis.) 
400
LABOR.
    If the face should present, the softness of the lips, and the flaccidity and
  immobility of the tongue, should lead us to suspect that the child is dead;
  since, when living, the firmness of all its parts, and the motion of the tongue,
  are often felt Avith ease.
    In breech presentations, the introduction of the finger into the anus will
  detect a resistance and contractile power on the part of the sphincter,if the
  child be living, Avhich Avill be absent if the child be  dead.
    Lastly, in shoulder and arm  presentations, the SAvelling of the member,
  and its violet hue, will afford an indication in favor  of its life.
    Should the cord hang in the vagina, its softness, Avithered  condition, and
  the absence of pulsation in the umbilical arteries,  Avould justify a belief
  that the child was dead.
    A thick  and fetid condition of the amniotic fluid, and a discharge of
i meconium,  have been regarded as indicating  the death  of the child.  The
  altered condition of the waters is of no great  importance, since it has some-
  times been found to coincide with perfect integrity of the foetal life, but the
  discharge of meconium is of greater significance.
    It is not at all uncommon to find the  meconium  escaping in  greater or
  less quantity during parturition;  and,  as previously  stated, this peculiarity
  most frequently occursin the positions of the  pelvic extremity, and is then
  of little consequence ; but this does not  hold good in any other presentation ;
  for  then  its discharge  is always an unfavorable sign, one calculated to
  arouse  the  anxious solicitude of the medical attendant, as it usually  indi-
  cates a state of suffering on the part of the child, Avhich is  almost ahvays
  due to a compression of the cord.  It must be apparent, on the least reflec-
  tion upon the part performed by the placenta during the intra-uterine life,
  that an interruption of the foeto-placental circulation produces asphyxia,
  Avhich latter determines a cerebral congestion, and sometimes even  an
  apoplectic effusion, whence a  paralysis  of the  sphincter  ani  results.  Now,
  if to this  palsy of the sphincters, Ave add  the instinctive acts of respiration1
  made by  the foetus, which are the more violent as they are the more ineffec-
  tual, we can understand Avithout difficulty hoAv an escape of  the  meconium
  may result from a compression of the cord.
    As regards  the  prognosis,  it is important to observe the precise moment
  at which  this discharge takes place, as it is ahvays serious when it does not
  occur till some time after the rupture of the membranes; though the Avaters,
  when they escape, are often colored yelloAv, and  the presence of the meco-
  nium then is not necessarily an alarming symptom.   In  some cases, it  may
  indeed  indicate an actual compression  of the  cord ;  but it may also result
  from a compression that had existed  some time before birth, which  may
  have compromised the child's life for a few moments, and then  have sud-
  denly disappeared  in consequence of some brisk movement of the infant.
    It is not difficult to conceive that the cord  might  undergo  a momentary
  compression during the  last  months of gestation, as also that it might be
  displaced by a sudden motion of the child, and  the foeto-placental circula-
  tion be  re-established  in consequence.  Noav, this  compression  may  have
   1 Mayer has observed respiratory movements in embryos, even within the ovum, ae
  Boon as he compressed the cord. 
            ATTENTIONS  TO  THE  WOMAN  AND  CHILD.         401

 lasted  50 long  as to threaten  asphyxia, and consequently to prod ice a dis-
 charge A' meconium.
   Endeavors have  been made to determine by the physical characters of
 the meconium,  Avhether its  discharge Avas  occasioned  by a  presentation of
 the breech, or by the sufferings of the foetus.   It has been said that, in the
 latter case,  the meconium  is very fetid, thinner, and more  diluted,  than
 when the breech is above the uterine orifice.   Such signs, hoAvever, are very
 inconclusive.
   On the Avhole, therefore, a discharge of meconium in breech presentations
 is of little consequence; but, in  the other presentations, and where occur-
 ring some time  after the rupture of the membranes, it is always an unfavor-
 able sign;  though, to  judge of its value at the time of the rupture itself,
 recourse must be had to auscultation.
   Of all these  signs, the best undoubtedly is that supplied  by auscultation
 of the heart, Avhose pulsations are ahvays perceptible if the  child be living.
 It is quite possible for the  pulsations of the cord to escape detection  even
 though the foetus be living, inasmuch as  they sometimes stop  during the
 pain and begin again Avhen it is  over.   Therefore, certainty of diagnosis
 would  require  that  the  pulsations should have ceased for a considerable
 time, ten or  fifteen minutes at the least.
   In vertex  presentations, as soon as the head is expelled its disengagement
 is effected.
   Immediately  after its expulsion, the disengagement of the  head.is com-
 pleted,  either by carrying it more and more toAvards the pubis, or by insinu-
 ating the index  upon one side of  the loAver jaAV; this  being accomplished,
 we must next ascertain Avhether the cord does not make one or  more turns
 around the neck, and if so,  gentle tractions must be made on its placental
 extremity, to avoid its being dragged upon, and to prevent strangulation
 of the foetus, cyjc. ; and Avhen a sufficient extent of it cannot  be brought out,
 to render the prevention of such  accidents certain, Ave have to  cut it, and
 terminate the labor  as promptly as possible, by hooking one or the other
 Rhoulder with the forefinger.1   After the head is  born, the womb, exhausted
 by its last efforts, remains passive for some  instants, and  it frequently hap-
 pens that the child begins to respire  and cry, even before  the delivery of
 the chest.  We  may, therefore, Avait patiently until the contraction is re-
 newed, simply supporting the  head, lest the mouth and nose be choked up
 by the cloths or blood found betAveen the woman's thighs; but if the atony
 is prolonged, and more especially if the face of  the neAv-born infant is ob-
 served to be  red and tumefied, as  sometimes happens  after  painful labors,
 the  remainder of the travail ought not to be left entirely to nature, but
 new  pains should be at  once solicited by frictions over the abdominal Avails,
 and  the patient  be encouraged to bear doAvn.  The disengagement can al-
 most ahvays  be accomplished by moderate tractions upon the head grasped

  1 These folds may occasionally be drawn so tightly as  to strangle and kill the infant,
as occurred in the following case:  "Upon approaching a woman who  had just been
delivered. I found  the child dead, and still lying near the genital parts; the cord made
three turns around its neck, and they were so firmly tightened  that a deep ecchymosis
was seen on this part."  (Guillemot.)
      26 
402
LABOR.
 by both hands; and if these measures prove insufficient, the index finger,
 curved like a hook, is to be placed in one of the armpits, and the disengage-
 ment of the anterior shoulder thereby first effected.
   After the shoulders are disengaged, the spontaneous expulsion  of the
 breech and loAver extremities  may also be delayed in consequence of inac-
 tivity  of the Avomb.  Here again, it is especially proper to endeavor to ex-
 cite the contractions by frictions upon the abdomen ; but should the life of
 the foetus appear to be in danger, the extraction  should be effected  imme-
 diately.
   The  artificial extraction of the  shoulders or of the lower part  of the
 trunk, Ave see, ought not to  be  resorted to until expectation  might become
 dangerous to the foetus.  When the expulsion is  left entirely to nature, the
 womb  contracts in proportion as it is emptied, and there is less cause to fear
 the consecutive inertia which is sometimes  produced by too rapid  an ex-
 traction.
   In those rare cases, Avhere the occiput remains posteriorly until  the  end
 of labor, most  accoucheurs  haA'e recommended that an  attempt should be
 made to bring  it round to  the front, but Ave doubt Avhether this will often
 prove successful, although we have never seen it tried, nor ever attempted
 it ourselves; for we believe that Avhere the process of rotation does not take
 place spontaneously, all efforts  to  produce it artificially would  be useless,
 not to  say injurious.  Nevertheless, most authors advise, wljen the head has
 descended into  the excavation, immediately after the discharge of the Avaters,
 to make it deviate either toAvards the right or the left in  the interval between
 the contractions (Velpeau), by slipping two or three fingers either along the
 sacrum, to press the occiput forward, or else upon the side of the forehead,
 behind the  pubis, to carry  it backAvard.   If we should ever entertain the
 thought of attempting this manoeuvre, Ave would much prefer acting during
 he contraction, for then Ave should only aid, Avithout absolutely supplanting
 lature;  Ave would prefer, whilst acting upon the occiput, as indicated by
 Velpeau, applying, at the same time, tAvo fingers on the temples, and  acting
 thereupon in  such a  way as to turn  the forehead posteriorly.   But, Ave
 repeat, this  appears unnecessary in the great majority of cases, because it
 only hastens the process of  rotation, Avhich would have subsequently taken
 place Avithout it; and even hurtful in others, for the efforts used to bring it
 about might exert a pernicious  influence both on the mother and her child.
  In fact, in ordinary cases, where the rotation is  produced by the natural
poAvers, the trunk folloAvs the movements of the head; but Avhere the latter
has been turned by the fingers, the body remains immovable, and hence the
process of forced rotation may dislocate the atloido-axoid articulation and
kill the child.
  The  older accoucheurs thought that a spontaneous delivery^ in face pre-
sentations, was altogether  impossible, and consequently they advised an
endeavor to be made, in the very outset of labor, to convert them into ver-
tex positions;  but we of the present day understand better the value of
such opinions.  However, the rotation by which the chin is brought under
the symphysis pubis, whatever might have been its primitive relation to the
superior strait  (see Mechanism of Delivery by the Face), is difficult, painful, 
           ATTENTIONS  TO  THE  WOMAN  AND  CHILD.        403

and sometimes, in the mento-posterior positions, does not take place at all.
It Avill be seen, further on, that the non-accomplishment of this movement
forms one of  the most serious complications met Avith in practice, and that
craniotomy often becomes necessary in consequence.  When the face is
engaged  at the inferior strait, and the chin is found under the pubic arch,
the movement of flexion begins, and then, as has been shoAvn, the pressure
to Avhich the  vessels of the neck are subjected, during the fourth stage, may
retard 'the  circulation enough  to determine death by cerebral  congestion.
Hence, Ave learn Avhat great precaution  is necessary in supporting the  peri-
neum, since it must be  evident  that too great a pressure made upon this
part would necessarily augment the compression of the child's neck.
  The delivery by the pelvic extremity' ought to be abandoned entirely to
nature, unless there are some unfortunate complications. We haA^e already
insisted upon this point in the  note at page 354; but do not hesitate to
repeat again  the advice,  not to  resort to any traction in a natural labor by
the breech, because, as there stated, a stretching out of the arms, and some-
times even an extension of the  head; result from such imprudent tractions,
whilst these complications  are scarcely  ever  met with Avhere the expulsion
is left to the  uterine contractions entirely.   Noav, there is no difficulty in
comprehending these different results, for Avhen  the womb is the sole agent
of the delivery of  the child,  the  latter is forcibly  urged on by the  circular
fibres at the  superior  part of the organ, and at the same  time  is strongly
pressed on its sides by the  longitudinal fibres.  The upper extremities are
therefore maintained against the  lateral and  anterior parts of the chest, the
head  is kept  flexed on the thorax, and all these parts descend together; but,
on  the contrary, if any  tractions are made, they only act on the trunk,
Avhich then descends alone, Avhile the arms, being arrested  by the  margins
of the cervix uteri, or by the periphery of the straits, do not participate in
the descent, and are ultimately found placed  against the sides of the head;
hence, the accoucheur's exclusive duty consists in receiving and supporting
the loAver parts of the child as  they become disengaged ; taking care, as
soon as the breech has cleared  the vulva, to  ascertain the  condition of the
cord.  For that purpose, the forefinger  is slipped up  as  far as the navel,
Avhen, if the cord is found to be tightened at its  umbilical insertion, he joins
the thumb to the index so  as to produce some traction on  its placental ex-
tremity only, Avith the vieAV of preventing both its being dragged upon, and
 ts possible laceration. The cord  sometimes gets betAveen the infant's thighs;
 md, in such  cases also, the loop  thereby formed must be enlarged  by pull-
ing on the placental extremity, and then by disengaging it from the poste-
rior limb, bring it into  contact  Avith the perineum, that is, Avith soft parts
whose compression Avill be less severe, and  consequently less dangerous to
the circulation than Avhat it Avould suffer from the symphysis pubis; but if
it is too short to be brought to the exterior, it must be cut, and have a liga-
ture applied  on its  umbilical  extremity, and the  labor be terminated as
rapidly as possible.
  But, whatever may have been the cause,  the death of the foetus ahvays
restil's from the slowness with Avhich the shoulders  and head are expelled,
for it is only  during this  last part of the travail  that the cord is compressed. 
404
LABOR.
or that a separation of the placenta takes place; hence, although we have
condemned all traction in general, it must be otherwise under such circum-
stances.  But hoAv is it  possible to determine the period beyond Avhich it
Avould be imprudent to Avait?   We ansAver, that as soon as asphyxia comes
on, the suffering condition  of the child may easily be detected by examin-
ing the portion of the cord Avhich has been delivered;  and if the pulsations
still maintain their intensity, their frequency  and habitual regularity, the
rest of the  process may be abandoned without danger to  the poAvers of
nature; but, on the contrary, if they are found to relax, or  even to become
more rapid,  though at the same time more feeble, thread-like, and especially
if intermittent  or irregular, every effort must  be used to remove the foetus
from the danger which threatens it.
   The signs furnished by the irregularity of the pulsations of the umbilical
arteries, and to which great importance has been attributed by some authors,
only become sensible after the  asphyxia has lasted for so long  a  time that
it is not  ahvays possible  to overcome it;  therefore  we regard as  much
more available the phenomena  next to be mentioned.
   When the head alone remains behind in the pelvic excavation, the child
is very often observed to dilate its chest actively, and make a violent inspi-
ratory effort, Avhich may be referred to a rapid convulsive contraction of the
diaphragm  and abdominal muscles, repeated  at  irregular  intervals; noAV
such acts never  take place while the foeto-placental  circulation  remains
intact, since the  pulmonary respiration is  unnecessary so long as  the pla-
cental one is going on, and therefore these struggles  constantly announce a
state of suffering, or of  imminent asphyxia,  from Avhich the  infant must
speedily be  relieved.   Where  the head  alone is  undelivered, the patient
must be encouraged to bear doAvn strongly, so as to  hasten  the termination
of her labor, and  avoid a prolonged compression  of the cord; and the
accoucheur  might facilitate the flexion of the head by gently carrying the
trunk up in front of the symphysis, or when  the flexion appears difficult,
he may, by  insinuating tAvo fingers  under the symphysis, press slightly on
the occiput; for a comparatively light force exercised on the posterior part
of the head  is often sufficient to reverse the great occipito-mental diameter,
and terminate the delivery.   Should the  head resist these efforts, other
measures become necessary; but they  belong to instrumental delivery, and
we shall treat of them in the article on Version.
   Finally, should it be impossible to extract the head immediately, Ave may
endeavor to introduce the fore and middle fingers into the mouth of the
child, and then separate  them slightly, so as to leave an open space through
which air might find its  way to the mouth.  The  same  object would be
effected Avith  still greater certainty, by introducing a large catheter  into
the mouth. 
ATTENTIONS  TO  THE  WOMAN  AND  CHILD.        405
                       CHAPTER  VIII.

   OP  THE  ATTENTIONS  TO  THE WOMAN  AND CHILD  IMMEDIATELY
                           AFTER DELIVERY.

                            ARTICLE  I.
   OF THE ATTENTIONS TO THE WOMAN IMMEDIATELY AFTER DELIVERY.

   As soon as the child has been expelled, the accoucheur should place his
 nand  upon the mother's abdomen in  order to  ascertain Avhether there is
 another child,  as also to learn Avhether the uterus contracts Avell, inasmuch
 as inertia of the organ should lead to  the anticipation of hemorrhage.   It
 would also be right to determine whether there be too free a discharge of
 blood from the external parts.
   The expulsion of the placenta and its  annexes, whether spontaneous or
 assisted by the accoucheur, generally follows very sliortly after  the exit of
 the foetus.   In order to avoid separating the study of this natural delivery
 of the after-birth from that of the difficulties and dangers Avhich may attend
 it, Ave shall treat of them  separately.   (See Delivery of the After-birth.)
   After the delivery, the  accoucheur should  ascertain, both by the external
 examination and the vaginal touch, whether the placenta has draAvn down
 or inverted the fundus of the Avomb, for the  purpose of rectifying it at once
 if such an accident has occurred.   If everything proves to be in  its natural
 condition, frictions with the hand are to be made over the hypogastric region
 from time to time, in order to excite  the retraction of the uterus, and thus
 favor  its disengorgement, and the expulsion of the coagula Avhich  may be
 still contained  there.  The patient is alloAved to remain for some minutes
 on the bed Avhere she Avas delivered, so as to  give her a little repose, as Avell
 as time to  the uterus and vagina  to clear themselves of the blood, Avhich
 floAvs at first in abundance, and  Avould soil the linen in Avhich she is about
 to be enveloped.   Besides, a  feAV minutes are ordinarily devoted  to paying
 those necessary attentions to the infant, hereafter pointed  out.  In  fact,  she
 might remain upon the same bed  a still  longer period,  when the delivery
 has either been preceded or folloAA'ed by syncope, hemorrhage, or any other
 accident, or even Avhere there is reason to fear something of this  nature,
 taking  care, however, to substitute dry things  for those that  have been
 soiled.  She ought to lie perfectly flat, the thighs stretched out alongside
 of each other, lightly covered, and be left  in silence, and the most absolute
 rest of both body and mind.   In about half an hour, the patient Avill again
 require special  attention;  the genital  organs, and upper part of the thighs,
 are to be first  Avashed carefully and gently Avith lukeAvarm Avater, pure or
 mixed Avith  a little Avine; then they are to be Aviped Avith warm and well-
 dried toAvels, and all  the garments  worn during parturition that  have been
 soiled by the perspiration, discharges, and  fecal  matters, are removed, and
 replaced by others, previously Avell dried and warmed; their shape is unim-
portant,  the  only  point  requisite  is  to have  them  large enough  not   to
incommode the Avoman in  any Avay, and  to admit of  being changed  easily 
106
LABOR.
and promptly.  The greatest celerity is to be used in this  toiht, lest  she
should be long exposed to the air ; the arms and breast particularly ought
to be Avell clothed, so that the patient may, during the day at least, keep
them out of bed without danger of taking cold.
 1 All these preparations  being completed, she is next to  be transferred to
the bed intended for her reception  during the lying-in.   Many females,
finding themselves Avell enough, Avant to Avalk across to the permanent bed;
but against such an imprudence the physician must interpose the whole
weight of his authority.   The one to which she is to be transported must be
previously Avarmed, and provided with a  sufficient amount of covering that
can easily be changed; though the coverlets  should not be thicker or more
numerous than those used before pregnancy.
  There is a custom much in vogue of surrounding the belly Avith a  moder-
ately tightened bandage; and the Avomen, for the  most  part, attach  the
highest importance to this measure as a  preservative against the Avrinkles
and folds that are found  after labor on the skin of the abdomen, as also to
prevent the latter from  remaining too voluminous.   Their  desires may be
yielded to the more Avillingly, as such a bandage, Avhen  moderately  draAvn,
supplies the pressure no longer afforded by the abdominal Avails, and thereby
prevents the afflux and stasis of the fluids, the engorgement of the  uterine
Avails, and the dilatation of the cavity of  this viscus; and it has the  further
advantage of obviating the tendency to  syncope,  and of diminishing  the
after-pains.   But, in order to  obtain  all  these benefits, it should be large
enough to compress the whole sub-umbilical region  equally.  Care should
be taken  to prevent its becoming doubled up, whereby a circular  cord is
formed, which, from  opposing the ready return of the fluids, would then
prove a cause of hemorrhage.
  The body bandage may be substituted  Avith advantage by a folded cloth
applied flat upon the abdomen Avhich it compresses gently by its Aveight,
which is sufficient for the purpose.
  Some Avomen, influenced by  a feeling of coquetly, also desire to (ompress
their  mammae by means of  a bandage, Avith a view of preventing their en-
largement, and their consequent softness  and flaccidity, and some even go
so far as to apply topical astringents for  the purpose of obviating an over-
abundant secretion of milk ; but such measures should be  proscribed in the
most  absolute manner, since they  might  prove  very dangerous.  These
organs only require  a  sufficient amount  of covering  to protect them from
the contact of the external air, and to maintain a proper degree of heat.

                           ARTICLE II.
  OF THE ATTENTIONS TO THE CHILD IMMEDIATELY AFTER ITS BIRTH.
  The management of the new-born infant necessarily varies according to
whether it is strong, vigorous,  and healthy ; or Avhether, on the other hand,
it is born  in a state of debility or disease.

  § 1. Of the Child in a Healthy  State.
  When  the child escapes from its mother's Avomb living, and in a  healthy
3tate, the  circulation existing between it and the placenta is observed to 
ATTENTIONS TO THE  WOMAN AND CHILD.         407
 continue  for some time, Avhere the  delivery is abandoned entirely to the
 poAvers of nature; the after-birth is soon detached and expelled, and then it
 as well as the cord  loses its vitality, the  circulation becomes weaker and
 Aveaker, and the pulsations in the arteries gradually cease, commencing at
 their placental extremity; and some authors have advised this event to be
 Avaited for before cutting the cord;  but as this spontaneous delivery most
 generally' requires a long time, it is  customary to make the section imme-
 diately after its birth, and then  the folloAving attentions to the neAV being
 become necessary, namely : Avhere the infant is  entirely clear of the mother's
 parts, the cord is disengaged if it  had been tAvisted around its neck or body,
 and the child is placed on the side, having its face turned aAvay from the
 vulva, so that it may  breathe freely without running  the risk of being
 suffocated by the liquids that escape from  the vagina.  The umbilical cord
 is next cut at about five or six fingers' breadth  from the abdomen, generally
 using the scissors for this operation, though it maybe done Avith any cutting
 instrument whatever.  As soon as the section is effected, the cut extremity
 is slightly pinched betAveen  the thumb and forefinger, Avhile the remaining
 three  fingers  grasp  the  breech, and the other hand is  placed under the
 shoulders and neck  of  the  child, AA'hich is thus lifted out of  the bed, and
 placed on the nurse's knees prepared  for its reception.   It may then be
 examined more at leisure, to ascertain that no loop of intestine exists at the
 base of the  cord, and to permit the latter to bleed if judged advisable,
 before applying the  ligature.  A ribbon, eight or ten inches  long, may be
 used for this latter purpose, or a cord consisting of a skein of coarse thread ;
 but, before applying  it, the gut is to be reduced if there is an umbilical
 hernia, and then it ought to be tied at about tAvo, three, or four inches from
 the surface of the abdomen; the only precaution requisite is to avoid  placing
 it around the skin, Avhich is prolonged more or  less upon the cord; for pain,
 inflammation, and  ulceration would  thereby result, the subsequent  cure of
 which might be attended with some  difficulty.  As a general rule, it is best
 to leave sufficient space  betAveen  the ligature  and the fold of the skin, to
 alloAV of the application of a  second, should the  first prove insufficient.  The
 ligature must bedraAvn tight enough to obliterate the arteries completely and
 permanently, Avithout cutting their  coats.  If the cord  happens to be thick
 and  infiltrated, the ligature  Avill  strangle its vessels  but.  very  imperfectly;
 and  Avhen it  afterwards  becomes  diminished by the escape or evaporation
 of the fluid parts, the vessels being no longer compressed, Avill obviously
 permit a free discharge of blood from the cut end.  Besides, the putrefying
 of the lymph will soon  produce a very fetid  smell, and irritate the skin
 wherever  it comes in contact; and it is therefore, to prevent such accidents,
 that  authors very properly recommend the expression of this viscid fluid by
 pressing and slipping  the cord between the fingers, and even by pricking its
 enveloping membrane, taking care,  hoAvever, to avoid wounding its vessels;
 and lastly, if the cord Avere unusuallv large, it might, for greater security, be
 bent  backAvard after the first knot AA-as tied,  and be included in a second one.
 Where there is reason to suspect a tAvin pregnancy, it is necessary  after cutting
the cord of the first-born to apply a ligature around its placental extiemity
ilso.   Though the application of the second ligature is, in most  cases, a use 
408
LABOR.
 less precaution, yet the fact  that in some very exceptional cases in AA'hich a
 communication exists between the vascular ramifications of the two placentas,
 it might prevent a hemorrhage which would quickly prove fatal to the second
 child, is sufficient reason for  never dispensing with it.
   Numerous discussions  have sprung  up as to Avhether the ligature of the
 umbilical  cord was absolutely indispensable, and, if so,  whether it  should
 be applied prior to the section, or Avhether the cord might be cut before it
 is tied.   Now,  although it is highly probable  that the  circulation  in  the
 umbilical vessels would be arrested spontaneously, after the regular estab-
 lishment of the respiration; as, also, that the ligature is almost or entirely
 useless in the great majority of cases, yet, if it is certain that a hemorrhage
 has taken place in some feAV, even though they be exceptional instances,
 from the core? having been imperfectly tied, or else not ligated at all;  this,
 of itself, is a  sufficient reason for not neglecting so simple a precaution; and
 as to the second question, the course just pointed out  is, in our opinion, de-
 cidedly preferable.
   The surface of the child's  body is next to be cleansed  of the ceruminous
 substance that  covers it, and from the blood  and other matters Avhich  be-
 come attached at the moment of delivery; but as this can  scarcely be re-
 moved  by a  simple rubbing Avith  dry towels, it should first be diluted with
 a little  oil, or fresh butter, and  then be  gently Aviped off; the yolk of an
 egg Avould produce the same effect, and besides, would  render  this  matter
 more miscible Avith water.  To get  rid of the blood  and other  impurities,
 water mingled with wine, or else  a simple  bath,  into Avhich the child is
 plunged, is most generally employed;  the temperature of the bath  should
 be about twenty-five degrees  (77° Fahr.).
   The infant being well Avashed, sponged, and Aviped,  is next to be dressed;
 but, before doing so, the  physician himself should first envelop the cord in
 a compress intended for that purpose; Avhich compress is merely a piece of
 fine linen, of a square shape, and  having an opening at its centre large
 enough to allow the cord  to pass through it easily, and then, after having
 ripped one of its sides from  the free margin doAvn to  this hole, the root of
 the cord is lodged at the bottom of the  resulting  fissure ; then the uncut
 part of this little-compress remains beloAV, and the tAvo halves of the divided
 portion are turned over and crossed in front of the cord, the Avhole being
 placed at the upper and left side of the abdomen.  A second  soft and square
 compress covers the first,  and a band  three or four fingers' breadth Avide,
 and long enough to go tAvice  round the  body, supports  the Avhole of the little
 apparatus in  this position.
   Before enveloping the cord, the dressing of the child  had already com-
 menced, its head,  arms,  and chest being  then covered.  The  rest of its
 clothing should be  Avarm, soft, and moderately tight.   In France, it consists
 of a camisole, or little woollen jacket, furnished Avith a soft chemisette  that
 is fastened behind by pins, then one of linen, and another of avooI or  cotton.
The English  envelop their children in a long, loose robe, or something like
a flannel sack.
   Befon ■•■ dressing  the child, the physician  should ascertain Avhether  it is
affected Avith any malformation; and during the three or four days following 
            ATTENTIONS TO THE  WOMAN  AND  JH,LD.         409

 its birth, he ought carefully to watch over the excretion of urine and of
 meconium (for the expulsion of the latter is sometimes  delayed for that
 length of time), and to facilitate it by plunging it into a tepid bath, when
 he is certain  the  infant  is Avell  formed.  The prolonged retention of the
 meconium is also an indication for the employment of some mild laxative,
 such as Avhey, the syrup of violets, the oil of SAveet almonds,  or manna ; th6
 compound syrup of succory is also very generally used, or the compound
 syrup of rhubarb, either alone or mixed with SAveet almond-oil, in the quan-
 tity of two drachms or half an ounce in the course of the day.  Some per-
 sons administer these gentle remedies to all  children Avithout distinction,
 more especially to those that are Avet-nursed, for the purpose of supplying,
 they say, the  place of the colostrum, or first maternal  milk, Avhose slightly
 purgative action clears out the intestinal canal; but the Avarm Avater and
 sugar ordinarily given to  the child as nourishment on the first day, is usually
 quite sufficient to facilitate  the expulsion of  the  meconium, and the viscid
 fluids that sometimes obstruct the fauces and stomach.
   All questions having reference to the hygiene and nursing of infants "will
 be treated of in a special chapter.

   § 2.  Of the Child in a  Feeble or Diseased State.
   The ordinary attentions to the child, Avhen  born in a healthy condition,
 have just been described ; but it not unfrequently happens  that the infant,
 at the moment of its birth, is in a state of great debility, or even of apparent
 death, Avhich would  soon  be folloAved by a real one, if adequate measures
 Avere not resorted to at once to  prevent it.  This apparent death shoAvs itself
 under tAvo Avidely different aspects, Avhich have been  described  by  most
 authors  as the apoplexy  and the asphyxia  of neAV-born  children.  Many
 English and German accoucheurs haA'c for a long time  rejected these deno-
 minations, as characterizing  but  imperfectly the pathological conditions to
 which they Avere applied;  and  M. P.  Dubois, in a more  recent article, after
 having  remarked that the most constant anatomical  character of apoplexy
 in the adult is Avanting in what has  been called the apoplexy of the child,
 and that Avide differences  also  exist  between the symptoms  of asphyxia in
 grown persons, and  those of the  asphyxiated  state of the  neAV-born infant,
 likewise concludes that the same name has been improperly applied to such
 dissimilar conditions ; and consequently he, like M. Na'gele,  designates that
 state of the child in Avhich no sign of life is observed, and none of those of
 death is recognized, under the title of apparent death.
   Both  terms of this definition are  evidently contradictory, since  death is
 characterized by an entire absence of the signs of life.   For our OAvn part,
 we regard apparent death as a state in Avhich, notAvithstanding the abolition
 of the actions of animal life, some at least of the functions of organic life
 continue, and, of necessity, the pulsations of the heart.
  Noav,  in carefully examining the symptoms of the child's apparent death,
it is found that it is sometimes characterized  by7 a vivid  redness of the face
and upper part of  the body, by a prominence and injection of the eyeball,
and a swelling of the countenance, the skin of Avhich  is  dotted  here  and
t lore AA'ith bluish spots ; Avhile at others, Ave are struck with the discoloration 
410
LABOR.
in the skin, and the flabbiness of the flesh.   In the former case, the head ts
swollen and very Avarm, the lips are tumefied and of  a deep-blue color;  tne
eyes start from the head, and the tongue adheres to the roof of the moutn;
the head is often elongated, hard, and the features slightly SAvolhn ; the pul-
sations of the heart, though sometimes quite strong and distinct, are at othera
obscure and  feeble; occasionally the umbilical cord is distended with blood.
   In the  second, the child exhibits a mortal pallor ;  its limbs are pendent
and flabby; the skin is discolored, and is often  soiled by the meconium ;  the
lips are pale;  the loAver  jaw hangs doAvn,.and  the umbilical cord and heart
either do  not palpitate at all, or but very feebly.  An infant, in this condi-
tion, often moves at the moment  of birth and cries, but soon falls back again
in a state of apparent death.
   These diversities  in  the physical characters  of children born in a state of
apparent  death, may be occasioned, doubtless, by various causes, though they
are also often due, simply, to  a greater or less  advanced  condition  of  the
same pathological state; hence  it is Avrong  to regard them as the charac-
teristic signs of quite dissimilar lesions.   Therefore,  although I am  convinced
that they sometimes furnish indications for very different kinds of treatment,
and that  under this point of view it is important to observe them  carefully,
I cannot  regard them  as affording a basis for  nosological distinctions Avhich
it is  impossible  to  justify.  As  the expression apparent death  presupposes
nothing in  regard to the nature and cause of that state, it deserves on that
very account to be retained.
   That Avhat Ave are  about to state respecting the apparent death of new-
born children may be the better understood,  Ave  shall give, first, a brief  ex-
position of the mechanism hy which respiration is established  immediately
after birth.
   All physiologists admit, that  the medulla  oblongata is the centre and
regulator of  the respiratory movements of the adult.  From it also is sent
forth the  motor impulse which gives rise to the first act of  inspiration.
   Marshall Hall has endeavored to prove, experimentally, that the first in-
spiration  is the result of  a reflex action,1 produced  by the excitement of  the
nerves of the surface of the body, especially of the trifacial, by the contact
of the  external air, and that the  respiration, when once established, is sus-
tained through the influence of the reflex action due to the irritation of  the
pneumogastric nerves by the contact of the air  introduced into the lungs.
  1 An impression made upon our organs may give  rise to movements of different char-
acters, by  pursuing different routes  to the cerebro-spinal axis.   Thus,  sometimes,
when transmitted directly to the encephalon by the sensitive nerves of the cranium,
or indirectly through  the nerves of the spinal marrow, it is transformed into a sensa-
tion  in that part of the encephalon  in which the sensorium commune is situated,  and
consequently reaches the consciousness of the animal, who is then  capable of reacting
by voluntary movements.   Sometimes, also, it is transmitted by the nerves of sensation
either to the encephalon or to the spinal marrow, which impression, without neces-
sarily being transformed  into a sensation, may produce an excitement Avhich is imme-
diately reflected upon the motor  nerves, and gives  rise to the so-called reflex move-
ments, in the production of which the will has no part whatever.
  The power which thus gives rise to movements without the participation of the will,
has been regarded as a special endowment of the cerebro-spinal  axis, and has been
designated as  the reflex power, faculty, or properly. 
            ATTENTIONS  TO  THE  AVOMAN  AND CHILD.        411

  The same phvsiologist also holds that the respiratory movements may take
place under the influence of other causes; such, for example, as the  impres-
sion produced upon the medulla oblongata by a great loss of blood, as also
the excitement Avhich it undergoes from  the contact of venous  blood.   Into
the latter category enter all the respiratory movements of incomplete as-
phyxia.
  In  normal cases, the foetus, having in no  Avise  suffered during the labor,
retains  its cutaneous sensibility intact, and  the  irritation  produced by the
contact of the air with the cutaneous nerves is transmitted to the medulla
oblongata, Avhich, acting in its turn  upon the  respiratory nerves, produces
the(moArements of respiration.
  But should it happen that the foetus from the moment of birth has been
deprived for a  certain time of those means of respiration Avhich it  finds in
the placenta, or that; the latter being  separated immediately after the child
is expelled, any obstacle should  arise  to  the introduction of air  into the
bronchia, there would be, in both cases, a commencement of asphyxia.  The
contact of the non-oxygenated blood Avould irritate the medulla oblongata,
and this irritation being transmitted to the inspiratory nei'A'es, may also give
rise to respiratory movements of the  muscles of the face,  breast, and abdo-
men,  and produce, in short, the first  inspiration.1  The central motor  im-
pulse Avould soon be substituted by the  reflex action of the ramifications of
the pneumogastric nerves, Avhich are irritated by the air introduced  into the
lungs, and the respiration Avould continue under its influence.
  When the foetus is threatened with asphyxia in the  latter stages of preg
nancy or during labor, in consequence of compression of the cord or separa-
tion of the placenta, its  death is preceded  by convulsive movements and
efforts to  breathe;  then the  mothers  tell us, that the child,  after having
moved  actively, suddenly became quiet; and Beclard saAv a foetus  inclosed
in  the  unruptured membranes  make inspiratory movements, and'breathe
water instead of air.  It is for this reason, also, that in certain positions of
the face the child has been enabled to respire, although still inclosed  in  its
mother's Avomb; and the  uterine vagitus, Avhich always supposes a previous
inspiration, can be explained in no other manner.  In all these cases, in fact,
the non-oxygenated  blood acts as an irritant to the medulla oblongata, Avhich
transmits the  irritation in its turn  to the nerves of inspiration.   Nothing can
be claimed here for  reflex action.
  We must  be  careful, hoAvever,  not  to confound these tAvo excitors of the
inspiratory act.  The first is the natural excitant, Avhilst the other is ahvays
pathological, and only intended to  replace the normal stimulus.  Noav, every

  1  Marshall Hall  removed the brain of a kitten, cut the pneumogastric nerves, and
opened the trachea. He found the respiration to become slower, though it continued
with regularity.   When he stopped the opening in the trachea, the scene changed im-
mediately ;  the animal opened its mouth widely, made violent inspiratory efforts, and
was affected with some movements of a convulsive character.  When the trachea was
reopened, the  respiration became as  regular as before, and when closed again, the
symptoms of asphyxia  reappeared; in both these cases, the central organ, or the me-
dulla oblongata, was evidently the source of the respiratory impulse: since the destruc-
tion of the brain and the section of the pneumogastric nerves rendered all reflex at tion
impossible. 
412
LABOR.
pathological act is but an effort to accomplish some physiological pucess
 vhich has become difficult or impossible;  and though it may in some cases
restore life to a child, it is likely, in many  others, to prove insufficient.
   It very often happens that a child born in a semi-asphyxiated condition,
in consequence of a difficult labor, makes a few sudden and violent inspiratory
movements,  but Avould  nevertheless succumb rapidly, Avere  not the  reflex
action called into play, and did  it not soon replace completely the patholo-
gical excitant, Avhich, just before, had acted alone  upon the spinal marrow.
As the skin, in this  state of diminished  sensibility, is no longer stimulated
sufficiently by the  external air, special means should be resorted  to  Avhilst
there is yet time to arouse  the exeito-motor action of the cutaneous nerves,
and provided the asphyxia  has not gone too far, they "will often be croAvned
Avith success.   But if the child  is small and feeble, or  if the causes of the
asphyrxia have acted  for too long a time, the contractions of the inspiratory
muscles are feeble and distant, and soon cease entirely; the heart, too,  ceases
to beat,  and the child dies.  Though, whilst the  heart  is  still beating, we
may succeed in exciting the reflex action of the muscles of inspiration,  to the
extent of producing  a sudden inspiratory movement  after every excitation,
the symptoms of asphyxia remaining, however; unchanged, the child will die
in spite of all that can be done.'
   If it be true that the impression produced by the external cold upon the
skin of the body and face, is the  first and only cause of the reflex action of
the medulla oblongata upon the nerves of inspiration, and thus produces the
first inspiratory act, we can readily understand  that  everything calculated
to diminish notably  or to  destroy the cutaneous sensibility, will retard, of
even render impossible, the  first inspiratory effort, and reduce  the foetus to a
state of  apparent death.   The causes of the latter  are, therefore, such as
paralyze to a  greater or less  extent the nervous  centres,  Avhose influence,
though completely  foreign to  the maintenance of foetal  life, becomes  indis-
pensable to the establishment and continuance of extra-uterine existence.
   Now, these causes are quite numerous; and, with the exception of a feAV,
exert their destructive influence during  the latter periods  of labor.   They
may be divided into: 1, lesions  of respiration;  2, lesions of circulation; 3,
lesions of the nervous centres.   The  first are capable of producing various
degrees of asphyxia ; the second may give rise to a fatal hemorrhage as
regards the child; the third affect the nervous  centres directly, and render
them incapable  of performing the functions to Avhich  they are  destined
immediately after birth.
   1. Lesions of the  Respiration.— These are occasioned by everything Avhich
obstructs the respiration.  Thus,  there have been pointed out as  occurring
during labor, the compression of the umbilical cord betAveen the sides of the
pelvis and the head or body of the child; the Avinding of the cord so tightly
around the neck or some other part, as to obstruct simultaneously the venous
circulation in the brain, and that of the blood in the umbilical vessels; the
premature separati  ,n of the placenta, Avhether it be inserted upon  the neck
or not, for since the separation necessarily produces the rupture of the  utero-
placental vessels, it renders  the  foetal haematosis as impossible as does the
compressim of the  cord;  the great retraction of the uterus, Avhen in delivery 
           ATTENTIONS TO  THE  WOMAN AND  CHILD.        413

by the breech the head  only remains in the excavation, and the child is
unable to respire;  for this retraction renders the vessels of the uterus almost
impermeable  to blood.   In all  these cases, the asphyxia results evidently
from  a suspension of the placental  respiration, and it is  the  contact of
black blood with the brain, Avhich paralyzes its action  in the foetus as Avell
as in the adult.
  Finally, it is plain that after the child is born, the accumulation of mucus
in the nose, mouth, and air-passages, may also produce asphyxia by prevent-
ing the introduction of air into the  bronchiae; here, hoAvever, the mode of
operation is precisely the same as in the adult, since  it results from  a me-
chanical obstacle to the introduction of the external air into  the  pulmonary
vesicles.
  In consequence of the action of some one of these causes, the foetus may be
born in a state of apparent death, and exhibit the very different symptoms
which Ave have already mentioned ;  thus, in most  cases, the surface of the
body has a sAvollen appearance, and is of  a violet, or rather of a blackish-
blue color, the discoloration being more  marked at the upper parts of the
trunk, and more particularly on the face than elseAvhere.  The muscles are
motionless; the  limbs preseiwe their  flexibility, and the body its heat ; the
pulsations of the cord, of the radial  artery, and even those of the heart, are
obscure or insensible.
   Where a post-mortem examination is made, the vessels of  the encephalon
are found engorged with blood; at times, this fluid is  even effused on the
surface of the  membranes, or into the substance of the brain itself, though
most generally, says M. Cruveilhier, the effusion is limited to the surface of
the cerebellum ;  sometimes it covers  the posterior lobes of the cerebrum, but
it is rarely found in the ventricles of the brain; and, in all the  cases examined
by him, there  Avas bloqd  enough in the cavity of the  vertebral arachnoid
membrane to distend the dura mater.  Again, those congestions of the liver
that are so common in infants, are  then particularly apt to be met Avith;
but, says Billard,  they vary considerably as regards the quantity of blood
accumulated  in  the tissues of the organ; for, in some instances, it is found
there  in such great abundance as to  give rise to a sanguineous exudation on
the exterior of the organ, the convex  surface of Avhich is  discolored and
moistened by a layer of effused  blood, and I have even knoAvn an extrava-
sation of this fluid into the abdomen to  result from this turgescence.   The
lungs  are also gorged Avith blood.
  The external condition of the asphyxiated foetus is not ahvays  such as Ave
have just described, for,  as M. Jacquemier has observed, nothing is  more
common than  to find the foetus born Avithout  any anomalous coloration of
the skin, and even Avith a remarkable degree of pallor and flaccidity of the
limbs; and this, notwithstanding the apparent death has  been produced by
compression of the cord.  Can  this  difference be due, as M. Jacquemier
supposes in the  latter case, to a sudden suspension of the placental respira-
tion, Avhilst in the former the cessation Avas slow and gradual ?   This expla,-
nation is probable, inasmuch as the same differences are observed in the
asphyxia of adults, and  as, according  to  M. Devergie, those persons  Avho
are killed by the falling  in upon them of earth, present  the  same discolora- 
414
LABOR.
tion of the integuments.   The suddenness of the real death may explain th«!
peculiarity under these circumstances ; but it must not be forgotten that this
external pallor is also the consequence of a slow but prolonged asphyxia, and
that it  often succeeds to the violet  hue of the tissues; that Ave every day
Avitness  this succession going on before our eyes when the asphyxia has lasted
too long, and that a child born Avith a very deep color, becomes rapidly pale
and flaccid, if the  means employed fail to excite respiration.
  In the latter case, the discoloration of the tissues is the symptomatic ex-
pression of a m ore advanced stage: the pulsations of the heart, Avhich before
were sufficiently strong and rapid, become less frequent and feebler, return
only at  long intervals, and  real  death soon succeeds  to the apparent one.
Noav these phenomena, Avhich Ave observe occasionally, take place  in the
same manner whilst the foetus is still  contained in the  womb, but is deprived
of the' placental respiration.
  When, at the moment of birth, the asphyxia has lasted but a short time,
the child will exhibit turgescence of the face, the violet hue of the skin, firm-
ness of  flesh, and  frequent and regular  pulsations of  the heart; if a longer
period has elapsed since the interruption  of the foe to-maternal circulation, the
child will be pale  and discolored, and the pulsations  of the heart and cord
feeble and intermitting; finally,  if the asphyxia has  lasted  longer  than  is
compatible Avith the life of the heart, the child Avill  be really dead  at the
time of its expulsion.
  These tAvo conditions, which are apparently so  different, are due  to the
same cause, and are simply tAvo degrees of asphyxia.  Though in an etio-
logical sense, no distinction  can be made betAveen them, they are important
as regards the prognosis, for one  is much more serious than the other, and,
as regards treatment, the same means are not applicable to both.
  M. Pajot  informs me that he has found  these observations  to hold true as
regards the  adult.
  2. Lesions of the Foztal  Circulation. — Ruptures of the cord or of the pla-
centa may, of themselves, give rise to such a degree of hemorrhage as to en-
danger the life of the foetus;  fortunately,  however, they are quite rare.   When
the hemorrhage is  profuse, the child dies  before the labor is over; but should
anything happen  to arrest  the discharge of blood, the child may be born
alive, but in a state of apparent  death resembling syncope.  The deficiency
of nervous influence is here manifestly due to the  fact  that  the medulla
oblongata and the brain no longer receive  a  sufficient  amount of blood  to
enable  them to react upon the  nerves of inspiration.  The condition is a
most dangerous one.  The child is  pallid,  and its muscles are completely
relaxed; sometimes, hoAvever, it  makes a few short inspirations,  and  utters
some very feeble  cries; but if the hemorrhage has  been at all profuse, it
succumbs in a very short time.
   3. Lesions of the Nervous  Centres.—The eerebro-spinal system  presides
over none of those functions whose integrity is necessary to the maintenance
of  foetal life; the respiration, circulation, and nutrition being subject ex-
clusively to the nerves of organic life.  These ganglions and their nerves
derive  from the  arterial  blood that principle of organic  sensibility and
motility which is  necessary to the production of involuntary or  automatic 
            ATTENTIONS  TO THE  WOMAN  AND  CHILD.         415

movements, as also to the maintenance of the irritability and vitality of the
organs.   Although the fietus  possesses  organs  of animal life, its  vitality
is  purely  vegetative or organic.  This fact serves  to explain the life and
development of acephalae, for where  the  organs are absent,  the functions
are also Avanting; yet these monsters  are endoAved  Avith irritability,  are
capable of motion, and their life is preserved intact, until the termination of
pregnancy.
   Since the brain and spinal marrow  have nothing to do with the perform-
ance of the fetal functions, Ave readily foresee that any lesions Avhich may
affect them during pregnancy or labor, cannot disturb the harmony of those
functions,  or have any influence Avhatever upon the intra-uterine  vitality.
Therefore it is only after birth that the cerebro-spinal alteration or paralysis
prevents the establishment of animal life, even though the  organic  life is
still manifested by the integrity of the circulation, and even of the placental
respiration.  The first respiratory act is, as Ave  have said  before, the conse-
quence of an excitement of the medulla oblongata, produced by the impres-
sion of the temperature of the surrounding air upon the skin of the new-born
child.   For this impression to be effectual, hoAvever, it is necessary that the
sensation  should be perceived by the central organ, Avhich is rendered in-
capable of perceiving  it by serious  lesions of the cerebro-spinal axis.   This
important distinction should therefore be made  betAveen  the A-arious circum-
stances  capable of reducing the foetus to the state of apparent death, namely,
that the foetus may be destroyed in the Avomb by asphyxia and hemorrhage,
whilst lesions of the nervous centres ahvays cause it to be born in a state of
apparent death.
   We should also interpret in this Avay the effect which may be produced by
the violent compression Avhich the brain  undergoes in certain cases of con-
tracted  pelvis;  that which may result from the application of the forceps or
lever under circumstances  of difficulty;  that Avhich results  from vascular
congestion due to  an  obstruction to the return of venous blood  in certain
deliveries by the  face; in cases Avhere the cord is wound tightly seAreral times
round the neck, as also where it is strongly grasped by a spasmodic con-
traction of the neck of the uterus; and finally^, to the compression sometimes
produced by effusions of blood, either upon the surface, or into the substance
of the brain itself.
   So, also, is to be explained the mode of action of lesions of the  medulla
oblongata, such lesions as Ave knoAV are easily produced by extreme rotation
of the head, by tractions upon  the head, or the pelvis Avhen the head is
arrested in an eleA'atcd position, and  finally, by effusions at the base  of the
brain and  upper  part of the vertebral canal.
   As lesions of the brain are not  absolutely incompatible Avith the establish-
ment of respiration, they are not so dangerous as those of the medulla  oblon-
gata.  The destr iction of a large portion of the encephalon has not ahvays
prevented  the child from breathing and crying after its birth, and  even from
living for several days.  A similar fact is presented by anencephalous foetuses.
By this avc are advised that, in difficult  labors, the temporary compression
of the head may also suspend momentarih' the action of the brain,  but that
as this  suspension does not absolutely preclude respiration, the species o+" 
416
LABOR.
shock or concussion which the brain experiences  may pass  away so soon as
not to interfere with the continuance of life.
  It is  different, hoAvever, with lesions of the medulla oblongata, Avhich is
the only motor of the respiratory movements:  it cannot be seriously affected
without rendering extra-uterine life impossible.   This explains the frequent
death of children in  pelvic  presentations, Avhen tractions have been made
upon the trunk with toe object of disengaging the head.
  Treatment. — Since apparent death,  however produced, may present  the
very different symptoms  already mentioned, it is evident that mere inspec-
tion of the child can afford no information as to the cause of its condition.
Although we regard  the  discoloration of the skin and relaxation of the  ex-
tremities as signs of very grave import, it  is impossible to determine  the
extent of the cerebral  disorders, and consequently to foresee the result of
measures calculated to restore the  child.  In this  state of uncertainty, all
cases should  be treated as though they afforded  a chance of success.  The
lapse of half an hour, an hour, or even more, from the time of delivery, is  not
sufficient cause for despair, since a number of facts may be mentioned going
to prove that children  have been in an asphyxiated condition for an hour,
and were afterwards restored to life.   Long continued silence of the heart, the
entire absence of pulsations at the praecordial region, frequently determined
at intervals, is the only sign Avhich can be regarded as destructive of all hope.
The heart is the ultimum moriens, and I do not believe that efforts to restore
its pulsations, AAhen once completely extinguished, have ever been crowned
with success.   But the  softness and  flaccidity of the  tissues, and coldness of
the body and face,1 are no reason for abandoning the child, provided  the
heart still beats, hoAvever feebly, sloAA'ly, or irregularly.
  When the  child  is born Avith a general injection of the capillaries of  the
face and trunk, Avhen, in.short, it presents the characters of the state formerly
termed apoplexy, it is evident that the first indication is to relieve the engorge-
ment of the  head  and lungs, which is done by promptly  cutting the  um-
bilical  cord, and alloAving  a few spoonfuls of blood to escape,  Avhen  the
respiration is most usually established soon after, if  there are no mechanical
obstacles, such as mucus in the fauces, to the introduction of air into the
lungs; and Avhere these do  exist, they may be removed by the extremity
of the little finger,  or "with the feathered end of a quill;  the blue and violet
color of the surface will then be found to gradually disappear, and give place
to a rosy hue, at first on the lips, then  on the cheeks, and afterwards OA'er
the rest of the body.  However, in  practice, we sometimes find the circula-
tion so enfeebled or benumbed, as  it Avere, that the blood will not run from
the umbilical arteries;  its effusion may then be encouraged by plunging the
child into a Avarm bath, or by squeezing the cord several times from its
insertion towards the cut extremity ; and Avhere this does not prove success-
ful in obtaining  blood, some advise the  application of a leech behind each
ear.  But as this application would  occasion the loss of precious time,  it is
better to have recourse at once to other measures.
  1  The  experiments of M. Brown-Se'quard on warm-blooded animals, prove that the
time for which they are capable of resisting asphyxia is greater in proportion as  they
are subjected to a lower temperature. 
            ATTENTIONS  TO  THE  WOMAN  AND  CHILD.        417

  The small bleeding being practised  or not, every effort should be made,
bv the use of various stimulants, to excite the  sensibility of the skin, and
the reflex action of the cutaneous nerves.
  According to Marshall Hall, the best plan is to sprinkle the face and body
of the child vigorously with cold water; immediately after which, it should
be immersed in a  Avarm bath, and then Avrapped in warm  flannels.  The
efficiency of this  plan  of treatment, AA'hich may be  repeated several times,
depends  especially upon the rapidity Avith  which it  is executed.  The im-
pression of both the cold and heat should be sudden.  Aftenvards, the skin
may be stimulated by frictions with the hand, or a brush, by  dry flannel, or
with any irritating liquors, such as vinegar  or brandy ; M. Moreau strongly
recommends, and with reason, slight blows to be  made with the palmar sur-
face of the fingers upon the shoulders  and thighs.  In grave cases, I prefer
flagellating the thorax and  loins vigorously with a piece of wet linen.  It is
also often very useful to irritate  the mucous  surfaces.   A little brandy or
vinegar may be placed in the mouth,  or the  fumes of burnt paper blown
into the anus.  A feather may be dipped into vinegar and  then  introduced
into the nose or fauces; this may be used at the same time to  clear aAvay the
mucous secretions of the latter, Avhich prevent  the  inhalation  of air; and
Avhere there is reason to suppose that such secretions  have accumulated to a
considerable extent in the air-passages,  the advice of Dewees  should be fol-
loAved, by placing the child on its belly, taking care to elevate  the feet higher
than the head, and at the same time gently shaking it, so  as to clear out the
trachea, and thus facilitate the introduction of air ; " for,"  says the American
author, " this is a measure  of great utility, by which I  am every Avay per-
suaded that  I  have  preserved the lives of many children."  After a feAV
moments, the child should be again plunged into a Avarm  bath, rubbed  Avith
warm flannels, and then immediately subjected to cold aspersions.
  All these measures should  be continued for  a long  time after  respira-
tion has  been restored and become regular, in  order to  prevent secondary
asphyxia.
  The child's body may be  exposed Avith advantage to a current of cold air,
giving it  at the same time a SAvinging motion,  and  even after it has  been
restored  and dressed, its face may be exposed to the fresh air, or, what is
better, fanned, for a short time.
  It has  been advised to make use of strong suction on the breasts, for the
purpose  of dilating  the thorax mechanically, "  Avhich,"  says Desormeaux,
"although Avithout  effect for the proposed  object, appears to  me admirably
calculated to stimulate the muscles that move the ribs."  But  a more power-
ful remedy, highly extolled  by the same author, is a sort of douche made by
the mouth directly on the parietes of the thorax ; this douche is performed
by taking a  mouthful of brandy and bloAving it forcibly against  the breast;
and  it is rarely necessary,  he remarks, to repeat it many times, for  it is
found to  produce a convulsive contraction of the  inspiratory muscles almost
immediately; the blood and air penetrate the lungs,  and the respiration is
irregularly established, being at first feeble and spasmodic, but soon becom-
ing  stronger  and more regular.   I  have often  used successfully with the
     27 
418
LABOR.
same object, a cold douche, produced  by pouring a stream  of cold  water
upon the precordial region, from an elevation of about a .yard.
  If the excitation of the spinal and facial nerves is insufficient, the branches
of the pneumogastric nerve should be acted on by insufflation.
  This measure can now boast of such a degree of success, as to make it
proper to have recourse to it Avhenever the means just mentioned have failed.
M. Depaul has, in an excellent memoir upon the subject, completely refuted
the objections urged against it, and confirmed by his experiments the pre-
vious results of Dumeril and Magendie.  Like  them, he found  that a false
idea has been entertained  of  the poAvers of resistance  of the  pulmonary
vesicles, and that it is necessary to bloAV much more strongly than is required
to produce  a simple dilatation,  in order to effect their rupture.  He has
proved by instances, that children have been restored to life, Avhom the
failure of the means commonly  advised seemed to devote to  certain death;
also, that in cases  where it Avas unsuccessful, because the lesions occasioning
the apparent death were beyond the resources of art, it had the effect, Avhen
the pulsations of the heart had not ceased entirely, to render them stronger
and  more frequent, and sometimes even to determine a spontaneous though
imperfect inspiration.
  I Avould add, that long continued insufflation seemed to me, in three  cases,
to be more effectual than is claimed in the above paragraph, for not only did
it excite spontaneous inspirations, but the respiration became gradually regu-
lar, and existence was prolonged for ten, tAvelve, and in one case for tAventy-
tAVO  hours,  in  spite of mortal lesions of the brain.  Noav it  will readily be
understood that, in very many cases, the family might  attach great impor-
tance to tAventy-four hours of life in a neAV-born child.
  M. Depaul, Avho has rendered a real service in calling attention to a mea-
sure generally abandoned  by some as  dangerous, and  by others as useless,
also  proposes some rules of conduct, Avhich I think it right to mention briefly.
  He uses Chaussier's canula, dispensing, hoAvever, Avith the lateral openings,
and  substituting for them a terminal one.
  The child, Avhose  temperature is to  be maintained  By Avarm coverings,
should be placed Avith the breast higher than the pelvis, and the head throAvn
a little back, so as  to  render the front of the neck rather more projecting.
Having cleansed the tongue and pharynx from  mucus, the forefinger of the
left  hand  should be conducted  along the median line of the tongue to the
epiglottis.   The right hand holds  the tube like a pen,  and directs its  small
extremity along the finger to the opening of the larynx, inclines it toAvards
the left commissure of the lips, and by  gentle movements endeavors to raise
the epiglottis ; it is then only necessary to elevate the instrument, carrying it
at the same time toAvard the median  line, Avhen its  extremity "will pass
through the glottis.   This is  the only  part of the operation  Avhich presents
any  difficulty, for  it is not uncommon  for the tube to enter the oesophagus.
Before resorting to insufflation, Ave should make sure of its situation by pass-
ing  the finger upon the larynx and  trachea, and observing Avhether  the
larynx folloAvs the instrument when the  latter  is moved from side to side.
However, the first insufflation  reveals the error immediately, for when the
instrument has passed  into the oesophagus, a considerable elewation of the 
             ATTENTIONS TO THE  WOMAN AND CHILD.         419

egipastrium precedes that of the base  of the chest;  if, on the contrary, it is
in the larynx, the chest is dilated uniformly, and the epigastric projection is
produced exclusively by the depression of  the diaphragm.
  To prevent the reflux of the air, and to oblige it to enter the air-passage3,
every point of exit  by the oesophagus,  mouth, and nostrils should be closed.
The anterior Avail of the  oesophagus is applied against the posterior, by a
moderate  pressure Avith the instrument.  The lips are pressed closely to the
sides of the canula by means of the thumb and forefinger,  Avhilst the nostrils
are stopped by pinching the nose betAveen the tAvo middle fingers.
   The insufflations should be quite near to each other.   M. Depaul thinks
that from ten to tAvelve should be made in a minute.  The greater part of
the air is expelled after  each by the elasticity of the pulmonary vesicles;
it may be  useful, hoAvever, especially  at the commencement, to render the
expiration more complete, by pressure properly applied with the Avhole hand
on Mie front of the chest.
   The length of time for Avhich it is necessary to continue the' insufflations
varies much.  Thus, there are facts showing that sometimes a  quarter of an
hour has been sufficient, whilst at others, it Avas necessary to continue them
for three-quarters of an hour, an hour, or even an hour and a half.
   When, under their influence, the action of the heart has been so far restored
as  to be at  from a hundred  to a  hundred and thirty times  a minute, I
think, says M. Depaul, that the physician should continue until spontaneous
inspirations  appear, and are repeated at the rate of at least five or six per
minute; since to stop after the first one, Avould in many cases endanger the
life of the child.  When,  hoAvever,  after having aAvakened the pulsations of
the heart, and even obtained  some efforts at inspiration,  all become more
feeble and disappear, the insufflation  may be dispensed Avith after the lapse
of from ten to tAvelve minutes, for, under these circumstances, I  have never
knoAvn a child to be saved.
   It is necessary to AvithdraAv the canula from time to time, in order to clear
 t of mucus.   When the trachea contains much mucus, Avhich  is manifested
by gurgling, it may be  draA\"n into the tube by suction, and the future in-
sufflations be thus rendered more useful.
   When spontaneous inspirations occur, the  insufflations  may  be suspended
for the moment.
   Finally, all these means having  failed, should a galvanic battery be  at
hand, currents of electricity might be passed through the muscles of inspira-
tion ; it is, hoAvever, an auxiliary upon which but little reliance can be placed.
   Electricity has, in fact,  much less action  upon the foetus  than upon the
adult.  It has, for example, been proved by experiment, that Avell-deAreloped
fetal serpents Avere but slightly sensitive to the action of  galvanism  before
having breathed, Avhilst shortly afterward they Avere endoAved Avith  a very
delicate sensibility.
   The same  measures  should be used in cases of apparent death, in Avhich
the children are pale and colorless: here, hoAvever,  far from  alloAA'ing the
umbilical cord to bleed, it should be tied instantly, even before dividing it.
  Some persons have  recommended that the umbilical ccrd be not cut in
cases  )f asphyxia,  until  after the  pulmonary respiration has  been fully 
420
LABOR.
 established, hoping that the continuance of the foeto-placental ci iculaticn
 might replace the extra-uterine one that is Avanting.  Without admitting, with
 Dr. King, that this  practice, by alloAving  the contractions of the heart to
 drive all the blood into the placenta, would  expose the foetus to death from
 loss of the circulating fluid, I think that in the majority of cases the pre-
 caution is, to say the least, useless, and even  hurtful, by occasioning the loss
 of  precious time.  In fact, the placenta is  almost ahvays  partly, or even
 entirely detached, shortly after  the child is expelled; and even Avere this not
 the case, the retraction of the uterus following its expulsion,  has so modified
 the circulation in  the walls of the uterus and that of the  utero-placental
 vessels, that the neAvly-born infant would certainly find its resources in that
 direction exhausted.,
   HoAvever, if the touch does  not discover  the placenta situated upon the
 neck, and, consequently, there is reason to suppose  that it retains its normal
 relations Avith the Avomb, we may, when the  foetus is pale  and discolored,
 defer cutting the cord, especially should it still exhibit pulsations.  As soon,
 however, as the pulsations have ceased, or it is ascertained that  the placenta
 is detached, its section should be practised immediately.
  Some children, after having cried and breathed quite freely, fall, after the
 lapse of several  hours, and sometimes even  days, into a state of  apparent
 death, which  soon  terminates in real death  unless assistance  is promptly
 rendered.   Therefore it is prudent to be carefully on the Avatch for the first
 feAV days.   This  secondary  apparent  death may  be  due,  like that just
 described,  to  a  true  asphyxia,  or  to  a deficiency of nervous influence, for
 which the stimulants employed immediately after birth have proved but a
 momentary remedy.   Asphyxia may be produced either by a foreign body
 placed over the mouth and nostrils, or by an accumulation of mucus in the
 fauces.   To remove the foreign  bodies, and clear out the fauces with the aid
 of  a feather, and the bronchia by exciting vomiting by  tickling the palate,
 are the first  measures to be used.  If the face is  of a violet color, a leech
 may be placed  with advantage behind each ear,  or, as recommended by
 Kennedy, upon the fontanelles.  When the  accidents are  attributable to
 deficient cerebral action, the excitants already mentioned must again be had
 recourse to.
  Excessive  debility of  the child, due to  some one of  the circumstances
 already pointed  out,  should  be combated  by  the same means  used for
 apparent death.  In those cases  Avhere the infant is only very feeble, because
 it is born before term, or in consequence of a prolonged sickness on the part
 of the mother, very great care is requisite to maintain a high degree of tem-
 perature by surrounding it with cotton wadding and  bottles  containing  hot
 water, since heat is  then  the best stimulant.
  For the first few days, and sometimes even weeks, its alimentation  demands
some precaution.   It is very important that  a nurse should be procured for
it as soon as possible, Avhose milk Aoavs so easily that she can herself project
a feAV spoonfuls into the mouth of the child; for its feebleness is often so great
as to render the necessary effort at suction impossible.
  It is equally important to give it only the first milk, which being  lighter
 is of easier digestion. 
      PHENOMENA  APPERTAINING  TO  THE LYING-IN STATE.  421

  WheneA'er a child is born in a state of apparent death or of extreme w eak-
oess, the accoucheur  should, in Catholic families, cause the rite of baptism
to be administered immediately.  For, whatever the religious opinions of the
physician may be, it is his duty to respect the feeling of  families, and  he
would be truly blamable, were he not to yield in this  respect to the Avishes
of the parents.
                         CHAPTER IX.
   OP  THE PHENOMENA APPERTAINING  TO  THE  LYING-IN  STATE.
  This term (or that of  the puerperal condition) is  applied  to the period
 immediately following  the  delivery, during which the uterus, and genital
 organs, and indeed  the Avhole  economy, gradually return to their ordinary
 condition.
  The attendant phenomena may be divided into the natural, and the un-
 natural or morbid, including under the latter head all the diseases to Avhich
 the lying-in woman is exposed ; but the former only claim our attention here.
  A feeling of depression, or lassitude, such as  that  experienced after  an
 unusual or an immoderate  exercise, succeeds the agitation caused by the
 labor; and it not unfrequently happens that the patient has scarcely reached
 her bed, when she is attacked by a chill, severe  enough at times to produce
 i chattering of the  teeth ; but  this  soon  passes off, the  pulse increases in
 strength, the heat of the surface returns, the skin becomes humid, a salutary-
 moisture appears, and the various functions are re-established, Avhile the most
 perfect calm and the most delightful  slumber  replace  the past disorder.
 Noav, although this slumber of the patient is to be respected, nevertheless it
 is desirable that it should not take place until a few hours after the delivery,
 unless  the physician should be at hand to watch attentively over the state
 of the circulation, and  the condition of the Avomb during this recuperative
 repose, because some Avomen haAre  been attacked when in this  state with
 internal  discharges,  and  have aAvakened  exhausted  by  the loss of blood.
 Therefore,  although  on account of  the rarity of this accident the  patient
 should  not be prevented from  sleeping, it is  necessary  to Avatch  over her
 during her slumber,  or  at least to haA'e her carefully observed  by an intelli-
 gent nurse.
  After the first nap is  over, she might sit up in  bed a few moments to take
 a little broth, as this position refreshes her, and also facilitates  the escape of
 the lochia that had accumulated in the vagina.  The patient is the more
 enfeebled as the loss  of  blood has  been greater, or the duration of the labor
 prolonged.
  The  nervous susceptibility is also highly exalted,  and  the skin, Avhose
 activity was diminished  during gestation, now regains a more exalted vitality;
it is soft, humid, and is  ahvays covered  AA'ith a dewy perspiration during the
first Aveek.  This  sA\reat  is sometimes very abundant, particularly Avhe a she
is too Avarmly covered, and it is not at all  unusual to  find it folloAved by a
niibary eruption and a distressing  pricking sensation.   Such eruptions Avere 
422                              LABOR.
exceedingly frequent in former times, Avhen it Avas thought useful to push the
skin, as it Avas called, and to make the Avoman perspire by surrounding hei
with thick coverlets; noAV,' on the  contrary,  they are quite rare, and Avhere
they do show themselves, are  easily made to disappear  by taking the neces
sary precautions to diminish the cutaneous secretion.

  [After delivery the pulse becomes softer, fuller, and soon slower.   We propose,
however, going someAvhat into detail in reference to  this subject, for the examina-
tion of the pulse in newly delivered females is of such capital importance that by
simply paying attention  to  the  information which it affords, Ave  are enabled to
diagnosticate almost  certainly a state of health  or of disease.   The study of the
pulse,  therefore,  yields  extremely valuable  information to the accoucheur, but
we  cannot in this place treat of the indications Avhich it  supplies in puerperal
diseases,  and shall confine our  attention to the changes Avhich it undergoes in  a
healthy woman after delivery.
  We would state in the first place, that the mean rate of the pulse in adult women
is  about  seventy-five per minute, and becomes  somewhat more frequent during
pregnancy (see page 157) and especially during labor (see page 286).
  Immediately after delivery the pulse falls to some  extent,  but  the diminution is
generally followed  in a short time by an acceleration,  which lasts for several hours.
  In healthy Avornen, this transient acceleration is very often followed by a second
diminution in pregnancy.   Without attempting to state the  exact proportion of
cases in which retardation is observable, I Avill only remark  that it is so extremely
common as to be found almost constant when  sought  for carefully.
  The diminution in the frequency of the pulse has been well studied and described
by H. Blot, in a memoir of which we give an analysis (Archives  Generate de  Mede-
cine, May, 186-1.)
  The greatest diminution of frequency observed by M. Blot, was  thirty-five beats
per minute.  "But," says he, "it must not be supposed that so great a difference
is common, — for I have met with  it in  but three cases.  Between thirty-five and
sixty-five beats per minute, the latter of which we regard as  the standard, Ave have
observed  every grade of  diminution.  Two numbers, however, forty-four and fifty-
six, have impressed us by their relative frequency."
  The slowness of the pulse may continue from one to twelve days, generally last-
ing longer in multiparse than in primiparae.   In the latter, it rarely continues
longer  than three  days,  whilst in  the former  it is often observed for four, six, and
seven days.
  The  time at which  it  comes on varies somewhat  in different women, though it
generally is observable within twenty-four hours after delivery.  In the twenty-
four hours following its appearance, the slowness of the pulse increases ; then, after
remaining for a time stationary, gradually gives place to the  rate which is habitual
to the woman.
  The slowness diminishes and sometimes even ceases entirely as soon as the breasts
experience the congestion Avluch precedes the secretion of milk.  Usually, however,
the pulse gradually becomes more frequent.  We shall  have occasion to revert to
this fact  when we come to treat of the secretion of the milk and what is known as
the milk-fever.
  The  slowness occurs also after  abortion  and  after  premature delivery, whether
spontaneous or artificial.
  When  the slowness of the pulse is observed in  a newly deliA^ered  woman, we may
feel  sure that  she is in a perfectly normal condition,  so that in respect  to the
prognosis it is an extremely favorable sign.
  In a lying-in hospital,  the frequency of the diminution of the pulse in proportion 
        PHENOMENA  APPERTAINING TO THE LYING-IN STATE.  423

  to the number of puerperal women indicates, in a general Avay, an excellent sanitary
  condition: its  rarity, on  the contrary, should  excite our apprehension of  an un-
  healthy tendency in the newly delivered inmates.
    The cause of this slowing of the pulse is obscure.  It would seem, however, from
  the sphygmographical experiments of MM. Blot and Marey, that, like the diminu-
  tion of frequency under all circumstances, it is connected with a certain increase
  in the tension of the arteries, Avhich tension the authors just quoted think may be
  explained by the sudden  and almost entire suppression of the circulation which
  existed  in the  uterine Avails during pregnancy.   When the uterus contracted, the
  blood which previously traversed it accumulated in the arterial system, from whence
  resulted a greater tension which became in its turn an impediment to the ventricular
  systole, giving rise to the temporary diminution in frequency of the pulse, followed
  by an establishment of equilibrium.
    Whatever the explanation, the fact is both established and shown to be of great
  clinical importance.]
    Let us noAV study the important changes Avhich take place in the genital
  organs.   To the  hypertrophy which  characterizes  the pregnant condition
  succeeds  an  atrophy  Avhich, during the  puerperal  condition, restores the
  uterus to its normal state.
    If the relaxed Avails of the abdomen be examined after delivery, the  womb
  is felt above  the  pubis as a  large  tumor, Avhich henceforth diminishes in
  size.  In thin Avomen, particularly those who have  often had children, the
  womb still remains at  the end of tAvo Aveeks about tAvo fingers' breadth  above
  the pubis, yet  the fundus in primiparae, more especially in such as are at all
  inclined to  embonpoint, cannot  be distinctly felt  after a Aveek;  and by the
  end of the sixth week  this organ has nearly regained  its primitive condition,
  being still, perhaps, a little larger than usual.
    [The diminution of the bulk of the  uterus, its atrophy, so to speak, has been
  studied so carefully by Dr. Wieland, who  noted its progress  day by day, that we
  think wo cannot do better than quote some portions of his excellent thesis,  which
  are of interest in connection with the subject under consideration.
   At the commencement of labor,  the organ has  generally an elevation of from
  eight to nine inches above the pubis, and from six and a  half to seven and a half
  inches in width.  When the clots which  follow the exit  of the placenta are ex-
 pelled, the uterus is found to have assumed a spheroidal  form, and is hard, resisting,
 and contracted.   Its vertical  diameter is then  only about  from four and a half to
 five inches, and  its transverse diameter from three and a half to four inches.   After
 nbout  half an hour and during the first few hours succeeding delivery, its size
 increases somewhat,—(vertical diameter, five to five and a half inches;  transverse
 dhinii'ter,  four and a quarter to four and three quarter inches :)  but thereafter it
 diminishes gradually and almost uniformly.  On the second day the  decrease in
 the diameters amounts to from three-eighths to five-eighths of an inch, the vertical
 then being often rather less than the transverse.   On the third day, in most cases,
 little change is observable except in women Avho have  had in the  interval of the
 two last examinations severe after-pains,  accompanied by an abundant lochial dis-
 charge when  tlie contraction takes place.  Dr. Wieland  observed  that  until the
 middle of the fourth  day the size of the uterus Avas unchanged but seemed softer
and loss regularly rounded in form, and that this inactive condition always coincided
Avith the commencing lacteal secretion.   From the end of the fourth day the retro-
cession of the organ progressed  regularly and continuously.   The distance which
then separates the uterus from the  pubic  symphysis varies from two and three-
lighths to two and seven-eighths of au inch, and in exceptional cases only is it less. 
424                             LABOR.
During each of the following days the observed difference varies from three-eighths
to three-sixteenths of an inch.
  By the sixth day the uterus has become hard, its anterior  surface less convex,
and its fundus reaches from an inch and a half to tAvo inches above the superior
strait.  Usually not before the  tenth day, and sometimes not until the eleventh, has
it disappeared behind the symphysis pubis; but even then, if the abdominal walls
are very thin upon the median line, the fundus may be felt in  the pelvic cavity by
pressing downward with the bent fingers.
  During all this time the tendency of the womb, which in the majority of cases
(79 in 100) is situated to the right, is to resume its position in the median line.
  The organ, however, is far from  having attained its  primitive condition, even
when the hand is unable to feel  it through the abdominal Avail; and its state can
be determined only by the vaginal or rectal touch.
  The laxity of the ligaments,  the mobility which it still retains, and its diminished
size, cause  it to settle into the excavation, so that its inferior segment, still con-
siderably developed (being  nearly an inch and a half or  two  inches in diameter),
depresses the vaginal cul-de-sac.   The neck is lower down in the vagina, and the
posterior surface of the organ is felt to be hard, convex, and of a size which can only
be approximatively determined.  The absorption seems now to go on more slowly,
so that no sensible difference  can be  perceived for eight or ten days longer.   By
this time  its volume is slightly lessened, there is less depression of the vaginal cul-
de-sac,  and  it  is more  movable.   Finally,  in women whom  I  examined  three
months after delivery, the original condition, as respects  situation, form, direction,
consistency, and  mobility, seemed  to  be restored,  the size only  appearing to be
somewhat greater.  In no case  had it resumed entirely its  primitive condition
either by the sixth week or the second month.  (Wieland.)]

  The rapidity with which  the uterus after delivery tends to resume the
volume and dimensions which it possessed before impregnation, is, to say the
least, quite as surprising as the rapidity with which it  underwent its enormous
hypertrophy during gestation.  An examination of the various  changes
through which this rapid absorption is effected, induced M. Retzius, of Copen-
hagen, to conclude  that  it  is preceded by a fatty degeneration of the mus-
cular fibres. The same observations have also been  made by Kolliker.
  This diminution in the size  of the uterus is not ahvays so regularly gradu-
ated as described, for Avhen  the contractility of the  tissue  has been feeble
after delivery, the walls of the uterus often preserve a considerable thickness
for four  or five days, the fundus being found all this time  close up to the
umbilicus.  The same observation  may be  made at a still  later period, in
cases where an inflammation of the peritoneum, of the uterine mucous mem-
brane, or of the neighboring organs has supervened.   Again, it happens that,
after having been diminished, its volume augments aneAv, for some hours, at
times, even for a day or two, and then soon returns to its former size.  I can
 sxplain  this circumstance only by supposing  some  local  congestion, which
has not  been acute enough to produce an active  hemorrhage, but Avho»y
action has been limited to distending and engorging  the uterine vessels, and
consequently to increasing  the thickness of the  Avails;  or this abnormal
volume  may be owing, in  certain  cases, to the presence of neAvly formed
coagula.   But, however that may be, I felt bound to point out these anoma-
lies, to prevent the inexperienced practitioner from falling into error.

  [The internal surface of  the uterus after delivery, has  lately been .studied care- 
      PHENOMENA  APPERTAINING TO THE  LYING-IN  STATE.  425

fully by MM. Colin, Robin, Pajot, and Behier.   Two parts, dissimilar in  appear-
ance, may be distinguished in it; one of these, which is extensive, was in relation
with the decidua  during  gestation ; the' other, having a lesser surface,  presents
traces of the insertion of the placenta.  We have next to study these two parts in
succession.]

   A feAV hours after  delivery, says M. Colin, the internal surface of the
womb  is covered with clots of blood, which,  upon being removed, discover
a soft,  moist, reddish  layer, lining the Avhole  internal surface of the uterus,
except where the placenta Avas attached.   If the surface be scraped Avith the
blade of a scalpel, a layer varying  in thickness from the one-eighth to the
one-sixteenth of an inch may be raised from it.  This laver, which increases
in thickness tOAvards  the middle and fundus of the organ, is of a reddish-
gray color  and friable, tearing like a neAvly-formed pseudo-membrane, and
even giving Avay beneath the fingers.  BeloAV it is found the muscular tissue,
of a Avhite or  grayish appearance,  entirely distinct from this  layer, and
easily recognized by its clearer hue,  the appearance of fibres and their trans-
verse direction, as also by its greater consistency.
   It is iioav demonstrated that this membrane is formed by a neAV uterine
mucous membrane in process of regeneration from the fourth month  of ges-
tation.   (See page 177.)
   At the upper boundary of the cavityr of the neck, this membrane is termi-
nated by an irregular edge  projecting above  the latter, and from Avhich are
put forth small shreds or laminae, from one to three-sixteenths of an inch in
length, of the same nature as the layer covering the Avail of the uterus.
   The cavity of  the  neck contains a  glutinous, transparent, and slightly-
reddish mucus.   The color of its internal surface varies greatly according to
the mode of death, from a reddish-gray to a blackish-broAvn.   The thickness
of the  mucous  membrane lining the cavity of the neck varies from the one-
thirty-sccond to the one-sixteenth part of an inch; it  is very moist and flex-
ible, although firm and torn Avith difficulty.   It remains intact, and does not
participate in the exfoliation Avhich  that of the body undergoes.
   The condition of the mucous membrane  at a period  still more remote from
delivery, has also been studied by M. Colin.   Not until after about the ninth
day are epithelial cells found upon the surface of the uterine  mucous mem-
brane in process of restoration.   Until the tAventieth day its tissue is com-
posed chiefly of fusiform bodies, nuclei, and granules; glands and numerous
capillary \"essels are found in it about the tAventieth day.  Thus, from  the
tAventy-eighth to the thirtieth day, the membrane has assumed a rose-red or
grayish color, especially in the vicinity of the neck; it is  smooth, moist, and
soft, but resists the action of a stream of Avater, though it  may be scraped
off entirely by the scalpel,  so  as to expose  the muscular  fibres.   Numerous
vessels, Avhose greatest diameter  does  not  exceed the one-ninetieth part of
an inch, proceed  from the muscular tissues and ramify ad infinitum in its
substance.  By the fortieth day, the membrane is of a rather deep-red color,
opaque, and of about the one-thirty-second part of an inch in thickness, toAvard
the fundus ; it is semi-transparent and thinner in the loAver part of the body,
Avhere it  is continuous Avith the mucous membrane of the neck, Avhich presents
nc  peculiarities   It is soft, and easily remoA'ed by the back of a scalpel.   It 
426
LABOR.
is  traversed by a very close netAvork  of capillary vessels.   By the sixtieU
day, it is smooth, gray, and supplied Avith small vessels; it has the true con-
sistency of a mucous membrane, and the scalpel removes from it but a slight
pellicle, Avhich has no longer the pulpy appearance of the substance detached
from it at an earlier period.
   This neAV mucous membrane, which, according to M. Robin, begins to be
formed by the fourth month  of  gestation, is, therefore, after delivery, the
seat of a reparatory process, which ends in the completion of a neAV  mucous
membrane.   The  mucous membrane of the neck is  not  thrown off; it  is
simply hypertrophied during  pregnancy, and after  delivery continues to
exhibit the arbor vitte, though of  a someAvhat modified form.
   The point of attachment of the placenta  is  marked  by an elevation,
presenting to  the vieAV a surface mammillated, rounded,  anfractuous, and
projecting to the extent of a quarter  of an inch above the level of  the sur-
rounding surface.   The anfractuosities are filled up Avith coagulated blood,
Avhich  is removed from them Avith difficulty.   It is the placenta Avound
   These inequalities,  Avhich have been regarded by some anatomists  as tufts
destined to dip doAvn betAveen the cotyledons of the placenta, are due, accord-
ing to  Desormeaux, to the excessive distention Avhich the arteries and veins,
the last especially, have undergone during pregnancy, and upon the sloAvness
of their subsequent retraction;  though, according to Velpeau, they are OAving,
in Avomen that die shortly after delivery, to the SAvelled and fungous  charac-
ter of that portion of the internal  uterine surface Avhich corresponded to the
placenta.  We prefer the folloAving explanation,  given by M. Jacquemier,
viz.: the internal muscular layer  of the womb is perforated in all the space
occupied by the after-birth, by a great number of holes, Avhich give a pecu-
liar aspect to this portion of its inner surface, and render  it less contractile
than at other parts; and consequently, as the organ retracts, it has a ten-
dency  to project  into its cavity, and when it  arrives  at  the final  state of
repose, a tumor is formed, Avhich  is ordinarily larger than the palm of the
hand,  Avith a very irregular lacerated surface, spongy, as it Avere, in  charac-
ter, and often standing out in considerable relief;  the torn  utero-placental
vessels are comprised in this mass, Avhich renders them tortuous and nearly
inextricable.  But Avhatever the explanation may be, it is highly important,
adds M. Jacquemier, to bear  this arrangement  constantly in mind, for an
attentive perusal of several cases  of artificial delivery of the after-birth,
has convinced me that, in those instances, the tumor formed by the most inter-
nal layer of the  Avomb was mistaken for debris of the placenta, which the
medical  attendants endeavored ineffectually,  though not Avithout  danger,
to extract.

   [Robin has shown that this projecting portion is  formed simply by the utero-
placental mucous membrane, which  remains adherent to the uterine wall,  with the
exception  of the thin  superficial layer which Avas carried aAvay by the placenta.
(See Deridua, and Placenta.)
   The  retraction of the uterus after  delivery diminishes greatly the superficial ex-
tent of this part of the mucous  membrane, being  soon reduced  to a diameter of
from two and a half to three and a quarter inches, and so progressively.   At first
it was circular in form, but soon becomes  irregularly oval, Avith the greater  diameter 
      PHENOMENA APPERTAINING  TO  THE  LYING-IN  STAVE.   427

 corresponding with  the longer diameter of the uterus.  What it  loses in length,
 however, it gains in thickness  by the contraction of the organ.  A few days after
 deliverv, it has  a thickness of from five-eighths to six-eighths of  an inch, and in
 some places even more.   At the same time, its surface becomes folded and rough-
 ened, and its substance brownish or reddish ; it also softens gradually, and assumes
 a pultaceous  or  mucous consistence.  Its  projecting  and irregular edges are con-
 tinuous with the thin, newly-formed mucous membrane  which lines the remainder
 of tlie uterus.
   It is not uncommon to find  on the surface  of the part just described vascular
 orifices plugged  up by reddish  or bleached clots, and  if the latter be traced by dis-
 section into the deeper parts of the membrane, they Avill be found to lead into the
 subjacent uterine sinuses.   The cavernous appearance given to this layer by the
 membranous  anastomoses of its vessels is very striking, and one cannot but observe
 at the same time that its  thickness and  the projections AA'hich it forms upon the
 internal surface of the uterus are principally due to the clots  which fill and distend
 the sinuses to a  greater or less extent.   If the latter  be emptied, the intervals
 between them Avill become very slight.
   The clots lose their color and lessen gradually, but they  are still found up to the
 twentieth day after delivery, and often  much later.  The tissue of the serotina it-
 self atrophies, and finally becomes continuous with and indistinguishable from the
 newly-formed mucous membrane. In some women,  however, the mucous membrane
 remains for several years both thicker and more projecting at this point than else-
 where.  It was a mistake,  therefore, to suppose, as has  been heretofore done, that
 the serotina is carried away Avith the placenta, or that it is exfoliated and eliminated
 during the continuance of the  lochial discharge.  (Robin.)
   In autopsies of puerperal fever cases, the layer, %vith a reddish, flocculent, black-
 ish and pultaceous appearance, formed by the serotina, has often been mistaken by
 persons not fully  acquainted with what had taken place previously, for portions of
 the placenta remaining adherent to the uterus, and then in course of decomposition.
   To recapitulate:  At  the  moment of labor there  is  already present a newly-
 forined but very thin mucous membrane between the muscular layer of the uterus
 and the parietal decidua.  The new membrane makes its appearance at the fourth
 month, but does  not continue to grow between the  muscular  layer and the  utero-
 parietal mucous membrane.  Finally, when the placenta is detached,  the greater
 part of the serotina remains adherent to the uterus.  This utero-placental mucous
 membrane does not, therefore, deserve the name of decidua, inasmuch as it continues
 and diminishes gradually in thickness until its surface corresponds  Avith that  of the
 recrudescent mucous  membrane.]

   Professor Stoltz has studied the modifications that occur in  the neck of
 the uterus, after the delivery, Avith a great deal of care,  and Ave extract the
 folloAving passage from his excellent thesis on this subject:  "As soon as the
 child is  born, the cervix  is  partly formed anew,  but  it  is soft, short,  wide,
 and irregular, and. one or  more fingers  can  easily be made to penetrate it;
 the internal  orifice offers the greatest resistance,  as is  proved Avhen an
 attempt  is made to introduce the hand  into  the Avomb, for  it enters with
 considerable difficulty, and  only when this orifice  has  been  progressively
 dilated.   The latter is  sometimes so contracted  as to induce  inexperienced
persons, who  endeavor for the first time to  carry  the  hand  up  into the
womb, to  believe they  have succeeded, Avhen in  fact they have only reached
the dilated vagina,  Avhere  they find a  large cavity, but no opening to get
any further,  and the clots  of  blood, then collected at the upper part of the
vagina and around the cervix, add still more to this confusion.' 
428                             LABOR.
  The internal  orifice, formed after the expulsion of  the child, offers but
little resistance; and, consequently, it has scarcely occasion to dilate again
for the passage of the placenta, as it yields readily; and when the delivery
of the after-birth is effected, the womb  contracts, and the neck  becomes
longer and  more consistent; although it must again open several times to
permit the  numerous  clots of blood  to  escape.   During  the lying-in, it
gradually returns to its natural size;  sometimes, even, it is  longer; but it
acquires the ordinary disposition more .or less, as it regains its proper con-,
sistence, and by the end of the first month it generally exhibits about the
same dimensions as it had prior to gestation; at times, however, it is a little
shortened, and the consistence is nearly as firm as usual, although the infe-
rior part has seemed to us rather more softened.  It no longer presents  a
conical shape, but is more cylindrical, from the fact of the summit having
become larger.  As a general rule, the scars  on the lips are proportionably
more numerous as the  patient has  had a greater number of children, and
her labor has been more  tedious.   The transverse fissure  is deeper and
more angular; and, in  such women, the upper part of the cervix is some-
times larger than the  base, though  it is  much shorter than  usual, and at
times is divided into two lips that are  more or  less  flat, broad, and unequal,
and the  anterior of which is longer  than  the posterior; indeed, in some
cases the latter seems to have been altogether destroyed, while in others it
is well marked, and the anterior one is scarcely perceptible.  In fact, almost
as manyr  varieties exist on this point as there are different subjects.
  The vagina becomes  shorter, and the ridges  that Avere effaced during the
last stage of labor, gradually but slowly reappear, and the orifice of this
canal, and  the vulva, also regain their primitive  condition.   At first, the
labia externa, as well as the perineum, are thin and distended, and the pos-
terior part of the contour  of the vulva is flabby, Avrinkled, and projecting
outAvard.  Sometimes the  epidermis is fretted, at others, actual lacerations
are found, Avhich  produce a smarting  sensation ;  and as to the fourchette, it
is almost inevitably torn in the first labor.
  The broad  ligaments seem to re-form by the approximation of their tvvo
constituent  layers, Avhile the round  ligaments  gradually become shortened
and retracted.
  The abdominal muscles and integuments, Avhich Avere  at  first  soft and
flabby, and exercised but a very imperfect pressure on the viscera and ves-
sels contained in their cavity, again retract;  although this process is very
often incomplete in women of a soft fibre, or Avho have had many children.
  This sIoav and gradual retraction of the uterus takes place, in some in-
stances, Avithout the least  pain, and without  the  knoAvledge of the patient;
but it  more generally becomes intermittent and distressing, and as the suf-
ferings the women then  experience have a great analogy to those of child-
birth, they are called the  after-pains.   At the same  time, a more or less
abundant discharge takes place from  the vulva, consisting at first of pure
blood, then  of blood  mixed Avith a Avhite fluid, and, lastly, of a Avhite sero-
purulent liquid;  and these discharges have received the name of the lochia
Finally, a function altogether new sets in, in the course of the first few days,
which  may be considered  as  the complement of the  puerperal functions; 
     PHENOMENA APPERTAINING TO THE  LYING-IN STATE.   429

this is the milk secretion, Avhose onset is attended by certain  general  phe-
nomena, Avhich are ordinarily described  under the term of the milk fever,
Ave shall therefore have to examine, in turn, these three principal phenom-
ena of the lying-in state.

  § 1. Of the After-Pains.
  The after-pains are certainly occasioned by the contraction of the Avomb;
to be satisfied  on  this point, it is only necessary to place the hand over the
hypogastric region, Avhen Ave will ascertain that the uterus becomes harder
just at the moment when the patient complains the most.  These pains are
much more frequent  and intense in women avIio have borne many children
than in primiparae;  as, also, after an easy than after a long and painful
labor; and Avhen the womb incloses some foreign body, such as  coagula, or
a portion of the membranes or placenta, than Avhen  its  cavity  is  entirely
empty.  Noaa', all these  differences in  character will be readily  compre-
hended, if the reader Avill only bear in mind that the object of the contrac-
tions is to express  from  the  uterine parietes  those liquids Avith  which the
walls are  still engorged  after the delivery, and to expel from its cavity all
the foreign substances contained therein;  that, in very prompt  labors, the
organ, from being evacuated too  rapidly, does  not retract so perfectly  as  it
ought, and alloAvs  the  blood to coagulate and accumulate in its  interior,
and that the very feeble  contractility of its tissue forces out but very im-
perfectly the fluids remaining in the thickness of the walls.
  The pains generally commence soon after the delivery, being at first feeble
and distant, then  more frequent and painful; and, at the  moment of  their
occurrence, the uterine globe  retracts, becomes harder, more resistant, and
sometimes even seems  to rise up, by resting on the posterior plane of the
abdomen, as a point d'appui,  and projecting  in the form of a globular tu-
mor through the Avails of the  abdomen.  The escape of the  lochia is  ordi-
narily more abundant toAvards the end of, or just after each pain,  and not
unfrequently a feAV small coagula come aAvay from  the vulva;  but Avhere
the uterus contains a large one, the pains constantly increase in force and
frequency, until it is expelled, after Avhich  they again diminish.  In  most
cases, they cease during the milk fever, though they may continue for the
first seven or eight days.  They are very commonly excited by putting the
child to the breast.   Sometimes they return  after  having  entirely disap-
peared, are folloAved  by the discharge of a  little blood from the vulva, or
the expulsion of a clot, or of a portion of membrane that has remained in
the uterus, and then  everything returns to its  natural  condition.  They are
sometimes so  severe as to extort cries  from the patient, and some Avomen
insist that they suffer more from them than from the labor pains.
  As regards  the diagnosis, it is highly important to distinguish the after-
pains from those caused  by peritoneal inflammation, but fortunately this is
not very difficult;  for hoAvever strong the after-pains may be, they are  gen-
erally intermittent, and are separated by an interval of variable duration ;
besides, the distress attendant upon them is rather alleviated than augmented
by pressure, and a rather more abundant lochial discharge accompanies or
folluAvs them.   While they last, there  is an absence of febrile movement; 
430
LABOR.
finally, when the child seizes the nipple, especially if the latter  is the seat
of any ulceration, the suffering thereby caused most frequently brings on an
after-pain, and this circumstance alone has often sufficed to make them re-
appear, even after a suspension of several  hours.   When existing, these dif-
ferential  characters  are quite sufficient to distinguish them, but  unhappih
they are  not ahvays  so well marked;  for,  Avhere they are very acute, or fol-
low each other in rapid succession, they are accompanied by fever and sharp
pains in the  hypogastrium.  But even then, there is  always a  remission,
which, conjoined Avith the absence of the other signs of peritoneal  inflamma-
tion, may aid in determining their character.
  Dr. DeAvees states that he had several times an  opportunity of observing
a singular pain which Avas manifested almost immediately after the delivery,
and yet Avas altogether different from the ordinary  after-pains.   It is a very
acute pain, referred by the  patients to the lower  part  of the sacrum and
coccyx.  It commences as soon as the child is born, and continues Avithout
interruption,  and of  a frightful intensity.   It is declared by the  patient to
be vastly more insupportable than the after-pains, for it is quite  as violent,
besides being constant; the latter character serving as a ready means of dis-
tinguishing it.  Camphor and  opium   appeared to him the  most successful
means of relieving it.
  The after-pains, of Avhich we have just spoken, are sometimes so severe as
to claim  the  attention of the physician, and  although  they may be useful
when caused  by the retention of  a foreign body, they are so annoying, that
it is certainly advisable to endeavor  to prevent them.   DeAvees  states that
this  may often be effected  by observing  the folloAving  precautions: 1. Do
not rupture the  membranes before  the neck is completely dilated; 2, after
the head is born make no tractions, but allow the uterus to expel  the shoul-
ders  and trunk ;  3, do not extract  the placenta until the Avomb is thoroughly
contracted ; 4, after the placenta is delivered, excite the  Avomb so as to oblige
the muscular fibres  to contract as much  as possible.  It is evident that all
these measures  have for their object to insure the sIoav and complete con-
traction of the Avails of the uterus, in proportion as its contents are expelled.
  In  the cases of Avomen Avho have suffered much from after-pains in pre-
vious confinements,  I have made it a practice to administer a feAV doses of
ergot immediately after delivery, Avith the effect, I have thought, of pre-
venting their occurrence in many cases, or  at least of lessening their violence.
When the Avomb contracts feebly, it has seemed to me of advantage to add
pressure upon the uterus to the use of the ergot.  This is done by means of
the ordinary bandage, and made more effectual by placing a compress, formed
of one or tAvo folded toAvels, upon the fundus of the organ.
  If the after-pains  are feeble, nothing need be done;  if, however, they are
very violent,  the  physician should interpose.  Provided the  patient  has not
suffered from hemorrhage,  or  been threatened Avith it, Ave may begin by
placing Avarm and emollient cataplasms upon the abdomen.  Lotions con-
taining laudanum may be used upon the belly, and  the cataplasm may be
Avet with  the same  substance.   An injection  may also be  given of  from
tAventy to forty drops of Sydenham's laudanum, in as  small an amount of
vehicle as possible.   DeAvees professes  to have derived great  advantage frcin 
     PHENOMENA APPERTAINING  TO  THE LYING-IN  STATE.   431

a camphor mixture, consisting of a drachm  of camphor to six  ounces  of
vehicle, a tablespoonful to be taken every hour or tAvo.   When the mixture
disagrees  Avith the patient, ten grains  of finely-poAvdered  camphor, every
hour or tAvo, mixed in a little syrup of any kind, may be substituted for the
julep just mentioned.  When the after-pains are accompanied by signs of
general plethora, blood may be taken from  the  arm. ■ Finally, should there
be catise to suspect the presence of large clots or portions of the membranes
in the cavity of the uterus, one or tAvo fingers may be introduced  Avithin the
neck, in order to seize them, or at least to bring about their expulsion.  These
are, perhaps,  the only circumstances under Avhich the use of  ergot, so highly
vaunted by Crozat and Velpeau as  a remedy for  after-pains, is likely to be
successful.

   § 2. Of the Lochia.
   Of all the various excretions that take place after the delivery, the lochia
are certainly the most interesting to  us as practitioners.  This name is applied
to the matters that  escape from the vuh'a during all the period from the
delivery of the after-birth  until the Avomb has regained its normal size and
consistence.   Immediately after the delivery of the placenta, and  the escape
of the accompanying blood, all further sanguineous discharge becomes tem-
porarily suspended, ■ probably because the blood that transudes from the
surface of the Avomb accumulates in the cavity of that organ; but the  pure
fluid  soon begins to Aoav again, although, in the course of tAvelve or fifteen
hours, it loses its consistence, and its color becomes lighter, and after a short
time it is changed into a bloody scrosity.  At the expiration of the first day,
the fluid secreted contains only about one-third part of red globules  ; the other
elements consisting of Avhite globules in rather smaller  proportion, and  very
numerous epithelial  cells.  The suspending fluid  is  sprinkled with grayish
molecular granules and granulations of fatty matter.   After  the second day,
the proportion of Avhite globules increases, and the red ones diminish or  even
disappear.  The secretion of  milk soon commences, and then the Aoav of the
lochia is either diminished or entirely suspended.   When it is OArer, the bloody
discharges reappear,  and continue during the four or five succeeding days,
though  Avith  characters varying  greatly in different individuals: thus,  in
some Avomen,  those  especially avIio  menstruate profusely, they appear  Avith
the same characters,  quantity excepted, as before the milk fever.   They are
still composed of pure blood, Avhich sometimes contains numerous small clots ;
with the majority, hoAvever, they become more and more serous, though still
exhibiting here and there some bloody streaks, or perhaps are slightly tinged
by the blood,  the quantity of Avhich diminishes every day.  It usually disap-
pears altogether about the eighth day;  the lochia being thenceforth com-
posed of a more  or less  consistent yclloAvish-white liquid, and  they  thus
continue for tAvo or three Aveeks or a month; though in some  Avomen, Avho do
uot nurse, they do not pass off until the menses reappear, that is, in about
mx Aveeks or two months1 after the delivery.
  These  discharges have  been divided,  according to their  color, into the
«uiguinolent,  the serous, and  the milky, j>ur[form, or purulent lochia.   As
the uterus retracts, its Avails gradually disgorge the fluids they  had imbibed, 
432
LABOR.
and these naturally run toAvards its  central cavity.   So long as the large
venous canals in its  substance are not empty, the discharge consists of pure
blood; someAvhat later, it  is composed of serum, together with the detritus
of the ovum and the mucosities of the organ;  and still  later, a true suppu-
rative  irritation is  established,  the products of Avhich, analogous  in some
respects to  the  non-contagious  discharges of  the  urethra, constitute, in a
great measure, the Avhite or the purulent issue.
  The lochia have a peculiar odor, called gravis odor puerperii, Avhich varies
in strength according to the individual and  her habits  of cleanliness; and
to this is  also added the scent  from the perspiration and the milk, Avhich
latter, distilling  from the breast, is  imbibed by her  garments and turns sour.
Sometimes the lochia become fetid, and Avhere this circumstance is not OAving
to slovenliness,  it is  always an  unfavorable sign, since it most generally
announces that coagula or  some other foreign  substances are putrefying in
the uterus;  and where the  lochial fluid has the color of coffee-grounds, and
a cadaverous smell, it is almost uniformly an  evidence of the existence of
an inflammation of the Avomb or vagina, which has terminated in gangrene.
Again, whenever the patient is afflicted Avith carcinoma uteri, the discharges
resemble the Avashings of flesh, and have a very nauseous smell.   In all such
cases aromatic  injections,  infusions of elder or chamomile AoAvers, Avhich
are rendered more useful by adding some disinfecting  fluid, should be made
several times a day.
  The lochia are also  very variable  in quantity and duration, though we
may state, as a general  rule, that the patient soils  ten or tAvelve napkins in
the course of the first tAventy-four hours, eight  on the second day, six on the
third, four on the fifth, and  tAvo on the following days.  After the milk
fever is over, the Aoav diminishes more and more, its amount being usually
proportionate to that of the menstrual evacuation.  It  is  more copious in
Avomen Avho have borne many children, or Avho  make use of an overnour-
ishing or a heated regimen, and in those who do not nurse.   The sanguineous
discharges vary  much in amount during the first days, according to the force
of retraction Avith which the Uterine Avails were endoAved immediately after
or during the delivery of  the  after-birth;  thus,  at  times, they are very
copious, frequently coinciding Avith a considerable development of the organ;
and  in such cases I  have knoAvn the womb to continue as high up as  the
umbilicus  for several days after the delivery.
  This condition, which Leroux calls humoral engorgement, depends, in his
estimation, on the fact  that the vessels and pores of the Avomb, from being
distended  with blood, do not  become empty as  soon  as usual, because the
contractility of tissue is not then active enough to expel  it; for the Avails of
the uterus constitute a true sponge, whose meshes are composed of muscular
fibres, and which must retract forcibly so  as to express all the liquids con-
tained in tne vessels and vacuities which they form ; hence, if this contraction
is not strong enough, the parietes remain engorged, and preserve an abnor-
mal thickness, Avhich singularly augments the Avhole volume of the uterus,
although its cavity may be entirely effaced.   Soon, hoAvever, the contractile
action  of  the tissue is  aroused, and  the muscular fibres forcibly compress
and flatten the vessels that ramify betAveen them, and thus force the liquids 
      PHENOMENA  APPERTAINING  TO  THE LYING-IN STATE.  433

 which had hitherto remained there to discharge into the cavity of the organ,
 whence they Aoav toAvards the exterior in considerable quantities.   This dis-
 charge might very readily be mistaken for a Aooding, occasioned by a reten-
 tion of some part of the  after-birth, or of voluminous coagula, the more
 especially as it is accompanied at times by sharp after-pains; but if one finger
 can then be introduced into the uterus, the accoucheur will ascertain that it
 contains no  foreign substance,  and by placing  the oilier  hand at the same
 time on the hypogastric region,  he Avill easily satisfy himself that the unusual
 size of the organ depends only  on the engorgement of its walls.   In these
 cases,  there is nothing to be done, as the sanguineous discharge is  itself the
 best remedy; for it sloAvly empties the uterine texture, diminishes the after-
 pains, and the Avomb gradually  returns to its normal size.
   This sloAvness of the  retraction also prolongs  the Aoav of the sanguineous
 lochia, and the same  result is  obseiwed Avhenever  one of  the layers of the
 uterus or its enveloping cellular tissue is affected  Avith inflammation.  Indeed,
 we can readily understand that from  this sluggishness of the uterine fibres,
 this defect of reaction, as Leroux called it, to a more  or less perfect inertia
 of the Avomb, there  is  but  a single step, and that  a secondary hemorrhage
 might result from the absence of contractility, if it Avere carried to the extent
 of relaxation.
   [The time at which the lochia assume a purulent form is also  liable to remark-
 able A'ariations.   In thirty-seven cases observed by M. Behier, in which eArerything
 was favorable, it occurred on the third day nine times, on the fourth day four times,
 on the fifth day ten times, on the sixth day six times, and  from the seventh to the
 tenth  day seven times.  Finally, in one case, in the most auspicious condition, the
 lochia  became decidedly purulent only on the sixteenth  day.   (Behier, Clinique
 Me'dicale.)]
   Lactation lessens  the duration  and amount of the lochia.   Some women
 have them for a feAV hours only (Van-SAvieten),  and others have none at all
 (Millot). •  An  instance of the  latter kind came under  my notice quite
 recently (1855), in the case of  the young Avife of a medical friend.   After
 an easy and happy labor, the lochia Avere almost completely suppressed. She
 hardly lost a feAV spoonfuls of blood Avithin the first tAventy-four hours; after
 the second day there Avas no discharge Avhatever, and the husband, Avho ex-
 amined the linen daily with the  greatest care, assured me that he Avas unable
 to detect  the slightest evidence of lochial discharge.   Everything Avent on
 well during the  lying-in, Avith the exception of a very fetid odor  from the
 genital parts during  the first seven or eight days.  After satisfying ourselves
 that there Avas no foreign substance  in the  uterus, Ave recommended the use
 of injections, frequently repeated,  and all passed off Avell.   This young lady
 had been delivered once before, on which occasion she had a perfectly regular
 loehial discharge.
   In  a case observed by Bruckmann, and quoted by Velpeau, the lochia
 Avere substituted by haematemesis.
  In  some instances, the sanguineous lochia are prolonged far beyond the
usual   term ;  Avhile in  others they reappear at various intervals,  but this
latter circumstance, in tr e  absence of inflammation of the  uterus or of its
appendages, is ordinarily vwing to some  error in  regimen, more especially to
       28 
434
LABOR.
 getting up too soon ;  and, therefore, the best plan is to persuade the patient
 to remain in bed.  In the course of a short time the lochia cease their con-
 tinual floAV, and intervals of several hours of  duration are observed  at first,
 then of a day, and sometimes of two days.
   When, in spite of this precaution, the bloody discharge continues for two
 or three weeks after labor, its cause should be sought for in a local alteration
 of the uterus  and of the neighboring  parts, or else in the general condition
 of the patient.  Thus, it is not unusual for  it to be kept up by a circum-
 scribed peritoneal inflammation,  an inflammation  of  the  uterine mucous
 membrane, a  chronic or acute engorgement of one or both ovaries, or a
 phlegmon of the broad ligaments, of the iliac fossa,  or of the cellular tissue
 surrounding the uterus.
  It is important to diagnose these various affections  from the outset, as it is
 they which should be attacked, in order to stop the discharge, which is here
 but a symptom of the disease.
  The continuance of red discharges is connected, perhaps, more frequently
 with ulcerations of the neck of the uterus,  having their origin in many cases
 in the lacerations which occur during  labor, and the cicatrization of which
 is prevented by circumstances which elude our detection.  When, therefore,
 it is certain that no symptom of engorgement or inflammation in the pelvic
 or hypogastric region is present, the  patient should be examined Avith the
 speculum, taking care to separate the lips of the neck with the valves of the
 instrument, when very often a fungous  and bleeding ulceration will be dis-
 covered either within the cavity of the neck or upon  the os tincae. The only
 means of arresting the discharge  consist in  cauterizations with nitrate of
 silver or acid  nitrate of mercury, and even, if the fungosities  are very pro-
 jecting, with the actual cautery.  In some cases, it is  necessary to repeat the
 cauteri7ation several times.
  Amongst the causes of these  anomalous  lochial  discharges, should be
 reckoned a local irritation sustained  by obstinate constipation. • Here the
 use of  purgatives is demanded.
  Sometimes no lesion can be discovered, but the discharge seems evidently
 to be connected with an over-excited condition of the entire organism.  This
 condition is indicated by  heat of the  skin,  fulness  of pulse, some febrile
 movement towards evening, and disturbed sleep.  Notwithstanding the ap-
 parent weakness of the patient, great care should be taken in reference to the
 use of tonics,  Avhich, unfortunately, are too  often employed;  a moderate
 antiphlogistic  treatment, on  the  contrary, is the  one indicated.  A small
 bleeding from the arm, mild laxatives, and a restricted vegetable diet, might
be directed Avith advantage.  Stimulating or even  tonic drinks should be
proscribed, and only after the general irritation  shall have been quieted, is
it proper to endeavor to increase the strength of the patient by the appro-
priate means.
  In some rare cases, hoAvever, the abundance and persistence  of the bloody
discharge seem to be sustained by the general debility.  The absence of the
general symptoms, just now mentioned, allow of recourse being had imme-
 diately to a tonic treatment;  then it is that infusions of cinchona and  sul-
 phate of iron are capable of rendering effectual services.  (See  in Part Fifth
 the article devoted to Secondary Hemorrhage.) 
     PHENOMENA APPERTAINING  TO  THE LYING-IN  STATE.   435

  The white or purulent lochial  discharges sometimes become very profuse,
and have at the same time an exceedingly disagreeable odor.  The discharge
is no longer covered Avith  blood, but appears as a reddish Avater floAving  in
large quantity,  and sometimes even escaping in gushes.  They are occasion-
ally so acrid as to inflame the parts over Avhich they flow.   The patients are
almost ahvays much Aveakened by the evacuation, and their general health
evidently demands the  use of tonics.   The irritated parts should be washed
frequently with Avarm  Avater, and injections of infusion of chamomile AoAvers,
afterAvards  made rather more astringent, should be throAvn into the vagina
five or six times a  day.  A feAV spoonfuls of chloride of soda might be added
with advantage.  My friend, Dr. Casaubon.  informs  me  that  he has met
with several cases of this kind.
  These purulent lochia, also, sometimes continue long after the usual period
of their cessation.  This circumstance is sometimes connected Avith some one
of the causes mentioned as productive of the  anomalous persistence of the
bloody discharge, though  it  has oftener seemed to me to be the result of a
catarrhal  metritis  or  peri-uterine phlegmon.  Both  these affections  may
hinder the gradual retraction of the uterus, Avhich may remain  of consider-
able size for a month or six Aveeks after delivery.  Large flying blisters upon
the abdomen, frequent alkaline baths, and bleeding from  the  arm,  when
there is fever and  the  strength  permits it, have  appeared to me to be the
most effectual under these circumstances.
  The suppression  of the  lochia long before the time at Avhich they usually
disappear  is  an unfortunate symptom only when it seems  to be  connected
with the development of  a serious inflammatory affection, or when it is re-
placed by a supplemental  hemorrhage.  It then merits the closest attention
of the physician; but Avhen the contrary is the case, there is no  occasion for
uneasiness,  since it is the evidence of a rapid  and forcible contraction of the
uterus, which is a favorable circumstance.

  § 3.  Of  the Milk  Fever.
  One of the most important phenomena appertaining to the lying-in  state,
is that usually designated  under the name of the milk fever.   It  has already
been seen, when studying the modifications impressed on the whole organism
by gestation, that the  breasts in most Avomen, even in the  very commence-
ment of their pregnancy, are apt to become tumefied, that the SAvelling per-
sists, and that sometimes they become the seat of an abundant secretion long
before  delivery. After the  delivery, they yield  on suction a liquid of a
yelloAvish color, and somewhat more consistent than the preceding, which  in
some women escapes during  the latter months of gestation.   This fluid has
a sweetish taste, and is called the colostrum.   It retains these qualities for
twenty-four hours;  but becomes Avhiter after that  period.   In the course of
forty to sixty hours, the  breasts enlarge greatly;  the subcutaneous veins,
seen through the skin, are  more SAVollen than during the pregnant state, and
the  former become manifestly harder.  The  secretion of milk in healthy
women is not usually attended Avith fever, the diminution of  the pulse hardly
being prcArented by it (see page 422.)  Still, if the SAvelftng of the breasts be
considerable, headache  may  occur, as also, at times,  though more rarely, 
436                             LAbOR,
slight shiverings, or heat and  dryness of the skin, Avhich is succeeded in a
*eAV hours by a copious perspiration; there are thirst  and loss of appetite;
the tongue is slightly furred; the  pulse, at first small  and contracted, soon
becomes full, soft, and accelerated ;  and the face is flushed  and animated.
M. Pajot maintains that the pulse rarely rises above 100, which is generally
true, though there  are  exceptions  due to individual susceptibility.   M,
Behier  has noted the pulse at 130 in a case in  AA'hich everything went on
very favorablyr.   During  this febrile movement, Avhich  is generally slight,
the enlargement of the mammae continually increases, extends as far as the
armpits, and involves the surrounding cellular  tissue, Avhence the patient
can no longer bring the arms down alongside of her body, and therefore has
to hold  them off.  The skin is  sometimes so stretched  as to become painful
and incommode the inspiratory movements of the chest; and lastly, as else-
where stated, the discharge of the lochia either disappears altogether, or else
is greatly  diminished.  This  fever lasts for tAvelve, tAventy-four, thirty-six,
or possibly forty-eight hours,  and then is folloAved by a calm ; at times,
hoAvever, it is continued for three or four days;  but in such cases it is often
due to a deep-seated inflammation, or else soon  exhibits a well-marked in-
termittence, and may degenerate into a true intermittent fever, which yields
readily  to sulphate of quinine.  The pulse is ordinarily not very rapid, and
whenever  it exceeds 100  per minute, the cause should be sought  else»vhere
than in  the lacteal secretion.
  Authors have stated that the  milk fever is less intense Avith primiparae
than Avith  others.   The  same  is the case with those who begin to suckle
their children very soon after  delivery; indeed, it is  not at  all uncommon
for the  latter to escape it entirely.  Finally, certain females, even of those
who do  not nurse at all, have no milk fever Avhatever, and this notAvith-
standing that the breasts are considerably SAVollen and the secretion of milk
is abundant.  This is a much  more common occurrence  than is generally
supposed,  and I have frequently had occasion to point it out to students.
Still, I  am far from supposing, as some do, that it forms the rule, and from
regarding  every febrile  movement occurring in a lying-in Avoman, even
Avhen the lacteal  secretion is  commencing, as indicative of an apparent or
concealed  inflammation.  Nothing, indeed, could be more reasonable than
to regard  the SAvelling and painfulness of the mammary glands as the cause
of the general reaction Avhich usually accompanies them, and Avhich dimin-
ishes or ceases, as soon as the breasts become soft, or the system  habituated
to the neAV condition of things.
  In some Avomen  the breasts remain  inactive,  and no milk it secreted; it
really Avould seem, as Prof. P. Dubois has remarked, that nature has left
her Avork  unfinished in them; that, being capable of becoming mothers, and
able during the whole term of gestation to furnish  the necessary materials
for the child's  nutrition, yet their organization is absolutely inadequate to
supply  its Avants after birth.   I have at this moment under observation a
young primiparous woman, convalescing, it is true, from an attack of vario-
loid Avhich came on immediately after  delivery, Avho  has not had a single
drop of milk.
  The  milk frver generally  manifests itself about  forty-eight hours subse 
     PHENOMENA  APPERTAINING  TO  THE LYING-IN STATE.   437

quent to the delivery;  at times a little sooner, at others someAvhat later;
thus, I have seen tAvo  patients at the Clinique (and  all "observers record
similar facts), Avho had this fever, the one on the fifth  and the other on the
sixth  day;  and  since that time  I have often had  occasion to make  the
same remark.
  [For the sake of greater precision, we  think it best to quote M. Behier's ob-
servations on the subject.  "I investigated," says this professor, "the cases of 974
women, in order to determine the precise period at which  the flow of milk takes
place.  In 22 it occurred within  the first day after delivery; in 170 on the second
day : in 347 on the third  day ; in 266 on the fourth day ; in 100 on the fifth day ;
in 22 on the sixth day ; in 5 on the seventh day; in 4 on the eighth day ; and in 1
not until the  eleventh day."]
  Where the child's  death takes place at an advanced stage of gestation, and
the dead body is  not expelled for several days aftenvards, it is by no means
uncommon to find all the phenomena of milk  fever manifesting themselves.
  In ordinary cases, by the time the fever is over, the breasts have acquired
their highest degree of distention, and the secretion of milk is very abundant.
If the child  draAvs well, they are emptied and the patient relieved;  but should
the mother  not suckle her infant, the engorgement continues for  a longer
period, though it Avears aAyay the  more promptly as it  was less considerable
in the first place, or as the milk flows more easily from the nipple, and as
the perspiration and lochia are the more abundant.
  The question as to the  cause of milk fever has  been discussed again and
again; but Avithout entering into all the arguments which this point of doc-
trine  has given  rise to, avc Avill  merely remark, that the febrile movement
(Avhich, howeA'cr, is not ahvays constant) most  probably is a consequence of
the greater activity the mammae then  assume, and that it  is nothing more
than what  takes place Avhenever  any organ undergoes a very considerable
and rapid development.
  To AAromen Avho do not  nurse, the lacteal secretion may be the cause of
accidents Avhich  are to be prevented  or opposed.  Everything  that  could
tend to increase the secretion of milk, such as  succulent food, and the prac-
tice of drinking  freely, should be strictly  avoided.  Warm and soft toAvels
should be applied to the breasts, and renewed as soon as they become moist.
A still better application is cotton Avadding.   By these means perspiration
is excited,  and  the  heat of the  parts maintained.   Should the secretion
diminish gradually, everything may be left  to nature, but should  the breasts
become too much SAVollen, the discharge from the nipple should be facilitated
by the use of emollient cataplasms, or  efforts  be made  to  empty them by
suction.  In case of these  measures proving ineffectual,  recourse must be had
to lotions containing laudanum for  the purpose of relieving pain, and to
sudorifics and purgatives  as revulsives.  As amongst  the most  commonly
employed diaphoretics, Ave may mention Aveak tea, and the infusions of Parie-
taria and Borage.  The  purgatives  are those  Avhich have been  already
mentioned.  Of all the preparations which have been  extolled as lactifuge,
the petit-lait of Weiss' is, according to Desormeaux, the only one which is
  1 The petit-liit (whey) of Weiss is prepared by infusing in boiling whey a species of
galium, flowers of elder, hypericum, and of the linden-tree, together w'vh sfntu,  nm)
sulphate of sooa.  It acts as  a purgative. — Translator. 
438
LABOR.
still employed.  The same author states that he knew a lady to  apply an
ammoniacal liniment with success.  Neuter asserts, as proved by experiment,
that the application of cups to the back  diminishes the Aoav of milk ;  and
Van-SAvieten kneAV a galactorrhoea  to yield to  a strong infusion  of sage,
taken in doses of from one to two ounces every three hours.

  [M. Blot was the first to discover the presence of sugar in the urine of lying-in
women as  a  phenomenon connected with lactation.   It would seem from his re-
searches that sugar, whose presence in urine had been regarded as pathognomonic
of diabetes, exists not only in the urine of all  lying-in women but in all nurses,
and in a certain proportion of pregnant females.  The term Physiological glycosuria
has been used to express this fact.
  "In all puerperal women (45 in 50)," says M. Blot,  "the sugar begins to appear
in the urine in determinate  quantity coincident with  the beginning of the flow of
milk ; and  in many cases it  does  not  exist until then.  In a feAv cases it may be
found previously,  but  generally in very small  amount.  If the secretion of milk
continues, sugar continues to be passed in the urine with diurnal variations as yet
unexplained.   When the flow of milk is profuse, the proportion of sugar is usually
large ;  if the  former be moderate, the latter is small.  In this way  an  examination
of the urine  may enable us to judge up to a certain point of the value of a nurse.
If the flow of milk be  lessened or arrested  from any cause, and especially  by the
development of a more or less serious  morbid condition, the  sugar diminishes in
quantity or disappears entirely.   If health be restored and the secretion re-estab-
lished, the  sugar reappears.   Finally, the  urine contains  sugar as long as milk
continues to be secreted:  I have found  it in considerable proportion (8 gramme's to
1000 of urine) in one case in which  the woman had been nursing for twenty-two
months.  In fact, the  urine is generally rich in sugar in proportion as the  health
improA'es and approaches most nearly to the normal or physiological condition.
  " When lactation ceases, the sugar  disappears, and that at periods varying in
different  individuals; earlier in those who  do not nurse, and later in those who,
having nursed, begin to wean the child.
  " Sugar Avas found in one-half the observed cases of pregnancy.  I think, with-
out  being able to affirm it  positively, that this peculiarity  is most likely to be
observed when  the breasts sympathize most with the pregnant condition; that on
the  contrary,  it is absent when the breasts remain indifferent,  as it were, to what is
going on in the uterus."  (Blot.)
  This physiological glycosuria is also present in the different species of mammalia.
  As a test of the presence of sugar in the urine, M. Blot used successively Fehling's
fhxd, caustic  potash, fermentation, and the polarimeter.
  Physiological glycosuria seemed then to be an established fact, when M. Leconte
appeared with an absolute denial of the presence of sugar in  the urine of nursing
women, and asserting that the whole was a mistake  due to  the  presence of uric
acid, which gives reactions similar to those produced by sugar.
  In this scientific dispute M. Bruecke espoused the cause of M. Blot, and, I would
add, that a personal repetition of the experiments convinces me of the existence of
physiological  glycosuria.  Further observations are, however, required in order to
clear the subject of all  doubt.] 
ATTENTIONS  TO  THE  LYING-IN  WOMAN.          439
                           CHAPTER  X.

     OF THE NECESSARY ATTENTIONS TO  THE LYING-IN  WOMAN.

   The patient  should be  placed in a  large, well-aired  chamber, Avhich is
 moderately warm, and free  from all strong odors.  In  s immer, the doors
 and AvindoAvs are to be opened every day; though, while the air of the apart-
 ment is being changed, she ought to be carefully  covered, and  have the cur-
 tains draAvn, so  as  to  protect her from  any draft;  but, at other times, the
 curtains need not be closed.   The room ought to be kept scrupulously neat,
 and the urine,  excrements,  and soiled linen should  be removed  at  once.
 The genital parts must be often bathed with lukeAvarm Avater, or some emol-
 lient decoction.  These frequent ablutions have  the further advantage of
 calming any inflammation in the parts that have been  contused during the
 labor;  they should be made  morning and evening, and Avithout uncovering
 the patient.

   [As the newly delivered female is liable to various accidents, and  diseases which
 make rapid progress, she ought to be visited every day.
   In the first place, the physician should  inquire into the  general condition and
 determine the acceleration or lessened  frequency of the  pulse, which will rarely
 deceive as regards the prognosis.   (See page 422.)   He will also ascertain carefully
 the condition of the  uterus as to size (see page 423)  and sensibility, the character
 of the lochia, and the severity of the after-pains.  The  turgescence of the breasts
 and  their  secretion will also demand his attention ;  and, finally, he  will inquire
 into  the state of  the bladder and rectum.]

   The secretion and excretion of urine generally present  nothing abnormal,
 though there is  sometimes  difficulty in the emission, due  to SAvelling of the
•meatus.   Occasionally, also,  the bladder suffers  temporary paralysis  from
 severe pressure  in tedious  labors.  In such cases the catheter should be used.
 The physician ought ahvays, during  the first  two or three days, to inquire
 Avhether the water passes  freely and  with ease, because  its collection  in a
 half-paralyzed and benumbed bladder may often explain a state of uneasi-
 ness or  suffering not otherwise to be accounted for.
   [Retention  of  urine  sometimes  occurs with lying-in  women immediately  after
delivery, and sometimes not  until after several days.  In the former case, it would
seem due to paralysis of the bladder or  contusion of  its neck; in the latter, it is
probably caused by consecutive inflammation.  At other times the patients do not
empty the bladder, and it remains considerably distended  Avithout  their  knowing
it.  Therefore, after  questioning the patient on this subject, the accoucheur ought
himself  to ascertain  whether the bladder is emptied.  It is very important not to
overlook a distended bladder, though it is often done,  for then  the physician neces-
sarily falls into an error of diagnosis in  regard to the cause of the suffering in the
lower part of the abdomen.
  The symptoms  of retention of urine in  lying-in Avomen have some peculiarities-.
The bladder, being pressed forward by the  uterus, which forms a resisting plane
behind it, almost  alwavs projects sufficiently above the pubis to form a tumor there
which is appreciable to the  eye.   The tumor is rounded,  soft and  supple to the
touch, fluctuating, and dull  on  percussion.   All  these characters haA'e but a sec-
ondary value, so that AAhenever" retention of urine is  suspected, the uterus should 
440
LABOR.
first be sought for, and will be known by its  size and especially by its hardness:
if the uterus cannot be felt, it is because it is concealed by the distended bladder.
Repletion of the bladder has, also, upon  the position of the womb  an effect which
should be well understood: when the distended organ rises into the loAver part of
the abdomen, it carries with it  the uterus, whose fundus is then found as high as,
and often even above, the umbilicus, and when the catheter is used, it descends as
the Avater flows.  Whenever, therefore, the fundus of the uterus is found too high
up, the sub-pubic region should be  examined carefully to ascertain  w"hether the
bladder projects there.  If the latter be empty, the fingers will, without difficulty,
feel the anterior surface of the womb throughout.
  Retention of urine sometimes continues in these cases for several days, and even
for several weeks.  So long as it lasts, the catheter should be used at least tAvice
a day according to the rules  already pointed out (see  page 61).  The  bladder
almost always recovers its power after a certain time, so that there is no occasion
for alarm should  the retention last for several days.]

  The constipation that is so common during the last  stages of gestation,
oftentimes still  persists after  the delivery for four, six,  or even eight days;
and this prolonged retention of the fecal matters may give rise to anxiety,
headache,- loss of sleep, and sometimes even to a feeling  of Aveight, or actual
pain  in  one of  the  iliac fossae;  all which symptoms disappear like magic
upon the administration  of  some  mild  laxative.   Where the costiveness
continues, a state of suffering very frequently results, Avhich may occasion a
blight febrile movement; and the frequency of  pulse, thus produced, coin-
ciding with  the pain caused  by an unusual  retention of the fecal matters,
which pain  is  most commonly  located  in  some  part  of the  hypogastric
region, and  is augmented by pressure, may give rise to suspicions of a peri-
toneal inflammation that really does not exist; and I have knoAvn this error
to be committed where the pain and fever that had resisted the application
of leeches, rapidly disappeared after the exhibition of a purgative.   'Xhe
retention of the faeces may also result from a paralysis of the  rectum, Avhich
paralysis itself  is a consequence of the pressure made upon it by the head
during its  prolonged sojourn  in  the  excavation.  I have known, says M.
Martin, of Lyons, the faeces  to be retained more than  tAventy days after a
laborious delivery, and to accumulate in  such large quantities, and acquire
such  a firm consistence as to  equal  the size of a child's head at term;  and
as all the  usual  laxatives failed, I Avas obliged to introduce a scoop,  and
bring the hardened  matters away piecemeal;  but even then the gut did not
at once regain its functions,  though a fresh accumulation was prevented by
the use of irritant injections, and the contractility of the intestine Avas not
perfectly re-established  until  twenty-nine days aftenvards, at Avhich period
the patient left  the hospital.   ( Comptes Rendus, p. 32.)
   A  temporary constipation, prior to the invasion of the milk fever,  is a
matter of no consequence ; but should it persist for several days aftenvards,
injections may be administered, either simple, or else rendered slightly  lax-
ative by the addition of an ounce or an ounce and a half of the miel mercu-
riile, or a  decoction of senna leaves ; and  Avhere these measures do not
answer, a mild  purgath e, such as the folloAving, is exhibited  by the mouth,
viz., from half an ounce  to an ounce of castor oil,  rubbed up Avith an ounce
of almond emusion and a little lemon syrup;  or the sal de duobus (sulphate 
             ATTENTIONS  TO  THE  LYING-IN  WOMAN.         44]

 of potash) might  be employed, in the dose of fifteen or thirty grains, dis-
 solved in her usual drinks.   The castor-oil can be SAvalloAved Avithout much
 difficulty Avhen  it is diffused in a cup of rich broth, made  as hot  as the
 patient can bear it.  I have observed that it is much oftener retained Avhen
 mixed Avith broth than Avhen mixed with  almond  emulsion.
  The Avoman should make no exertion during the first feAV days, and if the
 labor has been long and painful, or attended Avith any serious accident, it
 is best that she should be protected from violent and rude motions, and that
 the bed be not made up  until after the milk fever has subsided.   When,
 however, the patients are but slightly fatigued, the bed may be made on the
 evening of the day preceding that on Avhich the milk fever supervenes, after
 Avhich it should be left  until the next day but one; thereafter it may be
 made eA^ery day.  The woman should, on these occasions, be transferred to
 another couch.
  It is very important that the patient should not rise before the ninth  day,
 which is a favorite time for getting up with the working classes, and Avhere
 she is in easy circumstances, and  can, without detriment to her interests,
 abstain for a longer period from her household duties, she should be required
 to remain in bed for at least two weeks.  It were better not to adopt arbitrarily
 any particular day, but to regulate the conduct to be followed by the degree of
 atrophy of the uterus.  When the latter has lost the greater part of its bulk,
 and its  fundus descends and disappears in the lesser pelvis, the patient  may
 get up.   One Avoman may do so without  danger  on the eighth day, whilst
 another ought to remain in bed after the fifteenth day.  At this period she
 may be carried to an easy-chair, Avhere she will remain seated for  an hour
 or tAvo,  and again, on the following day,  for tAvo or three hours.   On the
 third, she might try her strength by taking a feAV turns around the chamber,
 and then through the apartments ; but it Avould be imprudent to venture
 out of doors, especially in the winter season, before the fifteenth or tAventieth
 day, and only then in fine Aveather and about the middle of the day.
  Most Avomen, actuated by a religious feeling, go to church  on the occasion
 of their first going out; and as these buildings are  always cold and damp,
 they often return with the germs of an  inflammatory disease, Avhich sooner
 or later develops itself; and hence the physician should advise the deferring
 of this religious ceremony, called the churching, to a more distant period.
  As  regards her diet, the articles ought to be of the mildest character, and
 of easy digestion ; thus, as a general rule, she Avill only need, during the first
 day or tAvo, a little porridge two or three times  in the course of the day, and
 some broth during the night; and  she should observe an absolute diet pend-
 ing the duration of the milk fever, for fear of adding to its intensity;  though
 even here, if the  general reaction  is moderate, she  might be alloAved some
 broth.   After  the  fever  is over, the quantity  of  nourishment is gradually
 augmented; so that, by the tAvelfth or the fifteenth day, the  Avoman has
resumed her ordinary habits.   In those who do not niirse, the regimen must
be more  restricted,  especially Avhen the  breasts still  remain engorged or
 painful.
  [The regimen of lying-in  Avomen, as just indicated, was rigorously observed until
within a few years;  but, Ave ought to add, there is  noAV a strong disposition to act 
442
LABOR.
differently.  Legroux, physician at the Hotel Dieu, introduced the innovation b]
showing that not only was there no danger, but often a real advantage in giving
nourishment freely to newly delivered patients.  Accordingly,  he  allows soups to
the Avomen in his wards on the first day, and solid food on the second day after
delivery.   I have followed his example for several years, and  have had no reason
to be other than  pleased with it.  Immediately after delivery, therefore, I allow
soup, taken  in small quantities, but freely.   On the next day solid  food  is per-
mitted; an egg  or mutton chop, for  example, with  bread and claret and water.
After the secretion of milk has begun, the patients can resume their usual diet.
This plan  has but the single inconvenience of eliciting, the disapproval of those whc
have grown up in other ways of doing; but inasmuch as it is better for the patients,
we shall have to disregard these objections.]
  Throughout the whole lying-in period, the patient should use some diluted
ptisan, moderately SAveetened and rendered aromatic, as an ordinary drink;
such as a solution  of gum, or an  infusion of malloAvs, of violets or linden,
the orange or chamomile AoAvers, &c, &c.;  but acidulated drinks must never
be alloAved to  those  Avho nurse.  About the  seventh or  eighth day, most
patients  ask their medical attendant  for something to  drive away the milk,
which, of course, is generally a useless precaution;  but, perhaps, it Avould
be better  to yield to a very popular prejudice, so as to escape all subsequent
reproach.   The  Canne  de Provence, and the infusion of periwinkle, &c,
enjoy a high reputation for this purpose;  and as the root of the former is
nearly inert, it will, on that  account, be preferably employed.
  Most Avomen  think it  necessary to be  purged tOAvards  the  end of their
lying-in ;  and though, Avhen  the physician discovers any positive counter-
indication to the administration of even a mild purgative, he doubtless should
not yield to their desires; yet, under  ordinary circumstances, he ought to
purge  them slightly,  both on account of  his own reputation and to avoid
subsequent unjust reproaches;  indeed, this  will become  necessary,  if the
tongue is broad, furred, and yellowish or greenish, the mouth bitter and
clammy, and there is a loss of appetite.  The  Seidlitz Avaters and castor-pil
are perhaps preferable, from their  mildness and certainty  of operation.
  The excitability of the  nervous system  is such, in lying-in women, that
the greatest care should be exercised in keeping aAvay everything that might
excite them, and in avoiding all acute moral emotions. 
PAET  IV.
              PATHOLOGY  OF  PKEGNANCY.

rpHE  pathology of  pregnancy  comprises  all  functional  derangements
 1  occurring in pregnant Avomen, as well as  all spontaneous or accidental
lesions of the ovum Avhich may compromise the health or life of the foetus.
As the latter class usually either escape detection, or  are not  discovered
until  it is too  late to remedy them, they Avill be considered briefly;  all, in
fact, that can be said of them is limited to certain questions of pathological
anatomy, foreign to the main object of this Avork.
  [Some of the numerous diseases observed during pregnancy are the result of this
condition ; others  occur, as it were, by chance, and often happen under other cir-
cumstances.  On this account, they are treated of in separate chapters ; a division,
hoAvever, which is far from perfect, as the distinction between the two classes can-
not  ahvays be defined.  The first chapter is devoted to the diseases which may
occur during pregnancy, and the second to those which are the result of it.   After-
ward are described extra-uterine pregnancies, lesions of the ovum  and of the pla-
centa, and diseases of the foetus and its death. The last chapter treats of abortion.]
                          CHAPTER I.

OF THE  DISEASES AVHICH MAY  EXIST  DURING PREGNANCY, AND OF
  THE  RECIPROCAL   INFLUENCE  WHICH  THEY  MAY  HAVE  UPON
  THEIR  PROGRESS AND TERMINATION.

  Though, says Antoine Petit, pregnancy exposes Avomen to various disorders,
it also protects them from many  very dangerous diseases, arrests the pro-
gress of others, and sometimes even  cures those Avith Avhich they Avere pre-
viously affected.  This proposition, though asserted almost as a maxim by
the author quoted, is, unfortunately, far from being strictly true.  Antoine
Petit was  indeed strangely deceived  in his appreciation of the influence of
pregnancy upon acute diseases existing before it or occurring during its
progress;  still, as many physicians partake of his error, Ave have thought it
right to notice it at the outset.

  § 1. Epidemic Diseases.
  1.  Influenza.—Though some epidemics have appeared to spare  pregnant
women,  many have affected them as severely, at least, as other individuals
exDosed to the same influences.   Thus I found, as did also M. Jacquemier,
                                                               443 
444
PATHOLOGY OF  PREGNANCY.
at the Maternity Hospital, that the epidemic of influenza attacked a great
many pregnant Avomen ; but, contrary to his observation, I Avitnessed numer-
ous abortions as a consequence either of the disease itself, or of the violent
spells of coughing Avhich tormented the patients.
  2. Cholera.—The severe epidemics of cholera Avhich, in  1832 and  1849,
were so fatal in the capital, did not spare pregnant women; and Ave had the
pain of Avitnessing the death  of quite a number.
  Dr. Bouchut has endeavored, in a  quite recent work, to  appreciate the
effect of pregnancy upon cholera, and vice versa.  Relying upon  52 obser-
vations, he commences by sliOAving that pregnancy has no influence upon
the invasion of cholera, that  it protects from it no more than it predisposes
to it, and that Avhen the disease appears, it does so Avithout any modification,
in all its forms and severity.
  Cholera has, hoAvever, an incontestable influence upon the course of gesta-
tion, often shortening its duration.  Thus, 25 women out of  52 aborted in
consequence of the disease, and  the  same Avould probably have  been  the
case Avith others, had  not the patients  been  removed by an  early death.
Except in some rare instances, abortion took  place only in cases  in Avhich
the disease lasted over twenty-four hours.
   Of the 25 women who  aborted, 16  recovered ; 12  had  the  disease with
moderate severity, though  lasting for a considerable  time; the attack in 4
was dangerous and rapid, and 9 died.
   The observations of M. Bouchut have elicited the  remarkable fact that
abortion is very common in cholera patients after the fifth month of preg-
nancy, but very rare  at  its commencement,  Thus, of the 16 women Avho
aborted  and recovered, only 1 Avas three months pregnant, 1 four, 6 five,
and 1 six;  and the least advanced of the 9 Avho died after abortion, had
reached four months and  a half.
   Of the 27 Avomen who did hot miscarry, only six recovered and had their
pregnancies to continue.   The attacks Avhich they suffered Avere of medium
severity, and of several days' duration :  21 died Avith  the disease  in a dan-
gerous and rapid form.
   Altogether there were 30 deaths out of 52 cases.  We see,  therefore, that
the prognosis  of cholera is  not  rendered  more favorable by the state of
pregnancy.
   We have said that 6 of the patients recovered, and had their pregnancies
to pursue their regular course.  Others, who had reached a more advanced
stage, Avere delivered prematurely of living children.   From this, it plainly
results  that cholera is not  always communicated to the foetus,  and that
though the latter usually succumbs either before its expulsion, or before the
mother,  in those cases  Avhere her  early decease did not allow the abortion to
take place, its death cannot be attributed to a transmission  of the disease.
Besides, the autopsy  of  the children revealed nothing  Avhich   could be
regarded as pertaining to cholera.
   What, then, is the cause of the death of the foetus, preceding, as it almost
ahvays does, its OAvn expulsion, or the  death of the mother ?
   M. Bouchut thinks that it is a consequence either of a mechanical  com-
pression of the uterus producol  by the cramps and convulsions of the ab- 
           DISEASES  OCCURRING  DURING  PREGNANCY.        445

dominal muscles, or to the severe diet to Avhich the  patients are subjected
again, he supposes that it may be occasioned by the  profuse discharges from
the boAvels, Avhich, by depriA'ing the blood of its serum, dry up, as  it were,
the sources of nutrition.  For my OAvn part, I regard asphyxia as the only,
or at least the usual,  cause of the death of the foetus.  The  coagulation of
the blood, and its stagnation in the vessels, are evidently calculated to sus-
pend the utero-placental circulation;  and the interruption of the latter,
depriving the foetus as it does of the means of respiration, must  necessarily
lead to its rapid death.
   M. Devilliers, Jr., read before the Academy of Medicine an observation
tending to prove that abortion has a favorable effect upon the termination
of cholera, and  causing him to feel justified in recommending the provoca-
tion of premature labor, as  a means of diminishing the danger of the dis-
ease.  In examining  under  this  point of view the  results furnished by M.
Bouchut, a  result favorable to the opinion of M. Devilliers is at once dis-
coverable ; since of the 27 patients  who did not miscarry, 21 died, Avhilst 9
deaths  only occurred  after  25 abortions.   Still, it should be observed, that
of the Avomen Avho recoA^ered after aborting, 4 only had the disease in a rapid
and dangerous form; Avhilst of the 21 Avho died undelh'ered, the disease Avas
very severe, and barely lasted a few  days.   This early fatal termination was,
very probably, the only cause which prevented abortion.
   The vieAV of M. Devilliers cannot, therefore, be received Avithout neAV con-
firmatory observations.
   In short, though pregnancy does not affect sensibly the progress and dan-
ger of cholera, the latter leads, in the great majority^ of cases, to the death
or premature expulsion of the foetus.

   §  2. Endemic Diseases.
   Intermittent Fever. — There can be no  doubt that, as M. Ebrard  has en-
deavored to  prove, the grave disorders and deep  perturbations produced
throughout  the  economy by the febrile paroxysms, the obstinate vomitings
which attended  many of them, and the  cough, diarrhoea, and colics,  may
disturb greatly the functions of the Avomb; also that the fluxion and  con-
gestion so often produced by this fever, may cause the premature expulsion
of the product of conception.
  The possibility of the occurrence being incontestable, the indication to
remove the morbid condition folloAvs as a  matter of course.   I mention this
influence of intermittent fever upon the pregnant condition only as affording
an opportunity of discarding completely the  advice of some persons who
recommend the rejection of  sulphate of quinine, as  likely to  produce abor-
tion or premature labor.  The miscarriages laid to the charge of the sul-
phate of quinine should certainly be attributed to the disease itself, and not
to the remedy.   For my OAvn part, I have  had occasion to use it six times
at various periods of  pregnancy, in  doses  of ten, tAvelve, and even fifteen
grains in the  tAventy-four hours, Avithout having had to repent of it.  Many
practitioners, who, like MM.  Thezet, Delmaz, Alamo, and Ebrard,  have
long  practised in localities  Avhere this fever  is endemic, have  never  been
obligod  to complain of the action of sulphate of quinine Avhen administered 
446
PATHOLOGY  OF PREGNANCY
during pregnancy.  Not only is it an innocent remedy, but the surest  pre-
ventive means Avhen abortion is  imminent in consequence of the fever.
  [Some facts go to prove that  pregnant Avomen attacked with  intermittent fever
may communicate the disease to the foetus.  Dr. Stokes, of Dublin, states, that he
saw a case of tertian ague during pregnancy in which the foetus was affected  with
convulsive movements remarkable for their correspondence with the apyretic  days
of the mother.                                              ♦
  M. Pitre-Aubanais relates two cases of intermittent  fever  communicated to the
foetus by the mother.  Both of these children were born with hypertrophied spleens,
and their attacks of fever coincided  both as to day and hour with those of the mother.
(Bourgeois de Turcoing.)
  M. Jacquemier also says, that it  would seem that intermittent fever may attack
both mother and foetus at the same time, and  the facts upon which he bases his
assertion, though  few, appear conclusive.   Schurig relates that a woman had a
rebellious  quartan ague in the second month of her third pregnancy,  and that in
the last month either before or after the paroxysms  she felt the child to be excited,
shiver, and roll perceptibly from  one side  to  the other.  At last, after a seA'ere
paroxysm, she was delivered of  a  girl which had a violent  attack of fever at the
same  hour with the mother, and Avhich  continued  to  return during seven weeks.
Similar cases were observed by Hoffman  and Russell.  (Jacquemier, TraiU d'Ob-
stetrique.)]

   § 3. Eruptive Fevers.
   1.  Variola. — The eruptive fevers seem, generally, to be much  more dan-
gerous to  pregnant women than to other individuals.  Variola,  especially,
of all these diseases, has the  most  disastrous influence  upon  the pregnant
oondition ; some authors, indeed, state that it is  almost uniformly fatal,  par-
ticularly when it produces abortion.
   It is important, as regards the prognosis, to  distinguish  betAveen the  con-
fluent and discrete forms of  small-pox.   (Chaigneau.)  The former, Avhich
is so fatal, independent of pregnancy, as to destroy a third of Avhom it at-
tacks, is still more to be dreaded during gestation,  sparing, as it does, almost
none of its victims;  the latter, on the contrary,  is far from always occasion-
ing abortion or  premature labor, and even where the  pregnancy is ended
before term, the mother often recovers.
   Dr. Gariel thinks that the  lumbar pains, which are so severe in the first
stage of variola,  have  a great tendency to produce  abortion.  I have seen in
two cases of the discrete form, slight contractions coinciding Avith  these lum-
bar pains; but I Avas able to arrest  them by the use of opiate injections.  In
several  other  instances, I Avitnessed  nothing of the  kind,  and I  think  with
M. Chaigneau (Thesis, 1847), that  abortion is specially liable to occur when
the pustules  are in full suppuration, and  the  secondary fever appears, in
connection Avith the grave symptoms which usually accompany it.
   To recapitulate: confluent small-pox nearly ahvays occasions abortion, and
this is almost uniformly folloAved  by the  death of the  mother:  out of 23
abortions observed by M. Serres under  these circumstances, there Avere 22
deaths.   Discrete small-pox, on  the contrary, generally allows the pregnancy
to continue its course,  and even  Avhen it  interrupts its progress, the mother
usually recovers, and in the latter months  the child is expelled alive.
   AVhen the foetus is not expelled, it may continue to grow, and often it does 
            DISEASES  OCCURRING  DURING  PREGNANCY.         447

 not appear at birth to have suffered much from the disease which  had endan-
 gered its mother's life so greatly; in other cases, however, either because it
 receives  the germ of the disease which affects the mother, or because the
 deep-seated  disorders which  the variola  produces  in the maternal  system
 also exert an unfavorable influence upon the foetal life, it soon perishes.   In
 the former case, variolous pustules, in  every respect  similar to those on the
 mother, may be detected on the body of the child.

   [We have just stated that the unborn child of a mother affected with variola  may
 contract the same disease, a fact  attested by various  authors.   In this case, the
 mother communicates a contagious disease with Avhich she is herself suffering; but
 it would be wrong  to  suppose  that eA'ery pregnant  woman having variola  must
 necessarily transmit it to her child.  M. Serres knew of twenty-tAVO non-variolous
 children born of women who had the*disease during pregnancy.   Mead even holds
 that if the woman does no.t abort,  her child  is exempt from variola for the rest of
 its life, provided it be not born  before the maturity of the eruption.   The fact  is
 carious, but denied  by Contugno, whose opinion  may find support in the following
 facts :  Two pregnant women were inoculated ; the eruption was' discrete, and gesta-
 tion progressed.  At the usual period  they were delivered of healthy children,
 which, at three years of age, were inoculated and had the regular disease.
   On the other hand, it seems that the foetus only may have variola before birth,
 even though the mother may never have had  it.   Though the fact may appear ex-
 traordinary, it cannot be questioned in opposition to the testimony of such credible
 authors as Ebel, Kesler, Watron, Jenner, Deneux, Royer, Bouchut, and Chaigneau,
 all of Avhom have seen children born with variola, the  mothers being free from the
 disease.  In several of these cases,  the mothers having been vaccinated were insus-
 ceptible to the epidemic influence,  yet were  able to communicate the virus to the
 foetus.
   Congenital variola appears at all stages of pregnancy.  Before the third month
 it is rare; and generally it  is discrete, so that there may not be at the utmost more
 than a hundred pustules on the entire body, and often  many less.  It is observed
 that the pustules do not follow the  same  course of evolution as they do  in the open
 air,  but being always bathed in the amniotic fluid present the same phenomena as
 those which affect the mucous membranes. They are Avhitish and flattened, but larger
 than such as are found in  the  cavity of the  mouth.   A few become resolved, but
 others  ulcerate quickly wdien the slight pseudo-membranous  disk covering them
 falls off.  The wound suppurates little,  never furnishes  crusts on account of the
 moist state of the parts, and cicatrizes without  leaving any mark.  Occasionally,
 however, the characteristic  scar  is seen, but even then is very superficial.
  When mother and  foetus have variola at  the same  time, the  pustules  appear
 at the same time in both.   M. Chaigneau has, however, seen a few cases in which
 it was later in the children,  not occurring until long after it had disappeared from
 the mother.  The unborn child affected with variola is almost sure to die.   (Bour-
 geois de Tourcoing.]

   2. Scarlatina, when of some  severity,  acts in  nearly the  same Avay as
 variola; the danger, hoAvever, is usually far  less  both to mother  and child.
 It sometimes gives rise to abortion, and then the patients very often succumb.
 My opinion coincides with that  of  M. Serres, Avho  thinks  that Avomen  are
much more likely to" contract  the disease Avhen recently delivered than they
are during pregnancy, for I  have  never  seen scarlatina during  gestation,
though I have  had  the misfortu le to  lose tAvo neAvly-delivered females from
the disease. 
448                PATHOLOGY  OF  PREGNANCY.

  3. Measles, according to Levret, is quite as grave as the preceding.  In
four cases, hoAvever, observed by M. Grisolle, the regular course of gestation
was undisturbed, and tAvo similar instances have come under my own notice.

' [Unfortunately, however, this is not always the case, for  M. Bourgeois de Tour-
coing, from whose excellent memoir Ave have made several extracts whilst prepar-
ing  this chapter,  has himself met with fifteen cases of rubeola in pregnant women,
eight of whom either  aborted or were delivered prematurely.  In the remainder
the  pregnancy Avas not interfered with.  In the former the disease was most severe
in the most advanced cases, and the first symptoms of abortion or delivery appeared
toward the end of the disease.
  Very rarely have children  been  born  affected with  rubeola; Rosen and Yogel
relate some  cases ; Guersant met with one, and Bourgeois mentions  another, in
which the child lived but three days.
  §  4. Various Sporadic  Diseases.
  1. Typhoid Fever. — Typhoid fever may occur at any  stage of pregnancy.  It often
causes abortion, Avhich may take place in the first or second Aveek of the disease.
  According to Bourgeois, of twenty-two cases attacked early in pregnancy, six who
had the  disease  lightly did  not abort, Avhilst  out of sixteen  grave cases  tweh'e
aborted.  Of fifteen cases  of fever occurring  during and after the seventh month,
the  same observer notes nine cases of premature delivery.  Of these, five occurred
during the first week of the disease;  five of the children were still-born, one lived
two days, and one survived.
  The remaining women were delivered during the second week of the fever; two
of the children died during labor ; one lived two days and a half, and one only was
raised, being an eight-month's child.  The two surviA'ing children presented nothing
peculiar.]
  Though I have rarely had occasion to observe typhoid fever during preg-
nancy, I have frequently seen it  occur  during the  lying-in.   Its commence-
ment is usually  insidious, the first symptoms having ahvays been those of a
puerperal inflammation, and presenting  all the  characters of the typhoid
disease only after the lapse of the first feAV days, and the disappearance of the
abdominal  symptoms.   What is very singular, if I may judge by the cases
Avhich I  have observed, the typhoid fever, so far from being influenced  un-
favorably by the puerperal state, is even less grave than in  the  ordinary
conditions of life.  ]STot one case of 17, of typhoid  fever supervening a feAV
days after delivery, proved fatal.   The same remark is made by M. Fauvel,
who did not Avitness a single death in  the cases of the lying-in Avomen Avho
had the disease.   Although the cases  are too few to Avarrant a definite con-
clusion from them, they seemed  to me of sufficient interest to be recorded.
  2. Pneumonia is, without  doubt, of  all  the  acute  inflammations of  the
envelopes or of the parenchyma of the organs, one of the most likely to pro-
duce abortion or premature labor.  M. Grisolle has himself observed 4 cases
of pneumonia in pregnancy, and collected the details of 11 others.  Of these
15  Avomen,  10 had not reached  the sixth month, and 4 aborted  the fourth,
fifth, sixth, and  ninth days from the  commencement of the  attack.  In 3
cases, the abortion was folloAved by disease of the lungs of the severest char-
acter, all proving fatal three or four days after; only one, whose  pneumonia
was limited, recovered Avithout serious symptoms.   The 6 Avho did not mis-
carry, died without exception  during the  progress of the disease. 
           DISEASES  OCCURRING DURING PREGN VNCY.        449

   Of the 5 Avomen who had reached an advanced stage, 2 Avere seven m uiths
pregnant Avhen attacked Avith pneumonia; one Avas delivered prematurely on
the tAvelfth, and  the other on the fifteenth day, both dying  tAvo days after.
The 3 others Avere in their ninth month:  2 Avere delivered of living children
on the seventh and eighth day of the disease; the other died undelivered on
the fifth day.
   From  the preceding data it may be concluded, that abortion usually fol-
Ioavs an attack of pneumonia during pregnancy.  I think, says M. Grisolle,
that its disastrous influence is explained by the importance of the organ
affected, by the gravity of the  disease, the intensity of the general reaction,
and the numerous sympathetic disorders Avhich it produces in all the func-
tions, much rather than by the paroxysms of coughing.
   That  the pregnant condition exerts a most dangerous influence upon the
disease is shoAvn by the fact, that of  15 women 11  died, though the general
state of health was apparently very favorable in most of them.   The prog-
nosis seems to be  more discouraging before than after the  seventh month.
Finally, if it  be  allowable  to conclude from so limited a number of facts,
abortion, contrary to Avhat we have seen in regard to variola, Avould appear
to be rather favorable than otherwise, since of the 4 cases of miscarriage one
recovered, Avhilst  the 6  Avho did not  abort, all  died.   This Avould seem to
confirm the following proposition of Desormeaux, namely: Abortion, which
occurs but too often in acute diseases, frequently leads to a favorable termi-
nation in inflammatory affections.
   3. Various Inflammatory Diseases. — We have but very imperfect data by
which to judge of the reciprocal influence of pregnancy^ and of other acute
inflammations.  The  statements of authors in  regard to it are limited to a
feAV isolated  and often contradictocy facts, Avhose  very restricted number
alloAvs no useful conclusion to be draAvn from them.
   Whatever be the acute affection from Avhich  the pregnant female suffers,
the treatment does not differ  materially from  that Avhich is proper under
ordinary circumstances.  So long as there remains  a reasonable hope of
saving the mother by the  use of mild  and  innocent remedies, none other
should be resorted to; but  if the disease  be dangerous, and demands more
active but  more  efficient means, it should be treated as though the woman
were not pregnant.  Bleeding and  purgation Avhich  have been reproached
with a tendency to produce abortion, may doubtless have that effect; but it
must not be forgotten  that  they are used  here to combat an affection Avhich
is, of itself, a much more active cause of abortion, besides endangering the
mother's life so seriously.
   4. Icterus.—Though  icterus appears to affect the pregnant Condition  un-
favorably, it is not exactly true to say that it ahvays arrests its  progress and
produces abortion, either as  regards the severest or the lightest cases of the
affection.  I have  seen  several cases of simple jaundice Avhich constituted
but a slight indisposition, and in no degree affected the gestation.   The  con-
trary has,  hoAvever, been the case in some instances, and the two folloAving,
quoted by M. Ozanam, seem to me to be evidently exceptional:
  A young primiparous woman, five  months gone, had  been  sick for  five
days AA'ith a very simple jaundice, when she entered the hospital;  three  lays
      29 
450
PATHOLOGY  OF  PREGNANCY.
after, she miscarried.  Another, seven months  and  a half  pregnant, also
aborted five days after the commencement of a simple icterus.   Neither of
the children presented a yelloAv hue.  Both mothers recovered.
  The life of  the child  is greatly endangered by its premature  expulsion,
though it is rarely affected Avith the mother's disease.   In none of the casc-i
which have come  under my notice did  the foetus present an icteric hue,
although  the  amniotic fluid Avas  more or less colored.  J. P. Frank, hoAv-
ever, relates the case of an  icteric female who Avas delivered of a jaundiced
child.
  It  is rarely that what is described  as  the grave form of essential icterus
does  not  determine abortion, and it is also rare for the latter not to be fol-
lowed by  the death of the mother.   Thus, out of the five cases reported  by
Dr. Kerksig, in  the account of the epidemic Avhich occurred in 1794, there
were four  deaths.  M. Ozanam relates  the case  of  a Avoman six months
pregnant  who  died before miscarrying;  and my friend, Dr. Founder, has
quite recently  had a case of abortion folloAved by death.

  [Churchill quotes the following account by Dr. Saint-Vel of an epidemic of jaun-
dice  in the island of Martinique in 1858.
  "This icterus, Avhich presented  all the  characters of an essential disease, sur-
prised the medical men  by its epidemic character, and  its gravity in pregnant
women, and in them only.  It began at  Saint-Pierre about the middle of-April,
reached its  height in June and July, and having gone through  the colony, ended
with some isolated cases toward the close of the year.
  "Attacking the various races of which the  population consists, the white as well
as the negro and the Indian coolie, the European as well as the Creole, it seemed to
prefer adults, and was  unattended with affection of the liver.   AVhen pregnancy
did  not exist, its termination was almost invariably favorable.  The only victims
were Avomen, amongst whom were three young females not pregnant, and a woman
of sixty-three years of age. In these it was always of a grave character, always the
same, always mortal, and always accompanied by coma.
  " Of thirty pregnant women attacked at Saint-Pierre, only ten reached term with
no other  symptoms than those of essential  icterus.   The remaining twenty died
comatose after abortion or premature delivery.
  " In the gravest cases  in pregnant women the disease always  pursued the same
course.  It always had the essential form, and was often light, until the occurrence
of abortion or premature delivery,  Avhich never took place before the  jaundice ap-
peared.  They were generally brought about by the latter after it had existed for
two,  or, less frequently, three weeks.   Until coma appeared, the symptoms had no
apparent gravity, nor presented anything peculiar. The coma preceded  or followed
the abortion or labor by a feAV hours, in two cases only coming on three days after.
  " The women who died had reached the fourth, fifth, sixth, seventh,  and eighth
months of gestation.  The coma Avas, in  rare cases, preceded by a slight delirium,
it never for a moment disappeared, but greAV more and more profound  until death
occurred.  It lasted but  for a few hours, though in two cases it continued for twenty-
four and thirty-six hours. Until it came on there was nothing special to be observed
in regard to the general sensibility, respiration, or circulation.   The pulse was  not
quickened, nor had it that slowness which is sometimes observed in cases of jaun-
dice.  None of the other features of grave attacks of icterus, not even uterine hem-
orrhage, were observed.  With perhaps one exception, the women who died had no
hemorrhage after  delivery, and  when death occurred  three or four days Mibse-
qjuently, the lochia were of a normal character. 
            DISEASES  OCCURRING  DURING  PREGNANCY.       451

  "Almost all  the children were still-born, a few only living  for a  few hours,
whilst but one survived and is still living.   None of them were jaundiced, nor had
any of the ten other children born at term of jaundiced  mothers any sign of  the
disease."  (Saint-Vel, Gazette des Hopitaux, Nov.  20th, 1862.)
  On  the other hand, Dr. Bardinet  read in 1863 an account of a grave epidemic
of icterus which prevailed in Limoges from the  month of October, 1859, to March,
1860.   In 13 women observed by him the pregnancy followed its regular course in
five castas which Avere delivered safely at the ninth month.  In 5  others the disease
was followed either by abortion  or premature labor.  In the remaining 3 the icterus
assumed a grave form with ataxic symptoms followed by coma, and both mothers
and children soon  perished.
  Both multipara? and primiparae were  attacked by the disease, but all had passed
the fifth month of gestation.1
  Dr. Bardinet recapitulates as follows:
  1.  Icterus may appear as an epidemic amongst pregnant women.
  2.  It then assumes three different forms, viz.:
  a.  In the first it is  simple or benign  in character, and allows  the pregnancy to
progress favorably to term.
  b.  In the second it assumes the first degree of malignity,  forming what might be
called  abortive jaundice, and occasioning  either  abortion  or  premature delivery
without other unfavorable consequences.
  c.  In the third it assumes all the characters of the grave form of icterus, producing
ataxic symptoms and coma, which soon terminate the lives of both mother and child.
  II. Blot,  in the excellent report from which  I  have quoted the preceding facts,
relates a severe case of icterus observed by him  at the  Hospital of the Clinique.
The patient died, and at the autopsy ecchymoses were found beneath the skin, and
on the surface of the brain, of the heart, of the  lungs, and of  the intestinal canal.
The liver was small, and of a deep-brown color, without  yellowish  spots.  Micro-
scopic examination shoAved that the  tissue of the latter  organ was destitute of a
single trace of an hepatic  cell.   All  the preparations  showed  merely fat globules
in abundance mixed with  biliary matter.
  The cause of grave icterus during pregnancy remains unknown.   I am  disposed,
however, to believe with M. Blot that  it is due to changes in the liver, which I
described long ago as occurring in pregnant women.  (See  p. 157.)
  In regard to treatment, we are obliged to admit the inefficiency of all measures
employed up to the present time.  Premature labor or abortion would probably be
more injurious than useful.  As to prophylaxis, Ave should not hesitate rn case of
the occurrence of epidemic jaundice, to advise pregnant women to change theii
place of residence.]

  5. Syphilis.—Syphilis may have the most disastrous effect upon the course
of gestation, being a very frequent cause of abortion, and especially of pre-
mature labor.  Its  mode of  action is various:  sometimes, for example,  the
mother is in such a cachectic condition as to be unable to provide the foetus
with the material required for its development, her enfeebled constitution
leaving the Avork incomplete; most generally, hoAvever,  the health of  the
mother is  not sensibly  altered, and  the action of the poison seems to  be
directed upon the foetus  only.   In most cases, indeed, the  disease  does  not
disturb the natural course of gestation, but attacks gravely the health of  the
foetus.   Nothing is mo 'e common  than  for the latter to perish at more or
less advanced  periods,  and  be expelled prematurely'.  In these instances,
numerous Adsceral  lesions are discovered at  the autopsy:  sometimes it is an
           1 H. Blot,  Bulletin de VAcademie de Medecine, October, 1864. 
452
PATHOLOGY  OF  PREGN A-NCY.
abscess of the thymus gland (P. Dubois);  sometimes purulent collections ii;
the lungs (Depaul);  sometimes, again, is found that singular alteration sf
the liver so Avell described of late by M. Gubler, or those traces of peritoneal
inflammation and sero-purulent effusions pointed out by Dr. Simpson as due
;o the same cause.   Neither is it rare to find numerous bullae of pemphigus
upon various parts of the body of the child, especially upon the soles of the
feet  and the palms of the hands.   For further  details, see Diseases of the
Fatus.
   Cases such as Ave have just mentioned are, unfortunately, but too common;
it is  not, however, to be understood that  every child born of infected parents
must necessarily suffer all the consequences.   We even  insist that such is
not  the most frequent result, for considering  the large number of parents
who are diseased, or who have been, the syphilitic lesions of new-born chil-
dren would be much more frequent than is really the case.
   M. Legendre, in discussing the question of the latent condition of syphilis
in the parents,  and of its influence upon  the health of the child,  arrives at a
denial of this influence in the majority of cases.
   Of the 63  patients Avho. came under  my observation, he says, there were
14, Avho had  altogether 68 children, during the period intervening between
the  disappearance of the primary symptoms  and the development of  the
venereal eruption.   Of this number, 35 died without- ever having had an
eruption upon the body.   The mean of the ages of these children at death
was  7 years; the extremes being 6 months and 22 years.
   All the  33 surviving  children enjoyed good health, the  mean of their
ages being 17 years;  the extremes 1 year and 38  years.

   [Inasmuch  as it is said that syphilis may be transmitted by either parent, it is
far more probable that it  should be Avhen  both are  diseased.  We will  examine
successively the first two conditions.
  a. Transmission by the father. — The father only  being syphilitic, can he commu-
nicate  his disease to the  child?  The question is, at present, much  disputed, for
although  the affirmative is maintained by Trousseau, Diday, Depaul, and Bourgeois,
a directly opposite opinion  is arrived at by Cullerier, who bases his view upon the
observation of healthy children whose  fathers were syphilitic, but whose mothers
were not.  He believes that inherited syphilis is always derived from the mother,
the father having nothing to do Avith  it.  The same doctrine is taught in the memoirs
of Notta  and  Charrier, and our colleague M.  Follin (Traite de Pathologie Exteme)
has observed six cases favorable thereto.
   It is not easy, therefore, to decide the question.   For our own part, we think that
although the  transmission of syphilis from the father to the child can  hardly be
denied in some cases at least, it is certainly less common than has been supposed.
  b.  Transmission by the mother. — This cannot be doubted.  Two cases, however,
present themselves: the mother may be syphilitic from the period of conception,
or she may not haAre contracted  the disease until  after she became pregnant.  In
the first case there is no dispute as regards the fact of infection, but the unanimity
ceases in the second case, when the question arises at  what period of  gestation the
mother must be infected in order that it should be possible for her to transmit the
disease to the foetus.  Cullerier thinks that it may occur at any time during preg-
nancy, whilst Ricord would restrict the possibility to the end of the sixth month,
and Abernethy the seventh.
   The opinion which would attribute  to the use of mercury the  effect due to the 
            DISEASES  OCCURRING  DURING   PREGNANCY.       458

action of syphilis, is both false and dangerous.  The observations of M. Dunal have
BhoAvn that syphilitic women who had never been treated, or if so, in an imperfect
manner,  either aborted  or  were delivered  prematurely of still-born or infected
children which died: with  those, however, who had the constitutional disease and
were treated  by mercury, the success was complete  in many instances  in respect
both to mother and child.
  6. Saturnine intoxication.—Women exposed  to lead poisoning are very liable to
abort.  A former hospital  interne,  Dr. Constantine  Paul (Archives  Generates de
Metlcr.iue, May, 1860), made a study of the effects of this action  during  gestation.
He observed, in 1859, the case of a woman who had been three times  safely de-
livered before being exposed to the influence of lead, and who afterward,  out of
ten pregnancies, had eight miscarriages, one child still-born, and but one delivered
at term,  but which  died five months afterward.  Struck by the observation,  M.
Paul thought that this great mortality might  be due to the action of lead.  The
woman also informed him that  almost all her  companions in the establishment in
which she worked either miscarried or were  unable to raise their children.  Then
it was that he began his investigations.
  M. Paul  found 81 cases  of women in  whom saturnine intoxication occasioned
either the death of the foetus or the premature  death of  the child after birth ;  also
miscarriages  at from 3 to 6 months, and  premature labors in which  the children
were born either dead or in a dying condition.
  Out of a first series of observations, 4 Avomen afforded a total of 15 pregnancies, in
which there were 10 abortions,  2 premature labors, 1 still-born child, 1 which died
within twenty-four hours, and 1  only Avhich survived.
  A second set of cases comprises  the history  of women who had been  safely de-
livered before exposure  to the influence of lead, but whose children afterward suf-
fered from its effects.
  Another set shows the alteration of results according as the woman gave up or
resumed her occupation on several different occasions.
  A final series proves that the foetus may die  of lead poisoning, even though the
mother may have had no symptom of the  intoxication.
  To recapitulate.  Out of 123 pregnancies there were  64 abortions, 4 premature
labors, 5 still-born children, 20 Avhich  died within the first year, 8 in the second,
7 in the  third, and  1 death at a later period, 14 living children, of Avhom 10 only
were more than three years old.]

  7. Phthisis.—Most authors, in writing upon this disease, have given cur-
rency to the idea,  that its progress is  arrested by the occurrence of preg-
nancy, but that immediately after  delivery,  the pulmonary affection  ad-
vanced rapidly to a fatal  termination.
  In a Avork read lately before the Academy of Medicine, M. Grisolle  has
endeavored to determine the reciprocal  influence of these tAvo conditions,
and in  so doing has arrived  at someAvhat  different  conclusions from those
which had been received as a general expression  of the truth.  We think it
right to give a brief analysis of this memoir.
  Of seventeen cases collected by M. Grisolle, and ten others furnished him
by M. Louis,  tAventy-four Avere those of women attacked with  the disease
during pregnancy,  at periods not far removed from its commencement;  the
three others  had reference to individuals Avho presented the rational signs
of tuberculosis at the  time of conception, but in  Avhom the disease became
well-marked only at a later period.
  In none of these cases Avas the pulmonary affection arrested, nor did it 
454                PATHOLOGY  OF  PREGNANCY.
fail to progress quite rapidly.   The symptoms  peculiar  to  tuberculosis,
whether local or general, Avere  developed Avith the same  order, the same
regularity, and the same constancy as  in the  ordinary conditions of life.
But, on the other hand, contrary to Avhat might have been expected, the
pregnant  condition neither  aggravated, nor rendered  more frequent,  the
accidents of the disease; bronchial  hemorrhage was noticed as being even
rather less frequent £han usual.
  The entire duration of the phthisis in 13 Avomen Avho Avere followed to the
end Avas rather shortened than otherwise.   Thus,  in all of them it lasted on
an average nine-months and a half, Avhich is a figure more than a third  less
than that  Avhich expresses its duration for women of the same age, but  not
pregnant.
  Pregnancy has not, therefore, the poAver of suspending phthisis, Avhich  has
been supposed.  But is  it true, as is  generally believed, that labor, and the
puerperal  condition, give to the  process of tuberculization  such an unusual
impulse as to make it prove fatal in a very short time ?  The facts appealed
to by M. Grisolle invalidate this opinion also.   Thus, 12 Avomen, in Avhom
the disease had reached the second, and in most  of them the  third degree,
at the time of delivery, resisted-its inroads for  four months on an average;
and in all, the symptoms folloAved the progression that is usually observed.
In 10 others, in Avhom the affection Avas in the  first degree, or at the begin-
ning  of the second, at  the period  of delivery, the pulmonary lesion  Avas
found in 3 to advance  slowly;  in tAvo only did it exhibit  a notable aggra-
vation ; Avhilst in 5,  or one-half the number,  there was a  considerable
amelioration both of the general health and local symptoms, without, hoAV-
ever,  encouraging the hope of a  cure, or of a long suspension of the disease.
   Does phthisis exert an unfavorable influence upon the progress of gesta-
tion ?  In  this point of view, it may at  least be regarded as much  less
serious than pneumonia.  Thus, of 22 women, only 3 aborted  in the fourth
and sixth  months, 3 Avere delivered prematurely about the eighth month,
whilst all the others reached their full time; hoAvever, in nearly tAvo-thirds*
of the latter, the pulmonary disease commenced in  the early  months of
gestation, passed through all its phases, and produced a deep-seated cachexia.
   With one exception, delivery was  accomplished after four or five hours
of suffering, Avhich is explained rather by the relaxation and want of resist-
ance of the soft parts,  than  by the small size of the  children.   Although
the latter were generally feeble  and emaciated, yet in  more than a quarter
of the number the tissues were firm, the form  rounded, and of an embon-
point contrasting remarkably  Avith the reduced condition of the mother.
   In  all the patients, except those who Avere in the last stages of consump-
tion, and who died a feAV days  or weeks  after  delivery, milk was secreted,
and in the majority of cases  so abundantly, that it Avas impossible to  pre-
vent them from nursing the children.
   The Aoav of milk, however, lessened, or  even  ceased, Avithin a period vary-
ing from one to four weeks; and even this short-lived lactation Avas ahvays
accompanied  by a sensible aggravation  of the  disease, and had the most
disastrous effects upon the children; for they died shortly after of softening
of the intestinal mucous membrane. 
            DISEASES  OCCURRING  DURING  PREGNANCY.       455

   From a very interesting memoir upon the same subject, by M. Dubrueilh, ■
 of Bordeaux, it appears that the result of his observations has been nearly
 the same.
   In short, neither pregnancy nor delivery affect the progress of phthisis;
 nor does the latter disturb sensibly the course of the former.
   8. Hysteria;  Epilepsy;   Chlorosis.— Some physicians  have  imagined
 that the occurrence of pregnancy might exert a favorable influence upon
 hysteria or epilepsy, either by suspending the attacks during the continuance
 of gestation, or even  by ridding the patients of these affections  entirely.
 Unfortunately  these  hopes  have  not been  realized  by experience;  for
 although the convulsive attacks have  seemed in some cases to be less fre-
 quent, or have even  ceased entirely, in  others,  they have occurred much
 oftener than before.   M. Malgaigne mentions a  remarkable case in which
 the first epileptic attack came on during pregnancy in an unfortunate female
 Avho had never before  been affected with it, and Avho retained it.throughout
 her future life.
   Marriage, and the consequent pregnancy, have often been recommended
 as the best means of curing chlorosis.   When this disease appears to have
 been produced by disappointed love, the cause may, indeed, be thus removed,
 and the remedies directed against it rendered more efficacious.  Pregnancy
 may, in this Avay, regulate the uterine functions for the future, cure the dys-
 menorrhoea, and consequently have a favorable effect Avhen the irregular or
 difficult menstruation  Avas the cause of the chlorosis.  Under all other cir-
 cumstances, hoAvever, pregnancy has seemed to me to aggravate the chlorotic
 symptoms.  I, therefore, think it most prudent to defer marriage until after
 the general health of the patient is improved.

   § 5. Surgical Diseases.
   1. The pregnant condition often has a favorable effect upon scrofulous
 ulcers.  Under  the influence  Avhich  it exerts upon the  entire organism,
 glandular  engorgements sometimes disappear, diseases of the bones  are
 modified favorably, ulcers become clean and covered Avith bright, firm granu-
 lations, and cicatrization folloAvs.
   In many cases, it has appeared  to  arrest the consolidation  of fractures.
 A curious instance of  the kind is mentioned by Alanson.   A Avoman broke
 her tibia Avhen  in the second  month of her  pregnancy, and during the seven
 succeeding months, the solidification made no progress.   Nine Aveeks after
 delivery, the  callus Avas  strong  enough to  admit of walking.  As  proving
 that no constitutional depravation could be adduced  in explanation of the
 retarded cure,  he adds, that three months before impregnation, she had
 recovered rapidly from a fractured thigh.' My friend, Dr. Fournier, cites
 three analogous cases from  Dupuytren's Clinic.  In all three, there Avas no
consolidation before deliveiy,  though  it  took  place  rapidly afterward.
Though other similar instances are on record, it must be acknoAA'ledged that
there is  also a considerable  number in Avhich recovery did not seem to be
delayed by the pregnant condition.
  2.  Serious operations  haA'e seAreral times been performed during gestation
without producing abortion, "whilst in other cases they have had this resulL 
456               PATHOLOGY  OF  PREGNANCY.

From these opposite facts, I think it fair to conclude that none  but urgent
operations  should be performed, and that all others, such as fistula in ano,
for example, which do not endanger the life of either  mother or child,
should be deferred to another time.
  3. Tumors in the Abdomen and Pelvis.—Most authors think that tumo'rs
in the  abdomen and pelvis during pregnancy, have no other effect than to
impede mechanically  the development of the uterus, or to  present  an
obstacle to  the delivery.   (See Dystocia.)  Sometimes, however, they assert,
they may give  rise to abortion or premature  delivery, though, generally,
they are not otherwise  dangerous.
  That this complication  is of no danger, independent of the risk of  abor-
tion which  it may occasion, cannot be  admitted in an absolute sense.   Dr.
Ashwell  has remarked, in his excellent  work,  that  the  uterus, Avhen  de-
veloped until term, exerts a strong compressing force upon the pathological
tumor; that this compression may give rise to an  inflammation ending
sometimes in suppuration  at the centre  of the diseased mass, at others, in a
rapid increase  of the  tumor immediately after delivery.  I have several
times had  the  opportunity of verifying the  accuracy of  these statements.
Death  may occur in a short time, as the consequence of this inflammation
or rapid enlargement, and the autopsy has  several times exhibited the uterus
in a perfectly healthy state, together Avith the more or less extensive altera-
tion of the pathological tumor.  '
  Deeply impressed by the cases  of this  kind which  he had  occasion to
observe, Dr. AshAvell asks, Avhether the development of the uterus,  and the
pressure which  it exerts upon the neighboring tumor,  are not the causes of
the pathological changes of the latter, and consequently Avhether the induc-
tion of premature labor Avould not be the surest means of guarding against
the dangers to which the female is so often exposed in  these cases, even after
having overcome all the difficulties of labor.  When treating hereafter of
premature  labor, we shall have occasion to criticise the affirmative  decision
which he has come to; but Ave have thought it right to direct  attention to
a peculiarity but little  knoAvn in the history of the tumors Avhich complicate
pregnancy.
  4. Intra-parietal fibrous tumors, or those developed in the substance of the
walls of the uterus, may  exert an  injurious  influence upon the course of
gestation, and  become a  cause of abortion  Avhen  they are  of large size;
though, generally, they have no effect Avhatever when small.  In the latter
case, the physiological  evolution  of pregnancy may accelerate Avonderfully
the increase of  the pathological tumor.  The usually sIoav growth of these
intra-parietal tumors is Avell known ; now I have knoAvn them in several in-
stances to acquire a size in the first three or four months, Avhich they would
not have done in several years in the non-pregnant condition.   Developed
as they are in the midst  of the  uterine fibres, they participate in the in-
creased vitality with Avhich the latter are endoAved during gestation; and,
like them, they undergo a considerable hypertrophy.
  In some  cases I have seen this hypertrophy of the morbid tumor continue,
and even increase after delivery ; but in others, the latter event Avas followed
by a notable diminution of the size of the tumor, Avhich gradually grow hss 
            DISEASES  OCCURRING  DURING  PREGNANCY.       457

as the womb resumed its normal  condition, finally attaining the size which
it  had before conception.  In one case, observed in 1852, this process  of
absorption Avent on, and the tumor disappeared.

 ,[g 6. Hypertrophy of the Thyroid Gland.
   It is by no means rare for the thyroid gland to undergo hypertrophy during ges-
tation apart from any endemic influence.   The enlargement is generally slight and
gives no trouble, though some women complain that their necks become large and
unsightly.  The swelling diminishes somewhat after delivery, though it rarely dis-
appears entirely.
   I kneAV one case in which the hypertrophied  gland  inflamed and suppurated,
giving rise to an abscess which discharged for a long time; nor was the cure com-
plete until after the lapse of several months.
   Although this hypertrophy of the thyroid gland in pregnant women is not usually
dangerous,  it may in  some very rare cases imperil  the life of  the  patient.  Two
instances of this kind are related by M. N. Guillot.   The first was  that of  a lady
who was surprised  during her first  pregnancy to find that the front of her neck
was gradually  enlarging.   When  again  pregnant, the  swelling  increased and
became uncomfortable ; still, the delivery was favorable, and she nursed the child
for fourteen  months.   The  gland,  however,  continued to enlarge,  respiration
became painful, and finally the  symptoms Avere so  threatening  that tracheotomy
was performed.  The patient died.
   In the second case, the  hypertrophy also appeared during the first pregnancy
and increased during the succeeding one, so that nineteen months after the second
delivery it formed a  tumor of about eight inches in circumference.
   The breathing was obstructed, slow, and whistling, during both  expiration and
inspiration, and the voice was broken and painful.   Paroxysms  of suffocation came
on, during one of which the patient  died.  At the autopsy the trachea was found
to be flattened and the pneumogastric nerves compressed.
   I witnessed for myself a similar case at the hospital of the Clinique in 1861.   A
woman, who for a long time had a goitre, found  the tumor to increase rapidly in
size during her  first pregnancy.  At the sixth month, respiration had become very
difficult, and attacks of suffocation brought her to the hospital.  By  the end of  the
eighth month the symptoms were so severe that premature labor had to be induced,
but the patient died in an attack of suffocation a few hours after  delivery.   My
friend Dr. Tillaux, then prosector of the Faculty, dissected the tumor and found  the
trachea compressed by the enlarged gland.]

   § 7. Ulcerations of  the  Neck of the Uterus.

   It is rarely that  cancerous affections of the  neck of  the womb seem   to
disturb the  course of gestation, and the impediments Avhich  they but   too
often present during labor prove sufficiently that they are  rarely a cause of
miscarriage.  On the other hand, I  have never observed that the increase
or degeneration  of these tumors Avas  sensibly  hastened  during gestation.
Therefore, I shall treat no further here of this subject, reserving its discussion
for the article on tedious labor; but propose to speak  briefly of ulcerations
of the neck during pregnancv.
   It has been but a short time since surgeons  have used the speculum in the
cases of pregnant Avomen.   A just fear of the mischievous effect Avhich might
folloAV its repeated introduction prevented them from obtaining  a correct idea
of the condition of the neck at the various stages of pregnancy.  These fearc 
458
PATHOLOGY  OF  PREGNANCY.
were, however,  someAvhat  exaggerated, for, if introduced  carefully, the
speculum never causes  serious accidents.   In all cases, the instrument with
two or four valves is, in my opinion, the best.
  In  default of great experience, there is considerable difficulty, no matter
Avhat  instrument be  used, in engaging the cervix  in  the extremity of the
speculum, unless the situation of the  neck is first ascertained by the touch.
This difficulty is known to result from the fact of the direction of the cervix
toAvard the anterior surface of the sacrum.
  The engagement once effected, it is only necessary to separate the vah es
of the instrument slightly  in order to bring the os tincae into vieAv.
  As the touch should have led to anticipate, the changes Avhich the eye
detects in  the  intra-vaginal portion of the neck, are  very different in the
primiparous  female from Avhat they are in one "who has had cbiMren;  Ave
would also add, that the appearance is far from identical at the beginning
and termination of pregnancy.
  As seen  in the latter third of gestation, the  neck is generally of a deep
violet-red color; and,  if it be a  first pregnancy, is usually quite  smooth
throughout its extent; the external orifice is ordinarily  more or less rounded,
and  though  larger than in  the unimpregnated condition, it barely  permits
the sight to penetrate its cavity, even though the valves of the instrument be
separated considerably.   The circumference of the external orifice  and the
free portion of  the neck rarely exhibit signs of ulceration, though it  is  quite
common to observe  a  series of granulations of a  cherry-red color,  of sizes
varying from that of ^ a  large pea to that of a pin's  head.  These species of
vegetations  bleed  upon the  slightest touch with the cotton used for wiping
them.
  In  the female who has had several children, the neck.is usually much less
voluminous, and it is somewhat difficult to include it  entirely in the speculum.
The  lips  of the os tincae seem divided in several portions, a sort of segmenta-
tion caused by the ruptures Avhich occurred in the preceding labors, and Avhich
give to the orifice considerable irregularity.  In consequence of these numer-
ous solutions of continuity, the opening is much larger, and is dilated with
great facility, provided the valves be  separated, thus  allowing  the eye t<
explore the cavity with readiness.
  The Avails  of this cavity are very unequal, frequently presenting an  unin-
terrupted series of fungous projections, separated by depressions of variable
depth.  Some of these  projections  are  transparent, being formed probably
by hypertrophied follicles ; others resemble soft vegetations.  The latter  are
generally covered by  an  intact epithelium, so that they may be touched
without  being  made to bleed;  again, Avhat is  by no means  rare, they seem
destitute of this external covering, and bleed upon the slightest touch.
  It is more especially in the furroAvs Avhich separate these, that linear ulcera-
tions  of  variable depth are discoverable.  These ulcerations sometimes
extend over a considerable surface, and are then readily perceived, though
they are  usually concealed in the depth of  the anfractuosities, and, in  order
to see them, it is necessary, after a thorough cleansing, to unfold the  neck,
as it were, by expanding the speculum  considerably.
  According to MM. Gosselin, Danyau, and Costilhes, these linear ulcera- 
            DISEASES  OCCURRING DURING PREGNANCY.        459

 lions are much less frequent than I had supposed, and are met Avith in barely
 more than half the cases, whilst I had observed  them  in  seven-eighths.
 However, as I stated very plainly, I intended to be understood as speaking
 only of multiparse who had reached the latter months, whilst M. Gosselin
 includes in his statement all stages of pregnancy, and M. Danyau does not
 appear to have distinguished primiparae from multiparae.
   Must Ave admit that, as  M. Huguier supposes, Ave have been deceived ?
 According to-this gentleman, a muco-pus of variable consistence is frequently-
 deposited in and adheres closely to the  bottom of the furroAvs observed on
 the internal surface of the neck.  This matter bears a complete resemblance
 to the bottom of an  ulcer;  but efface the folds and Avipe  them well, and the
 supposed ulcerations disappear.....It is difficult for us to believe that Ave
 have been so decehed;  still, the assertion of M. Huguier merits serious
 attention, and shall receive it hereafter.
   Unless  my observations  have been for a long time subject to  a series of
 singular coincidences,  it is probable that Avhat we have just described is the
 normal condition, and should not be regarded as pathological, but simply
 as a consequence of  the progress of  gestation.  As the violet-red color, the
 swelling, the softening, and the almost fungous condition of the Avails of the
 neck, are peculiar to pregnancy, and in no Avise interfere Avith  its progress,
 so I  regard  the ulcerations  as  a ■ consequence of a physiological process,
 extreme in degree, and of no greater importance'than the other physiological
 changes.
   Especially am I convinced of their non-injurious character, and therefore
 regard all treatment employed against these ulcerations, even -when fungoid,
 as much more hurtful than useful.  I say, even fungoid; for, contrary to the
 opinion of M. Coffin, avIio attributes a great prognostic value to this character
 of the ulceration, I think that they are fungoid, not because they have a
 natural tendency to become  so, but because the tissue  Avhich  they affect
 always  presents  at a  certain period the color and consistence of fungous
 tissue.
   If, therefore, I am not deceived, and  if the peculiarities just described
 really form a part of the pregnant condition, and are merely an exaggeration
 of the changes Avhich the structure and vascularity of the Avails of the uterus
 undergo at this period, the condition  should disappear Avith the cause Avhich
 produced  it..  Like  the vomitings, varices, hemorrhoids, and other sympa-
 thetic disorders' of pregnancy, it should disappear Avith it.  Noav this is
 exactly Avhat happens, and it may be regarded as a principle, that no traces
 of it remain tAvo months after deliveiy.  The  non-specific  ulcerations some-
 times met Avith in recently delivered Avomen are of different appearance, and
 have  their origin, in my opinion, in the non-cicatrization of the ruptures
 which took place during labor.
  In short therefore, the fungous condition of the neck, and the ulcerations
 of greater or lesser depth Avhich complicate this state of the parts near the
 termination of pregnancy, seem to me to be the consequence of the active or
 passive congestion with which the organ is affected.   I think that, except in
a feAV rare instances  marked by specificity of character, or  strong tendency
to spread,— a tendency, by the Avay, Avhicli I have never observed,--all local
treatment should be refrained from. 
460                PATHOLOGY  OF  PREGNANCY.
   Is the case the same at a  less advanced period, and are the  ulcerat ions
 which  may  affect the neck in the early months of an equally innoxious
 character ?
   MM. Boys de  Loury,  Costilhes, Coffin, and  Bennett, Avho have directed
 their attention more particularly to the ulcerations occurring in the first half
 of gestation, have been so forcibly struck Avith  their tendency to produce
 abortion and puerperal diseases, that they class them Avith the most common
 causes of miscarriage.  Mr. Bennett goes so far as to call  them the keystone
 of all  diseases of  the pregnant female, and  the most frequent cause  of
 difficult labors,  obstinate vomiting, (see page 465,)  moles, abortion, and
 hemorrhage.
   Notwithstanding the smallness of their number, the observations Avhich I
 have been able to make  differ so completely from  the results  obtained  by
 these gentlemen, that I Avas tempted to accuse  them of some exaggeration.
 Hovever, after having heard MM. Huguier, Gosselin, Danyau, Cloquet, etc.,
 proclaim the innocence of these ulcerations, I have  no hesitation in saying
 that they have misconstrued the facts "observed by them.  Finally, we Avould
 add,  that  after  having read  their observations, there seemed  reason for
 inquiring Avhether, in many cases, syphilis may  not have been the principal
 cause of the accidents, and in others, Avhether the frequent introduction of
 the speculum and the numerous cauterizations which had been practised,
 may  not have played  the most important part  in the  production of the
 abortions.
   I  ought, perhaps, to except the peculiar species of ulceration described
 by my friend M.  Richet.   All the varieties of  ulceration, says  this learned
 surgeon, Avhich are observed in  non-pregnant  women, may occur during
 pregnancy; but it has seemed to me that they had a tendency in some cases
 to assume a fungous character, to excavate the  lips of the cervix, to bleed
 readily, and give  rise  to serious  accidents: abortion, for example.  In all
 my patients,  these ulcerations with well-defined  edges, and red and bleeding
 bottoms, Avere covered Avith reddish fungosities, Avhich projected betAveen the
 partly opened lips of the cervix.   Of six patients, four miscarried, and two
 left the hospital  apparently cured;  of  the  four Avho aborted, one only had
 been cauterized, the three others not having undergone any/ treatment.
   Whoever, like myself, has examined women  at the end of gestation, Avill
 find the ulcerations observed by M. Richet  in the early months, and Avhich
 he has had the kindness to shoAV me, to bear a close resemblance to those
 sometimes met  Avith in the latter stages.   I  see  no difference except in  the
 rather greater extent of the ulceration.   Their size leads me to suppose that
 their  origin dates back long before impregnation, and their sharp, well-
 defined edges excite a suspicion of their being specific in character (five of
 these six women had syphilis at the time, or had previously been affected with
 it).  Noav Ave may readily conceive that under  such  circumstances the soft-
ening, congestion,  and  fungous condition Avhich  pregnancy usually produces
at an  advanced period, may here take place prematurely, and give to  the
ulcerated tissues the livid  hue and fungous aspect described by M. Richet.
Thus, Ave may understand  Iioav such an  affection of the cervix, connected
most frequently Avith a general disorder, under Avhose influence it  has a con- 
DISEASES OF PREGNANCY.
461
?tant tendency to increase, may ultimately give rise to abortion.   It  also
seems to me important to distinguish  the  ulcerations Avhich existed before
pregnancy, and continued, and even increased after conception, from those
which Avere developed after the formation of the germ : the former, in  con-
sequence of the irritation Avhich they may suffer as a consequence of fatigue,
and especially of too frequent coition,  might readily excite the contractility
of the uterus and occasion miscarriage;  the latter, on the contrary, should,
it seems to me, rarely exert such an influence.
  I agree, therefore, Avith the opinion of M. Richet, that Avhen an ulceration
presents in the first half of gestation, possessing the characters  which he
describes,  and which, in my opinion, are an evidence of its chronicity, mis-
carriage should  be anticipated, and means be taken to prevent  it.   Noav,
aside from a  specific treatment in those cases Avhich indicate it, I may be
allowed to ask of those who would have these ulcerations treated as a matter
of necessity, Avhat are the best local means to be used ?   Which caustic is
preferable ?   Is not the solid nitrate of silver accused of producing abortion
by the partisans  of  the caustic of Filhos, of the acid  nitrate of mercury, or
of the actual  cautery; and has not each  of these latter  means  also been
reproached Avith  giving rise to miscarriage ?  The thesis of M. Coffin affords
some curious details on this subject, and evidently proves, that though cauter-
ization by any agent Avhatever may claim some doubtful successes, the latter
are generally compromised by the abortions which have folloAved it.  From
the statements of Bennett and Boys de Loury, the same inference  follows.
M. Coffin  himself, though attributing  such great importance to these ulcer-
ations, arrives at this discouraging therapeutic  conclusion, viz., thus far, nc
treatment  has succeeded, and the question remains open.  This, which Avao
true in 1851, is so still; for quite recently Ave heard  M. Chassaignac speak
emphatically of the inefficiency of all methods, and M. Richet declares
himself  undecided  as to  the best  course to pursue.
  The insufficiency of local treatment, and the mischievous effect which it
may have upon the progress of gestation, should, it seems to me,  in the
present  condition of science, lead us to dispense with it Avhenever  the ulcer-
ation has no marked tendency to invade a large extent of the cervix.
                         CHAPTER  II.

                      DISEASES  OF  PREGNANCY.

  Those Avho have studied the various affections of the Avomb are Avell aAvare
that its diseases excite numerous sympathetic disorders.   The commence-
ment of the physiological acts  which devolve upon  it, and their periodical
fulfilment, exert upon the functions of the alimentary canal, and upon those
of the nervous system, an influence which "has for a long time attracted the
attention of practitioners.  It were useless to mention all  the morbid  phe-
nomena Avhich so often precede, accompany, and folloAV the first menstruation.
These are more striking when the latter is postponed or difficult.   In some 
462                PATHOLOGY  OF  PREGNANCY.

individuals they appear at each menstrual period for a long time, thus seem-
ing to show an impossibility on the part of the organ to perform its functions,
without occasioning extensive disturbances of the  economy;  and it is only,
so to speak, Avhen the sensibility of the Avomb  has been blunted by habit,
that the return of the menses ceases to produce the general disorders which
accompanied it previously.
   If the diseases of the organ, and even the simple monthly congestion, are
capable of giving rise to such troubles, it is easy to foresee that pregnanev,
which changes simultaneously the form, size, and  even the structure of the
uterus, can hardly pass through its various periods Avithout deeply affecting
all the functions.
   The effects produced  by the pregnant condition vary greatly, as regards
both the degree and the nature of the symptoms; all of them  being influ-
enced by the constitution of the female.  Occasionally, it results in a salu-
tary change in the entire system, better health being then enjoyed than at
any other period.  In the majority of cases, hoAvever, tiresome, or  at least
very disagreeable symptoms are experienced, Avhich  are the expression of
the unpleasant influence exerted by the uterus upon important functions.
These troubles, which are so slight in some individuals as to amount merely
to discomforts, are, in other cases, so great as to injure their health, and even
to excite fears for their existence.
   These accidents may appear at almost any time; for though some persons
begin to suffer at the very outset, and are relieved by the third, fourth, or
fifth month, others are attacked only in the latter  half of gestation.
   The pregnant condition  operates differently at the different periods of
gestation, in the production of the accompanying discomforts or diseases;  this
fact, Avhich is important in  a therapeutical point  of view, was felt vaguely
to be so  by Burns,  but clearly expressed by  M.  Beau, Avho, I think,, has
throAvn much light upon the pathology of pregnancy.
   Most of the functional disturbances may occur  in the early,  as Avell as in
the latter months.   At first  they were regarded as the result of the numerous
sympathies existing betAveen the uterus and the digesth'e apparatus, and, at
a later period, the purely mechanical difficulties produced in the neighbor-
ing organs by the pressure  of the uterine tumor  Avere thought to assist in
their  production.  Noav, the pressure of the  Avomb is  of quite secondary
importance, if, indeed, it be of any Avhatever; for, according  to  M. Beau,
Ihe folloAving is Avhat usually occurs: The Avomb, as modified by pregnancy,
affects the digestive functions through sympathy, giving rise to the dyspeptic
symptoms described hereafter.  The disturbance of these results necessarily,
if prolonged, in deficient nutrition, Avhich, in  a woman Avho is obliged to
furnish the  material for the development of the  child, must soon occasion
a  greater or less  diminution of the blood corpuscles, and  a  considerable
increase of the serum; in short, to all  the anatomical  characteristics of
chlorosis or polyaemia.
   Noav, this impoverishment of the blood soon occasions neAV morbid symp-
toms in the pregnant Avoman, as Avell as in the young chlorotic female, and
so serves  to explain the reappearance of the disorders of digestion, verti-
goes, headaches, congestions of the face, palpitations, and difficult  respira- 
DISEASES OF  PREGNANCY.                  463
tion,  so  frequently observed  at  an advanced period  of pregnancy.  We
thus see that the functional disorders, which at the outset are purely sympa-
thetic, become afterward intimately connected Avith the  chlorosis Avhich they
themselves helped to produce.  (See Disorders of the Circulation.)  Though
Ave shall  have occasion to treat hereafter of this latter etiological peculiarity,
we cannot help calling attention, at present, to the importance of taking it
into consideration in the choice of remedial measures.   For, though it be
proper at the commencement to reduce the over-excitement of the uterus, and
the sympathetic irritation produced by  it in other organs, by soothing reme-
dies,  as  baths,  mild  laxatives,  antispasmodics,  and  sometimes even  by
moderate blood-letting, an entirely different course should be pursued toAvard
the end of gestation.   All  the restorative agents, as iron, animal  food, and
tonic wines, are here the surest means of opposing the plethora and removing
the disorders Avhich it occasions.  Still, it is right to observe, that beside the
chlorosis, Avhich plays the principal part in the production of the disorders
of the latter months,  the uterus  still retains its sympathetic influence, and
is subject at all  times to  congestions, Avhich  increase its irritability, and
cause it to react upon other organs; of all Avhich account should be taken
in the treatment.  The subject Avill claim attention hereafter.
   Finally, the connection Avhich Ave have endeavored to demonstrate as
existing  betAveen the sympathetic  troubles of the beginning of pregnancy
and the chlorosis of the latter months, cannot ahvays be readily discovered.
The sympathetic influence  of  the uterus upon the digestive functions is not
ahvays manifested by vomitings, nausea, and strange and depraved appetites.
All these symptoms may be Avanting, and  yet  the stomach fail to perform
its functions with  its normal regularity.  Nutrition  may  be disordered,
giving rise to a dyspepsia, Avhich  M. Beau proposes to distinguish as  latent;
a  dyspepsia which cannot fail  to occasion eventually a general deterioration
of the blood.  Exactly the same thing occurs in young girls Avhose menstrua-
tion is either difficult, irregular, or imperfect.   Confirmed chlorosis is ahvays
preceded in them by sympathetic disorders of digestion;  though sometimes
the deranged function  is  evinced  by very marked symptoms, at others it is
hardly a cause of discomfort.
   Desormeaux, in his excellent article on this subject, ranges all the diseases
of pregnancy under the following heads, viz.: lesions of digestion, of circu-
lation, of respiration, of the secretions and excretions, of locomotion, and
of the sensorial and intellectual functions.  And we propose partly to adopt
the same order in our description.


                           ARTICLE  I.
                        lesions of digestion.
   § 1.  Anorexia.
   The Avant of appetite, or the disgust for aliments, Avhich pregnant Avomen
are so  often affected Avith toAvards the end of  gestation, and  still more fre-
quently at  its commencement, may be referred to various causes, and con-
sequently will present different indications for  treatment.  When it seems
to  result merely from the sympathetic relations existing between the  uterus' 
464                 PATHOLOGY  OF  PREGNANCY.
and the organs of digestion, there is little or nothing to be done, for it Avould
be in vain to attempt removing the disgust Avhich some patients have to
certain articles of food.  In general, they dislike all  meats, and  this is an
indication, or rather an obligation, to permit  the use of vegetables in such
cases.  Again, if at an  advanced stage,  the anorexia  be accompanied  or
preceded by the phenomena of general plethora, venesection, proportioned to
the general condition of the female and the stage of pregnancy, may relieve
it.  Care, however, should be observed not to mistake the symptoms pro-
duced by anaemia  for the  indications  of plethora;  the  former being far
more  effectually treated by ferruginous preparations.   (See Disorders of the
Circulation.)
  In those cases Avhich exhibit evident signs of  an  overloaded condition of
the alimentary canal, some  purgative, such as rhubarb, or even the neutral
salts,  may be administered.  Indeed, certain authors  have recommended
an  emetic, Avhen  there  is any gastric distress; but  I  think practitioners
ought to be very reserved in the employment of this last measure, since the
shock of vomiting has often produced abortion.

  § 2.  Pica, or Malacia ;  Pyrosis.
  Pica, or malacia, frequently accompanies  the  affection just  described.
Pregnant  Avomen, like chlorotic girls, often have  irregular  and depraved
longings for the most absurd or disgusting  articles.  For instance, I have
knoAvn a young female to eat pepper-grains almost continually.   Another,
at the Clinique, scraped the walls to  appease  her cravings for chalk ; and
M.  Dubois often relates in his lectures the history of a young  pregnant
woman whose greatest pleasure consisted in eating small bits of well-charred
Avood.  Again, they have been observed eating greedily substances that are
still more disgusting.   Unfortunately, all our persuasions are useless Avith
such monomaniacs in the majority of instances,  and consequently Ave must,
as a general rule, grant them an indulgence, and avoid  too strong an oppo-
sition, unless the coveted articles Avould evidently be  injurious to their health.
  I have but little to say of the acidity of stomach, of the spasmodic pains
of that organ, and of the pyrosis and other symptoms of gastralgia, Avhich
are  also quite frequent during pregnancy.  The  treatment of the symptom
is here the same as under ordinary circumstances.  Thus, for sour eructations
and acidity of the primae viae, magnesia and the absorbents, bicarbonate of
soda, the water and pastilles of Vichy, may be administered.  Pyrosis and
cramps of the stomach are usually treated successfully by powdered columbo,
and most  of  the antispasmodics, in connection Avith small doses of opiates.
The latter may also be used after the endermic method.
  If,  hoAvever,  it  be  desired to attack the first cause  of these  gastralgic
symptoms, it is important to remember  that  this  is  different for the first
and second half of gestation, and that the measures employed should vary
accordingly.

  § 3.  Vomiting.
  The vomiting of pregnancy presents tAvo different forms.  In the  first it
occasions discomfort and fatigue, without endangering life.  In the second, 
DISEASES  OF  PREGNANCY.                 465
  it is sometimes so severe as to prove  fatal.   The first we shall term simple
  vomiting; the second, grave or irrepressible vomiting.
    1. Simple Vomiting. — This symptom is so common that most females are
  affected Avith it;  in fact, vomiting frequently commences in the very earliest
  stages:  whence many women, taught by their former pregnancies, recognize
  it as an almost certain sign of a neAV gestation.  At other times it does not
  appear  until toward the third or fourth month, though seldom later than
  that; but it is not at all uncommon to see it reappear near the end of preg-
  nancy in some who had been previously tormented in this way at its beginning.
  As  an ordinary rule, the vomiting only lasts six weeks or tAvo months ; some-
  times, however, it extends over four or five months, rarely persisting through-
  out the whole term.  Some females have the unenviable privilege of vomiting
  every time they are pregnant; others, more fortunate, pass through several
  gestations without feeling any digestive disorders  Avhatever.   It is a very
  remarkable fact,  if we  may  rely on the  testimony of numerous mothers,
  that the sex of the child is not wholly irrelevant to the production of this
  Bymptom;  and however ridiculous this may appear at first sight, I have
  heard it repeated by so many  Avomen that I cannot refrain from believing
  that it, like most  other popular prejudices, has some foundation.
    But what is the cause of such vomiting?  When it occurs near term, Ave
  may justly attribute it to the  pressure, to the mechanical constraint Avhich
  the uterus, whose fundus reaches  the  epigastric region, exercises upon the
  stomach; but in the early stages it is much more difficult to explain it unless
  Ave content ourselves  by referring it  to the numerous  sympathies  existing
  between the uterus and the stomach: sympathies  so intimate that they are
  manifested in certain Avomen at every menstrual period, and  even in nearly
  all those afflicted  Avith a disease of the Avomb.
    Although the intimate nature of these sympathies is very obscure, Ave can
  admit them more readily in the etiology of vomiting than the influence of
  most of the anatomical causes  adduced by some  authors.  In  endeavoring
  to trace a relation of causality between the vomiting and an inflammation
  of the uterus, placenta, and membranes, like Dance; softening of the stomach
, and fatty degeneration of the liver, like Chomel; or, finally, to the existence
  of organic lesions  of parts in the neighborhood of the uterus, observers have
  merely noticed simple coincidences, Avithout. throAving  the least light upon
  the  question of etiology.  Hoav often, indeed, is  nothing of the kind dis-
  coverable !
    I am persuaded, says Dr. Bennett, that those gastric disorders and obsti-
  nate vomitings, AA'hich so often bring Avomen to the portals of the tomb, are
  almost ahvays caused by inflammatory ulcerations of the neck of the womb.
  For my  oavii part, he adds, since my attention has been directed  to this
  subject,  I have almost invariably found ulceration of the neck in cases of
  this kind.
   I  cannot receive this opinion of the English accoucheur, at least as relat-
  ing  to the majority of cases, for I have frequently examined with  the specu-
  lum each of four  primiparous  Avomen affected Avith incorrigible vomiting,
  and in whom I ascertained the cervix to be perfectly healthy.
   It has been said that  primiparous women are more subject to vomiting 
m
PATHOLOGY OF PREGNANCY.
  than others, on account of the uterus yielding less readily to distention  in
  first pregnancies.
    Although this opinion  is quite conformable to  the  theoretical vieAvs al-
  ready gh'en, the fact is, that it is liable to very frequent exceptions.   Some
  multiparse, who  suffered very  slight disorders of the stomach in their first
  pregnancies, have vomited almost  constantly in  later  ones.   The rigidity
  of the uterus is not, therefore,  the only cause which is capable of sustaining
  an irritability of the organ Avhich reacts sympathetically upon the stomach.
    I do not think that an epidemic influence can be admitted  as a cause of
  these vomitings.
    The vomiting varies much  as  regards  its frequency, intensity, and the
  greater or less ease with Avhich it is accomplished.
    Thus, some Avomen vomit only upon aAvaking or rising in the morning.
  They then  throAV up  some  viscid or glairy matters, which  are generally
  colored Avith a little bile, especially if the retchings have  been very severe.
  Others vomit only after eating;  occasionally after only one of the  daily
  meals, but  sometimes after all of them.  Again, in some unfortunate cases
  it continues even in the intervals of the repasts ; everything taken into the
  stomach, whether liquid or solid, being immediately rejected.  There are
  cases, finally, in which the mere thought of food, or the sight or smell of it,
* is sufficient to provoke it.
    The vomiting is sometimes easy, and causes little pain ; it is indeed not
  uncommon to find ladies suddenly interrupted at their meals, who can return
  in a feAV minutes, and sit down and eat Avith a good appetite and pleasure.
    In other cases, however, the ingestion of food is productive of pain in the
  stomach or inexpressible uneasiness of variable duration, and it is only after
  five or six hours of suffering, that the food is vomited and  then found  to be
  almost unchanged, notwithstanding its long  retention in the stomach.  In
  such cases the vomiting is  preceded by such prolonged and violent retchings
  as to reduce the patient to a state of extreme suffering  and agitation.
    It is occasionally folloAved  by considerable epigastric pain, which  is in-
  creased by  pressure, and might for a moment be taken as  a sign of inflam-
  mation of the  stomach ; it gradually diminishes,  however, and disappears
  entirely after a  time.   The shocks and violent efforts sometimes extend
  their influence to the hypogastrium, and give rise to abdominal pains and
  even uterine contractions,  Avhich may be active enough  to produce abortion.
    But it must not be supposed that vomiting, even Avhen prolonged and oft
  repeated, is necessarily disastrous.   No doubt many women waste away, but
  I haATe often satisfied  myself that the emaciation is not apt to be excessive,
  by examining females who, according to their OAvn expression, could retain
  nothing at  all;  and hence it is-exceedingly probable that all the food  taken
  by them is not rejected.
    Burns  states that he has never knoAvn vomiting depend  on pregnancy
  alone to have a fatal termination.  I might cite, says Desormeaux, examples
  of emesis  accompanied by cruel pains  and violent general spasms, yet the
  gestation has happily gone on to full term.  At this time, I  have myself
  under care a lady Avho has been vomiting throughout the Avhole period of
  gestation, and who has just been  delivered of a daughter weighing  seven
  pounds and three-quarters. 
DISEASES  OF  PREGNANCY.
467
  Finally, it  must not  be forgotten that in some cases Avhich even appear
serious, the vomiting may cease abruptly, either spontaneously, or because
the sympathetic irritation of the uterus has been translated to some other
organ, or again, as a consequence of a violent mental  emotion.   A remark-
able instance of the latter  has quite recently come under my notice.  A
young lady, tAvo months and a half advanced in  her pregnancy, had  been
tormented for three Aveeks Avith such  obstinate vomiting, that, according to
her own statement, the smallest mouthful of fluid excited it, and that she
was unable to retain anything whatever in her stomach.  All the remedies
employed against it had proved useless.  At this juncture, her husband fell
suddenly and  dangerously ill Avith symptoms of strangulation of the bowels,
and from this time her vomiting ceased, nor did she suffer the least disturb-
ance of her digestive functions aftenvards.
  I have been induced thus  to hold forth from the outset a favorable prog-
nosis, which indeed is true for the vast majority of cases,  in order to relieve
young practitioners from the anxiety Avhich some recently published articles
on the gravity of this affection are calculated to produce.
  2. Grave or  Irrepressible  Vomiting. — The  vomiting  is not,  generally,
serious, but only painful and fatiguing  to the mother;  it must,  hoAvever, be
acknoAvledged that in some  very  rare cases, it is so  violent and  constant as
to exhaust the strength  of the patient  in a feAV Aveeks, and after producing
extreme emaciation terminate in death.
  The display of symptoms  given by M. Chomel  in one of his clinical les-
sons, applies  to  these exceptional cases  only.   The disease, he says, is char-
acterized  by  frequent bilious vomiting, an acid, fetid breath,  and fever;
then the brain becomes involved, and Ave have delirium, coma, and death.
  The vieAVS of M. Dubois correspond closely Avith those of M. Chomel, and,
like him, he describes three  stages.
  [a. First Stage. — The irrepressible form  of vomiting rarely  begins suddenly, but
almost always follows insensibly the simple form.  The time at which it commences
is very variable.  Generally appearing during  the early months, it may not cjme
on until after the  middle of gestation.  In 43 cases collected in the excellent thesis
of M. Gueniot, hospital surgeon, and  former chief of the lying-in hospital, and from
which we shall borrow largely,  vomiting occurred 9 times during the first weeks of
pregnancy,  15 times  toAvard the end of the hist month,  9 times between  the first
and second months, 5 times between  the second and third months,  I time between
the third and fourth months, 2 times betAveen the fourth and fifth months, and 2
times betAveen the sixth and seventh months.  The first of the cases enumerated are
of the early and benignant form, and it is  impossible to distinguish accurately the
period of transition from the simple to the graver form.
  The irrepressible cases present in themselves nothing  very  characteristic.  The
vomiting, hoAvever, is very frequent,  and occasions the rejection of all or nearly all
the food and drink which the patient takes.   The smallest quantity of fluid is often
sufficient to excite it.
  The dejections  in these  cases  are  composed of mucous or glairy matter, bile or
food, according as the boAvel happens to be full or empty.  Generally they are very
acid, and sometimes streaked with blood.
  To these symptoms may  be added a disgust for or aversion to food, so grea't as to
he often insurmountable.
  Soon appear  the grave signs of insufficient nutrition:  emaciation,  debility, and 
468
PATHOLOGY  OF  PREGNANCY.
altered features.  Certain accessory phenomena may also complicate the situavf>n
such as the almost constant ptyalism indicated by Stoltz and Yigla, and confirmed
by an observation of my own.
  The first stage is devoid of fever, unless it be a little febrile action in the even-
ing and  slight perspiration during the night.   We invite attention to this fact,
inasmuch as fever is the dominant symptom in the second stage.
  b. Second Stage. — In this  period  the  symptoms  of the  first stage  grow more
severe ;  the  attacks of vomiting are more  frequent and violent; the  emaciation
increases; finally, fever sets in Avith a  pulse of from 100 to 140 per minute.  The
mouth becomes dry, the thirst is intense, the breath acid and fetid.   The acidity
and fetidity of the breath are  such, says M. Chomel, as to strike  one on entering
the room of the patient.   Still, should we  consult our personal  experience, we
should say the odor is uncommon,  inasmuch as we have never observed  it in the
many cases of irrepressible vomiting which we have seen.
  c.  Third Stage. — In this stage the symptoms undergo a change, the attacks of
vomiting ceasing or becoming less severe; but  it is  a deceitful  calm which the
experienced physician knows to be the  prelude to death. There will,  however, be
no risk of deception if we but observe that  the fever persists  with a pusle of from
120 to 140 pulsations per minute.   Attacks of syncope  and cerebral symptoms soon
come  on.  These are: intolerable  neuralgic  pains, disordered  sight and  hearing,
hallucinations, delirium, and, finally, coma, which ends shortly in death.
  D. Progress, Duration, and  Termination. — The paroxysms of the graver form of
vomiting often remit more or less completely ; the remissions being sometimes, as
it were, spontaneous, or in  consequence of almost insignificant circumstances.  Thus
an emotion,  travel, some  change in the mode of life, a new article  of food, and
numerous similar eventualities seem occasionally to produce a transient amelio-
ration, or even a momentary cessation of the symptoms.  The hope thus excited is,
unfortunately, but too soon destroyed  by a  more or less rapid recurrence of the
disease.  (Gueniot,  These de Concours.)
  At other times these remissions may  be attributed to the use of a remedy whose
action is exhausted, or the momentary cessation may  follow and be due to prema-
ture labor or abortion.  Then the A'omiting returns with increased severity.
  The progress of this terrible affection is usually slow, as the patients do not gen-
erally succumb until after the second or third month of the disease.
  e.  Etiology and Pathological Anatomy. — We know nothing  of the causes of irre-
pressible vomiting.   Some have attributed it to  albuminuria,  an opinion which
nothing goes to confirm, and which would hardly be  adopted were it remembered
that Aomiting is most frequent at the  beginning or middle of pregnancy, whilst
albuminuria is rarely observed except during the latter months.
  Of the silence of  pathological anatomy in regard to this disease, I  have lately
had an additional proof.
  A woman with irrepressible vomiting entered my ward, at La Pitie, where I was
temporarily on duty.  She was delivered spontaneously during the eighth month,
but, after a remission, the symptoms reappeared, and  she died a feAV days subse-
quently.   The autopsy, conducted with the  greatest care, discovered  no lesion in
any organ ; the genital organs, the  abdominal and thoracic  viscera, and the en-
cephalon, being perfectly healthy.]

  F.  Diagnosis. — In moderate cases  the diagnosis  is easy.   Here, the
absence  of acute symptoms, such as redness of the tongue  and pain  upon
pressure on the epigastrium, Avould settle the question, even Avere pregnancy
doubtful.  But if, in the cases  just  spoken of, the  nature of the epigastric
pain  be  misunderstood, the practitioner would  be more liable  to  error;
therefore he  should  be very careful  in his proceedings.   For example, I 
V
                      DISEASES  OF  PREGNANCY.                   469

have knoAvn  a case of vomiting, which  the autopsy proved to have been
dependent upon  tubercular peritonitis attributed to a pregnancy which did
not exist.  In the case of another female, Avho  had actually been pregnant
for tAvo months and a half, the examination after death discovered a serious
disease of  the stomach, amply sufficient  to account  for the vomiting.   In
the  latter  case, it  is  true, that an admixture of blood Avith  the matters
vomited, had, during life, excited suspicion of organic disease.   This very
case has, hoAvever, been quoted to me by some persons as one of incurable
vomiting occasioned by pregnancy.  Mistakes  of this kind ought not to be
made, and the same may be said in regard to epigastric and other hernias.

  [g. Prognosis. — The prognosis in the grave form of this affection is  serious.
In 118 cases collected by M. Gueniot, there were 72 recoveries and 46 deaths, repre-
sented as follows:
                                 Recoveries.
  Without abortion in very severe cases and after a very diversified treatment... 31
  Following spontaneous abortion, also in very severe cases............................ 20
  After abortion or induced labor in cases more or less desperate..................... 21
                                  Deaths.
  Without abortion................................................................................... 28
  After abortion or spontaneous premature labor..........................................  7
  After procured abortion.......................................................................... 11
  It  is but just to say, that in this table of mortality, M. Gueniot included all the
cases he Avas able to  collect, and that amongst them are some in which death was
evidently due to some other disease than the vomiting itself.
  Cases of irrepressible vomiting are serious from the outset, inasmuch as, notwith-
standing all the modes of treatment employed, abortion  included, it is impossible
to know whether they will be certainly arrested.
  The prognosis becomes still more unfavorable in the second stage of the disorder,
for when the patients are much  debilitated  and the fever constant, some will suc-
cumb without having either the fetid breath or cerebral disorders.  Of such cases,
two have come under my notice.
  In the last stage, death is almost inevitable,  and we ought not to be deceiA'ed by
the remission of vomiting Avhich then occurs.  It should also be borne in mind that
the cerebral symptoms which accompany this phase of the disease are various.  In
two  cases, I observed only a little hebetude  and slight strabismus without other
nervous disturbance: so that, before reaching the correct diagnosis,  typhoid fever,
or a  cerebral tumor might be suspected.]

  Generally speaking, even Avhen the A'omiting is not so  great as to com-
promise the life and health of the mother, it has but an indirect  influence
upon the life of the child, nor do I knoAV of a single Avell-attested case of
death of the foetus from inanition through defective nutrition of the mother.
  Still, Ave may understand Iioav the violent efforts of the mother may some-
times communicate such shocks to the uterus as to bring on premature con-
tractions and even abortion.  We can also comprehend how the same efforts
may produce vascular congestion of  the  Avomb, giving  rise to  rupture of
some of the utero-placental vessels and  detachment of the placenta; such
accidents are,  hoAveA'er, rare.   In grave cases, results of the kind are rather
to be desired than deprecated, for vomiting generally ceases upon the death
of the fit tus, and the mother escapes the threatened danger. 
470
PATHOLOGY OF  PREGNANCY.
  3. Treatment of the Vomiting of Pregnancy. — There are  but feAV medi-
cines that have not been proposed, at one time or another, for this affection
of pregnant Avomen ;  and at other times recourse has been had to surgical
procedures.  We will, therefore, examine successively the medical and sur-
gical treatment.
  A. Medical Treatment. — When the emesis is slight, and  only occurring
in the morning, we may recommend an aromatic  infusion of the lime-tree,
orange-floAver, common tea, &c, &c.  Where it comes on after a meal during
the day, it is advisable to change  the order of the repasts: for example, if
it  be generally  more  distressing after  supper,  the  patient  should  sup
sparingly  and eat more breakfast.  Cold  aliments  are sometimes retained
when others  are rejected.  Iced  drinks,  mineral Avaters, and  sAvalloAving
small pieces of ice, have arrested some cases of obstinate vomiting, which set
at defiance the whole series of antispasmodics.   The subnitrate of bismuth,
in doses of from four to eight  grains, before each meal, has appeared to me
of late to  be  of some service.  I have also directed two  or three spoonfuls
of kirsch  to be taken after meals, and 1 think Avith  some success.   Should
it persist,  notwithstanding these measures, a resort may be had to a remedy,
which has often succeeded perfectly in my hands, — I allude to the narcotics.
About an  hour before the meal, let her take one-third or one-half  a grain
of the  aqueous extract of opium made into a pill;  but Avhen she is consti-
pated, it will be necessary to administer some mild purgative to counteract
any  action the opium may have on the large intestine.
  Whenever the emesis is attended with  pain and  stricture at  the  epigas-
trium, leeches have been recommended over this part, though I have rarely
seen their application folloAved by any benefit.  I should prefer laudanum
lotions, or  the application of a cataplasm  Avell  tinctured with this fluid.
Sometimes I have successfully applied a small blister to the epigastrium,
and  subsequently sprinkled  the sixth or the third of a grain of the muriate
or acetate of morphia over it.
  M. Dezon  mentions three cases of obstinate vomiting, which yielded to
the continued application to the epigastrium of a towel Avet Avith cold Avater
and  reneAved  every five minutes.
  If the vomiting occasions pains in the loins or hypogastrium, in  a AA'ord,
if it threatens an abortion, or if the patient be plethoric,  and this condition
is manifested  by local or general phenomena, venesection in the arm should
be resorted to, as  this is one of the best measures  I am acquainted Avith,
especially during the last half of gestation.   Enemata containing laudanum
are also very7 useful for the prevention of abortion, as well as for alleviating
the vomiting, and calming the irritability of the uterus.   General  bathing
may be added to these measures with advantage.
  Dance reports tAvo cases, from Avhich he feels authorized to conclude that
these vomitings are often an evidence of a morbid  activity in the uterine
system, of an inflammation of the membranes ; and consequently he advises
direct antiphlogistic measures, especially in the neighborhood of the womb;
but  as  his opinion  is founded on tAvo cases only, Avhich, after  all, arc not
conclusive, it seems to me that it cannot be admitted as  a rule of practice.
Still, leeching the neck of the uterus yielded unlooked-for results in cases of
Oh.  Clay  and  M.  Clertan (of  Dijon)'. 
                    DISEASES  OF  PREGNANCY.                 471

  With regard to the regimen, doubtless a  mild liquid  diet, composed of
aliments that are easily digested, seems at first to possess  decided advan-
tages over all  others; but hoAv many exceptions! hoAv many Avomen reject
the mildest articles — even liquids, and yet  readily digest less suitable sub-
stances !  How often, indeed, have I  not seen Avomen eat  ham, liver, pie,
&c, avIio could not digest a piece of sole, or the Avhite meat of foAvl!  Of
course, we must respect these peculiarities of the stomach.
  Among the various measures recommended, but which I have rarely had
occasion to resort to, may be  mentioned  the  application of  cups to the pit
of the  stomach (Mauriceau) ; of a plaster of theriaca (Sydenham) ; a few
spoonfuls of sherry-wine, or even some brandy, ether, peppermint-Avater, the
potion of Riviere, and the Colombo root.
  In those  cases in Avhich there Avas some degree of regularity in the return
of the  pains, and febrile  action, Desormeaux gave tAvo or three  grains of
the dry extract of cinchona  with success.    Lastly,  Walter and Blundell
have highly extolled the use of hydrocyanic acid in the dose of one or two
drops, in some mucilaginous drink,  several times a day.   With  the same
idea, I have successfully7 given  kirsch after meals, either undiluted or on a
lump of  sugar.  The latter  plan has seemed  especially useful Avhen the
vomiting Avas preceded by uncomfortable sensations in the stomach or long-
continued nausea—a state of things  resembling sea-sickness.
  To overcome the acidity of the primae viae, M. Chomel recommends the
use of alkalies, as the Avater from the springs of Vichy and Bussang; also
dilute  solutions of potash and soda, magnesia Avith  milk, but  never milk
alone, and  an avoidance of acids.
  Alcoholic liquors, given to the  extent of intoxication, have met Avith real
success.  M. Bayer tells  me that he  has used them Avith great advantage,
and champagne Avine, recommended by M. Moreau in a case so obstinate as
to cause great frequency of pulse and delirium, put an end at once to the
symptoms.   M. Jacquemin, Avho  related the case to me, considered the pa-
tient as lost, and  had only called  the  professor in consultation, in  order to
obtain  his opinion in regard to the propriety of producing abortion.
  M. Brctonneau, being induced to try belladonna, in the idea that possibly
the vomiting might  be  occasioned by rigidity of the uterus, succeeded in
quieting  it, even in very  grave cases,  by rubbing  the abdomen Avith a
concentrated solution of that medicament.
  In one very serious case, in Avhich  the vomiting had resisted every effort,
even Bretonneau's measure, and in which the poor patient seemed  doomed
to a speedy death, I conceived the idea  of  applying the belladonna to the
neck of the uterus; this Avas done by means of the speculum.   A brush,
laden Avith the soft extract, Avas introduced, and  the neck, together Avith
the inferior segment of the uterus and  the Avails  of the vagina, Avere be-
smeared Avith it.   From  this moment, a  marked change for the better Avas
manifest, and after the same unctions had been repeated on four successive
days, I had the satisfaction of finding my patient cured.  It is my duty to
add, that in another case the  same means failed completely, though I think
the  failure  due  to the mode of application.   When, as in this case, a brush
is used, it is difficult to apply the ointment, and too little of it is sometime* 
472
PATHOLOGY  OF  PREGNANCY.
left behind.  I have, therefore, for a long time preferred covering a tampon
of charpie or cotton with the extract of belladonna, and, after placing it in
contact Avith the cervix by means of  a  speculum, leaving it there.   This
may be done morning  and evening.  The first symptoms of intoxication,
such as dilatation of the eyelids, a sense of heat in the throat and slight
hallucinations, need occasion no alarm, inasmuch as the effects  of the medi-
cament are not felt until then.   The patient ought, hoAvever, to be Avatched,
and the tampon removed  if the  symptoms become  more  serious.   This
method has been thrice successful in my hands.
  M. Stackler overcame the vomiting in tAvo cases by the  black oxide of
mercury, in the dose of one grain daily.   The prolonged use of the remedy
was unaccompanied by salivation.
  [Iodine in various forms has been recommended.   Eulenberg (of  Coblenz), fol-
lowing the example of Schmidt, has used the tincture  successfully, whilst Ricord
and Bacarisse derived equal  advantage  from  iodide of potassium  given to the
amount of from ten to fifteen grains daily.                 ,
  "Simpson," says M. Gueniot, "found  the  salts of cerium A'ery efficacious,  espe-
cially the oxalate, in 45 * grain doses three or four times a day.  I Avould add that
the latter salt failed entirely in a case related by M. Panyau, in which it was used
by him and M. Dubois, nothing short of a partial detachment of the ovum sufficing
to relieve the patient from the danger which menaced her."]
  The obstinate constipation which the patients suffer is very remarkable,
iind has not received the attention  it deserves.   The boAvels sometimes re-
main unmoved for eight, ten, or even fifteen days.  Strongly impressed with
this fact, and supposing that the  constipation might have some effect upon
the continuance of the vomiting,  I endeavored to overcome it;  but, fearing
the effect of emetics or drastic  purgatives upon a weakened and pregnant
female, my first efforts Avere too cautious to be successful.   Encouraged
since then by the experience of other practitioners, especially by M. Forgue,
of Etampes, I have had every reason to be  satisfied Avith a bolder course.
  The above-named physician addressed to the  Academy of Medicine a
memoir, in Avhich he  lauded the effect of emetics and purgath'es, but in-
sisted much upon Avhat he called a preparatory treatment,  consisting in the
administration to the patient for tAvo or three days, a ptisan of barley-Avater,
weakened Avith honey,  to each quart of which he adds a drachm and a  half
of sulphate of  potash; giving also, morning and evening, an enema of a
strong decoction of mercurialis annua.  When some stools have been  thus
obtained, he orders a bottle of Seidlitz Avater containing a grain and a half
of tartar emetic, after Avhich he  continues  the  purgative for several  days
longer.  M. Forgue claims to have treated  five  cases successfully by his
method.
  In endeavoring to try this plan, I  have  ahvays found  it impossible to
overcome the dislike of the patient to drinking enough of M. Forgue's ptisan
(about tAvo quarts in twenty-four hours).  I am, therefore, in  the habit of

  1 The translator ventures to suggest that the dose of oxalate  of cerium here  de-
scribed ("3 grammes")  may be an  oversight on the part of the author or printer,
it being his impression that it greatly exceeds the dose recommended by Dr. Simpson
It miglit stand "3 grains."
» 
DISEASES OF  PREGNANCY.
473
 giving the emeticvat once, when the saburral  condition of the tongue seems
 to indicate  it: which is not often the case.  Generally, I order at once ten
 grains of scammony Avith fifteen grains of jalap.  As the first dose is often
 rejected  by  vomiting, I order it to be followed immediately by another, and
 sometimes even by a third,  should the vomiting continue.
   The second or third dose is generally retained, and the purgative effect
 folloAved by a marked relief.
   In the case of a  patient tAvo months and a half advanced  in pregnancy,
 to whom I  was called in consultation by Dr. Briau, Professor Moreau dis-
 covered  by the touch that the uterus was not only completely retro verted,
 but wedged, as it were, in the depths of the pelvic cavity.  Suspecting that
 this displacement might have some effect to  maintain the vomiting, he cor-
 rected it by lifting the uterus above the superior strait and bringing it into
 correspondence with its axis.   Immediate relief folloAved, and the vomiting,
 Avhich had proved intractable to a host of remedies, ceased on the same day,
 nor did it again return.
   M. Moreau said, that he had seen several  similar cases.  I had indeed
 myself, before this, observed the same accident, but not having acted upon
 the  indication, our Honorable master conferred  a real  service  in making
 knoAvn the fortunate result  Avhich he had thus obtained.
   In future, therefore, the state of the  uterus should be ascertained in all
 cases of  incorrigible vomiting.  Experience  has,  hoAvever, taught me, that
 although displacement of the uterus  often coincides with gastric disorder,
 M. Moreau's good fortune is not ahvays  to be expected.  Three times since
 M. Briau's case have I observed the coincidence indicated by my colleague.
 In three patients suffering from obstinate vomiting, I found  the  uterus not
 retrovcrted, as in M. Moreau's case, but  so far anteA'erted that the anterior
 surface of the Avomb projected considerably at the upper part of the cavity,
 its upper border resting against the posterior face of the pubis.  The reduc-
 tion, though easily  accomplished, could not  be maintained, and the organ
 very soon resumed  its primitive position.  Several attempts at  reduction
 were equally unsuccessful.
   Why, then, Avas I less fortunate than M. Moreau ?  I am inclined to think
 it Avas because of the different stages of  pregnancy in our patients respec-
 tively. That of M. Moreau  had reached three months or  three months and
 a half; tAvo of mine Avere only tAvo months gone.   Noav, if at three months
 and  a  half the size of  the uterus is sufficient to keep it above the  superior
 strait after reduction, and that  it can  only, in some exceptional  instances,
 fall back into  the cavity, the case is very different at an earlier period. At
 two months, in fact, the uterus is so much smaller, and therefore so  much
 more movable, that it yields readily to every  cause of displacement brought
 to bear upon it, and, as though by the force of a bad habit, readily resumes
 its faulty position Avhen the  restoring effort is no longer made.
  We  ought, therefore, in  reference  to  M.  Moreau's plan, to have great
 regard to the duration of  the  pregnancy;  very efficient after  the third
 month, it will  generally be  useless at six weeks  or  tAvo  months.  Unfor-
tunately it happens  that  incorrigible vomiting is  more apt to occur at the
latter period. 
474
PATHOLOGY OF  PREGNANCY.
   All my efforts to remedy the difficulty by means devised for keeping tne
uterus in situ after reduction, have been fruitless.  I had made an elongated
compress, Avhich, Avhen placed above the pubis, depressed strongly the Avail
of the hypogastrium, and at first seemed to keep theAvomb in place.   Soon,
hoAvever, it  slipped  beneath the pad, fell back into the pelvic cavity, and
as the bandage thenceforth did more harm than good, I Avas obliged to give
it up.
   It Avas natural to think of Gariel's pessary, but I dared not keep so large
a body in the vagina of a pregnant Avoman, lest it should have the effect on
the uterus of a tampon which so often causes abortion or brings on prema-
ture labor.
   In short, M. Moreau's  success in the  cas.e related by M. Briau, is  an en-
couragement to make similar attempts, as, after all, they do no harm Avhen
prudently conducted; yet, they are not to be relied on Avhen the patient has
not advanced beyond the first tAvo months of pregnancy.
   I have thus enumerated all these remedies, because they may be succes-
sively  employed in this  affection.  In fact, the same medicine may act on
one female and have no  effect on another.  And  it must be confessed that
sometimes  all "will fail,  and we  can scarcely succeed in moderating the
patient's sufferings.  The change of medicine is, hoAvever, useful, either by
really  calming her distress  in a measure, or by sustaining her spirits, not
seeming  to abandon her, but holding out the idea that each neAV remedy
may  effect  some  amelioration.  In this way  she gradually approaches
toAvards term, or at least to a period of gestation when the symptoms often
disappear of themselves.
  B. Surgical Treatment.—But where the vomitings continue, notwithstand-
ing all the  rational measures resorted to, the Avoman absolutely throAving
up everything she takes, and the privation  from  food has reduced her to
such a state of emaciation as to endanger life, and  the symptoms Avhich Ave
have described as  belonging to the  second and third stages appear, some
accoucheurs have  advised  (if her term is still remote) the production of
premature  labor.  This  operation has already  been practised, in  similar
cases, by several English and German accoucheurs, Avith full success, both
for the mother and child.
  It seems to  me that it  cannot be improper to resort to this measure after
the seventh month of gestation, for it then appears to be fully justified both
by the dangers to Avhich the mother is exposed, and by the possibility of the
child living after its expulsion.
  But is  the case the same before the sixth month, Avhen the sudden termina-
tion  of pregnancy  must necessarily lead to the death of the foetus.  This is
one of the gravest questions Avhich  can come up  in practice.  Although
fully disposed to sacrifice the child whenever that  sacrifice will surely save
the life of the mother, as  in  cases of extreme narroAving of the  pelvis, I
make no hesitation in declaring myself against the production of abortion
under  the circumstances  in question.
  I shall proceed to justify  this proscription : —
  1. When a Avoman having a contracted pelvis presents herself to a physi-
cian, he  knows very well that if the pregnancy be alloAved to go on until 
DISEASES OF  PREGNANCY.                 475
  rerm, he will have to choose betAveen embryotomy and the Caesarean opera-
  tion ; also, that in some cases the latter operation will be the only resource.
  If, after mature consideration of the inevitable consequences of the one and
  the probable consequences of the other, he decides upon the mutilation of
  the child, it will doubtless appear to him reasonable  not to wait until the
  increased size of the foetus at term shall add to the difficulties and clangers
  of embryotomy; therefore, the production of abortion within the first four
  months of gestation will seem to be fully justifiable.
   But the conditions are different when  the life of  the mother is  compro-
  mised by vomiting, hoAvever severe it may be.
   In  the first  case, the  danger is  inevitable ; and, unless  abortion occurs
  spontaneously, the  Caesarean  operation is the  only  resource,  and Ave are
  aAvare of the  usual consequence of the latter.   But hoAvever intense the
  vomitings may be, and  liotAvithstanding the state of exhaustion to Avhich
  they reduce the female, still they are not  inevitably fatal.   Patients, Avhose
  condition justly excited  the greatest solicitude, have been  knoAvn  to resist
  until the latter months and  even until the  term of their  pregnancy, and
  then give birth to strong and healthy children.   Others, Avhom the vomiting
  had reduced  to a hopeless condition,  have been suddenly  restored to the
  most complete health.   A case of this kind has fallen  under my own notice,
  and the following Avas related to me (June, 1849) by M.  P. Dubois.
   A young German lady, two months and a half pregnant, had been troubled
  with the most obstinate  vomiting from the first tAvo Aveeks after conception.
  For the last six Aveeks especially she vomited almost Avithout intermission;
  the smallest spoonful of fluid  exciting violent contractions of the stomach.
 She Avas extremely emaciated  and feeble,  and her breath Avas disgustingly
 fetid ; in short, her symptoms Avere so serious that M. Dubois, who avus called
 in consultation, requested the  additional advice of M. Chomel.  Both
 these gentlemen came to a most unfavorable prognosis, and left the  patient,
 under the impression that she had but a feAV days to live.   Some cold appli-
 cations Avere the only remedies advised ; but the  attending physician, being
 alarmed at her extreme Aveakness, limited them to slight aspersions.   On
 the second day after the consultation the patient Avas  attacked with violent
 purging, and from that time the vomiting  ceased and never returned.   The
 poor sufferer Avas at once able to take and  retain some nourishment, Avhich,
 being  gradually increased in amount, soon restored  her strength.  Noaa',
 this Avoman, who had been so greatly reduced that tAvo eminent men regarded
 her fate  as sealed, is  in  the enjoyment of perfect health, and  has almost
 reached  the middle of her pregnancy Avith every prospect of a happy ter-
 mination.
   In two other cases, Avhich the professor related Avith commendable frank-
 ness, he had deemed it his duty to propose the induction of premature labor.
 The Avomen declined submitting  to the operation, and reached  the  end of
 their pregnancies in good health.
   2.  When abortion is produced in cases of extreme contraction  of the
pelvis, there is a certainty that, Avhen  once accomplished, all the dangeis
which threatened the termination of the pregnancy are at an end, and that
enly the  usual consequences of  miscarriages can folloAV from  the operation. 
476                 PATHOLOGY  OF  PREGNANCY.
Even supposing that the artificial  means  should add to the ordinary risks
of spontaneous  abortions, the object is nevertheless certainly attained in ter-
minating a pregnancy Avhose progress so greatly endangered the mother's life.
  The conditions  are very different in  cases of spontaneous  vomiting, for if
all the instances on record be referred to, it will be found that the operation
is far from removing the danger.   I  am  well aware that four or five  for-
tunate cases have been cited from the practice of English accoucheurs, but
we are not told how often it has been followed by death.
  Are the circumstances the same in  cases of obstinate vomiting ?  If un-
successful,  the  operation was  performed too late, say they, Avhen the pro-
longed defective nutrition of the mother  had exhausted  the vital poAvers;
and had the uterus been emptied sooner, the chances  of success  had cer-
tainly been greater.
  I believe this fully; but here it is that the most difficult  question arises.
When is the operation proper ?  If you  act  too soon, may it not be  said,
whilst instancing  the cases of spontaneous cessation of the  vomiting, as in
those which have been quoted, that you have destroyed the foetus Avithout
advantage ?  If you act too late, may you not be equally reproached, in
view of the failure of all knoAvn  operations, Avith an attempt Avhich  may
have hastened the fatal termination ?
  Where Avill the prudent practitioner place the limit of expectancy ?   If
it be remembered that the ancient accoucheurs  declared, as do Mauriceau
and Delamotte, that the  vomitings  may possibly produce abortion, yet are
not dangerous for the mother; also that  many moderns assert, Avith Burns
and Desormeaux, that they have never known  them to terminate fatally, •
there Avould certainly be.small temptation  to operate before all hope has
been dissipated by the gravity of the symptoms.   Our hopes, indeed!  But
does not nature sometimes mock at our expectations?  Did  not the patient
of MM. Dubois and Chomel seem doomed to certain death ?
  I knoAV it may  be ansAvered that it  must be left to the  tact and skill of
th.e practitioner to think deeply,  and choose conscientiously betAveen the
dangers of expectation and the chances of an operation ; that the difficulties
which I raise, present in a host of surgical  cases;  that there is barely an
amputation Avhich may not be authorized by affirming, dogmatically, that a
spontaneous cure  is impossible ;  that the exceptional preservation of a  limb
proves nothing against the propriety of amputation in a majority'of similar
cases.
  All this  is doubtless true; but let us not decide too quickly, for the  com-
parison is far from being strictly just.
  When the surgeon has to deal Avith a serious traumatic lesion, he regards
nothing but the interest of his  patient;  and after explaining to him the
grounds of his conclusion, may, in cases of difficulty, consult his  wishes, and
then leave  his  life at his OAvn disposal.  The accoucheur  has  the  serious
interest of  tAvo  beings  to care for; and  though the  instinct of self-preser-
vation may silence in the female the voice of  maternal feeling, it  is never-
theless his duty to protect  the foetus, with  Avhose welfare he is equally
intrusted.
  In a given traumatic lesion, all experience shows that spontaneous recovery 
DISEASES  OF  PREGNANCY.
477
 is a rare exception.  On the other hand, the experience of all  accoucheurs
 goes to prove  that the spontaneous cessation of vomiting is of almost uni-
 versal  occurrence.
   We  thus see that the  surgeon "and the accoucheur stand on a different
 footing, and that the difficulty which I have suggested is not  removed by
 the comparison which has been made between them Avith that object.

   [We  shall proceed no further Avith this discussion, but first of all  examine the
 tacts.   Experience  having shown that abortion and  spontaneous  labor were,  in
 cases of obstinate Aomiting, often followed by  recovery, it was naturally asked by
 physicians whether the process adopted by nature might not  properly be effected
 by art.   Some trials having been made  here and there, M. Denieux  succeeded  in
 collecting 32 of them, which he quotes in his thesis, giving as a result 21 recoveries
 and 11  deaths.   Of the 21 successful cases, 15 were  abortions, and  6 premature
 labors.   To, these we would  add a case of our  own, in which  the vomiting being
 severe,  and death imminent, it Avas decided, in  consultation with Drs. Millard and
 Charrier, that abortion should  be  produced.  The operation was successful.   It Avas
 a twin pregnancy of two months duration.
   Our conclusion is, that procured abortion, as well as  premature delivery, is a
 valuable resource in intractable vomiting.  It  is  nevertheless true that it has the
 great disadvantage of certainly sacrificing the  life of the child ; therefore, before
 undertaking the operation, the conviction derived from mature consideration  that
 no other course remains by which the  mother's life can be saved, should be sus-
 tained by the concurrence of several medical friends in  consultation.
   It is,  in fact, more difficult under these circumstances than in a case of extreme
 contraction of the pelvis to determine the propriety of producing abortion, and that,
 too, without having the same certainty of saving the patient.   We shall not revert
 to the comparison of such cases, already made on page 474.
   Another difficult question remains to be settled:  At what time ought  abortion
 to be effected?   In reply, we can do no better than quote the opinion  of P.  Dubois.
 " The production of abortion in the third stage of the disease is liable to the gravo
 objection of not saving the patients, but of hastening their end and compromising
 our art.   If done in the first stage, there would be the not less serious error of
 sacrificing a pregnancy which  might, perhaps, have progressed  happily to its term.
 Therefore, we conclude that the operation is applicable  to  the  period intermediate
 to those mentioned."  AVe Avould here  call to mind  that this second  period  is
 characterized: 1, by almost incessant vomiting, produced by all kinds of food, and
 sometimes, also,  by the least quantity of  pure water; 2, by debility so great as  to
 keep the  patient at rest,  and occasionally by syncope ; 3, continued fever; 4, in
 certain cases by a fetid and even putrid breath.  When to these symptoms is added
 the failure of all the medication which has been tried, it is right to advise abortion,
 leaving  Avith the family the responsibility of deciding upon it as a last resort.
  Different operative procedures may be employed, the comparative value of which
 will come under  discussion  hereafter.   (See Operations.)]

  § 4.  Constipation.  Diarrhcea.
  Constipation  is  a very common  affection in  pregnant  women, and it is
usually attributed to the pressure of the developed uterus on the upper part
of the rectum, by Avhich  not  only the calibre is diminished, but its action is
also  paralyzed.  Would it not be more reasonable to attribute it in many
cases to a commencing chlorosis ?  We knoAV, indeed, that constipation is sc
common in  the  latter disease that Hamilton regarded it as one of its causes. 
478
PATHOLOGY  OF  PREGNANCY.
Some authors attribute it  to  diminished secretion of bile.   When carried
too far it often produces anorexia, and disordered digestion, and becomes a
cause of agitation and loss of sleep.  Whatever be its cause, the strainings
necessary to expel the hardened faeces  that  have accumulated in the intes-
tine, may give rise to hemorrhage and abortion.
  The best measures  for preventing and remedying this state are nearly-
identical Avith those used at other periods of life.
  The same remarks apply to  the diarrhoea Avith Avhich Avomen are often
tormented.
  [Constipation, as just said,  is very common during pregnancy.  Diarrhoea some-
times occurs, and that more frequently than  seems to be generally suspected.
  The diarrhoea of pregnancy varies  in character, and is due to different causes.
Sometimes it alternates with  the constipation which  gives rise to it, and which is
relieved thereby.  At other times it coincides so nearly with conception as to be its
first symptom ; again, it may appear only during the last days of gestation, and
indicate the imminence of labor.   In none of these forms does it present any gravity,
and is amenable to the treatment usually employed in such cases.
  Exceptionally, however, severe diarrhoea may supervene during pregnancy, with-
out any assignable cause.  The passages are profuse and frequent, and accompanied
with tenesmus ; emaciation takes  place Avith exhaustion of strength, the mouth
becomes dry, and fever sets in.
  Some of these cases resist  all  kinds of treatment, and may lead to abortion or
premature labor.   This form,  to which the term intractable might well be applied,
may prove fatal to the mother either before or after delivery.   One case of the kind
has come under our own observation.]

                           ARTICLE II.
                       LESIONS  OF RESPIRATION.
  Cough and dyspnoea are  about the only affections claiming our examina-
tion under this title.
  The dyspnoea that supervenes towards the end of pregnancy is evidently
produced by the croAA'ding  of the lungs from the excessive uterine develop-
ment, and  the delivery alone can cure it; but sometimes it  is sooner mani-
fested in consequence  of a  pulmonary congestion, Avhich must be remedied
by general blood-letting, a light regimen, repose in a suitable position, and
loose clothing.
  The same may be said of such palpitations as are not due to organic dis-
ease Avhich existed before the pregnancy; but it must not be forgotten that,
though bleeding is  useful Avhen the dyspnoea or palpitations  are very severe,
by diminishing the  local  congestion for  the time, the latter is  much more
frequently due to  hydraemia than to a true plethora,  and that  the best
means for preventing its return is to follow the bleeding by  tonic remedies.
(See the folloAving article.)
  As to  the cough, it  is only dangerous as regards the pregnancy, by the
violent jars sometimes given, Avhich may produce an abortion.   Indeed, all
observers Avho have Avritten  on  influenza ha\re carefully noted the frequency
of this accident in Avomen who Avere affected with it.
  When th cough is the effect of pregnancy, it may sometimes be attributed 
DISEASES OF  PREGNANCY.
479
to local plethora, and then we should bleed.  But at other times it has a
spasmodic character resembling whooping-cough, Avith the exception of the
alteration of the  voice.  In  such cases, I have derived much advantage
from baths, repeated for several days in succession.
  When it is the symptom of a chronic malady, existing prior to gestation,
the treatment Avill vary Avith the  disease that produced  the cough.  What-
ever may be its origin, the accoucheur should  ahvays resort to such demul-
cents and pectorals as are calculated to diminish its intensity.


                         ARTICLE III.
                    lesions of  the  circulation.
  § 1.  Alterations  of the Blood.  Plethora and Hydremia.
  The  general circulation is more active in pregnant Avomen than in others
(see page h>7), and this increased activity manifests itself by a greater fre-
quency of pulse, Avhich is often harder  and fuller than in the non-gravid
state.  Though all this may be regarded as normal, it  sometimes  becomes
exaggerated and  gives rise to a slightly  morbid  condition.   Thus, some
Avomen experience, at the same time,  vertigo, dimness of vision, ringing of
the ears, sudden flushings of  the face, spontaneous heats over the body, but
more especially of the head.   If  bleeding be practised under these  circum-
stances, the blood Avill  sometimes  afford a large and consistent clot Avith but
little serum; though  much more frequently there is much serum, and a
small clot, covered with  a  distinct  Avhitish coat, resembling that observed
in inflammatory diseases.  (See page 160.)
  The  differences in the appearance of the blood draAvn by venesection ought
to have  excited the suspicion  that, notAvithstanding their identity, these
functional disturbances might be produced by different causes ; and although
some scattering therapeutic measures  induce the supposition  that the  idea
had suggested itself to some good  minds, it is also evident that it Avas almost
immediately stifled;  for the majority of authors, even the most recent, do
not hesitate to refer them to plethora, and making the treatment correspond
with the etiology, recommend blood-letting as  the best  means of overcom-
ing it.
  The  little advantage which  I  had derived  from this practice had, for
several years,  excited  doubts in  my mind as  to the  value of the  theory;
which  doubts  Avere  especially increased by reading the admirable  investi-
gations by M. Andral on the blood.  Therefore, in treating, in 1844, in the
second edition of this Avork, of the plethora of pregnant females, I Avrote as
folloAA's:  "After having read  the  curious statements just given (analysis of
the  blood by M Andral), the reader  will perhaps find them to disagree  with
the title of this paragraph, and possibly  also with the therapeutic measures
hereafter recommended; for hoAv,  indeed, can Ave reconcile this denomination
of plethora, applied to the totality of the phenomena observed in most gravid
females,  Avith  the evidences  of anaemia  furnished  by the analysis of the
blood?   Is it not probable that the profession has heretofore  been in error, in
attributing to  this cause Avhat in fact  is only due to an  impoverishment of 
480
PATHOLOGY  OF  PREGNANCY.
the blood?  Because, if to these results we add the beating of the carotids,
the caprices of the stomach, the digestive disorders, and the varied nervous
phenomena that occur during pregnancy, and Avhich closely resemble those
so often observed in chlorotic patients, are we not irresistibly brought to the
conclusion, that the chlorosis Avhich produces them in the one case also does
in the other? and, consequently, that the bleeding  generally recommended
is more likely to augment than to diminish such  disorders?  A sufficient
number of facts are still wanting to decide the question satisfactorily; but,
while presenting in this work the vieAVS most  generally received, we cannot
conceal the effects produced on our mind by the experiments of Andral and
Gavarret."
   From that time we have endeavored to test by facts the inferences which
we had draAvn from  the documents furnished by the  experiments of these
two learned professors; and Ave have to say, that the theory is confirmed by
practice.  Therefore we now assert boldly, Avhat Ave before expressed timidly
in a simple note: That hydrozmia is  the most frequent cause of those func-
tional  disorders of pregnant women which have hitherto been attribxded to
plethora.
   HoAvever strange this proposition  may at first  appear,  it seems to us to
be proved by  the results of the chemical analysis  of the blood, by  the
symptoms presented  by the patients, and by the  happy  effects  of a tonic
treatment.
   It is iioav Avell proved that the essential  character of  plethora is based
upon  a great increase in  the proportion of  the blood corpuscles, as their
diminution is  the distinctive fact in  anaemia.  And  it is  Avell knoAvn that
diminution  of  the corpuscles and  increased  proportion of Avater are  the
essential characteristics of anaemia and chlorosis.   Now we  have shoAvn
(pp. 157 and 159) whilst  describing the changes in the blood during preg-
nancy,  that  the  amount  of corpuscles diminishes,  Avhilst that  of Avater
increases.   In this respect, therefore,  pregnant Avomen may be strictly com-
pared Avith  those affected with chlorosis.  The increase of fibrin and dimi-
nution of albumen also observed during gestation (see pages 157 to 159), are
of more difficult explanation.
   The  deficient  nutrition of the mother, Avho is obliged, Avhatever  may
happen, to  supply the foetus Avith  the food  required for  its development,
may also  explain the excess of fibrin, and in addition, the decrease of the
corpuscles;  for the experiments of M. Andral have shoAvn that the blood
of dogs, subjected to certain degrees of abstinence, presented the characters
of chloro-ari!emia, and  coincided  Avith a marked  increase of  the fibrin.
Again, if Ave admit,  Avith some modern chemists, that the fibrin is formed
at the  expense of the albumen of the blood, may Ave not find  in the con-
siderable  diminution  of the latter the cause of the increase of the former?
   Finally, Ave Avould add that MM. Becquerel and  Rodier, the  only ob-
servers Avhose analyses give the proportion of iron in the blood of pregnant
Avomen, have  shoAvn  that  it is beloAV the physiological average.   Thus, in
1000  grammes of the calcined  blood of a healthy and non-pregnant woman,
the average proportion of iron is 0'541; in that of the pregnant female it is
0"449; and in well-marked chlorosis it is  0-366.  The proportion of  iron 
DISEASES OF  PREGNANCY.
481
 folloAvs, therefore, that of the corpuscles, and the expression of its amount
 during pregnancy Avill serve to indicate  the transition  from the healthy
 condition to confirmed chlorosis.
   From all that has been said, Ave think it may be concluded that the prin-
 cipal elements of the blood undergo alterations during pregnancy analogous
 to those of chlorosis.   These changes are doubtless in many cases purely
 physiological, as Ave have already stated (see page 159), but may so increase
 as to become pathological by the establishment of hydraemia and chloro-
 amemia.
   The  view Avhich Ave take will become still  clearer Avhen we shall  have
 proved the folloAving proposition.
   The Functioned. Disorders of Pregnancy hitherto attributed to Plethora are
 those of  Chlorosis.  Most of the authors Avho  have Avritten upon the func-
 tional disorders  of pregnancy have attributed them to plethora, on account
 of the peculiar  physiognomy which  they present.  Thus, because in  many
 pregnant females they  observed fulness and hardness of the pulse, a feeling
 of heaviness in- the head  Avith somnolence, vertigo, ringing in the  ears,
 flashes of heat, sudden flushings of the  face, &c, they regarded them un-
 hesitatingly as the expression of encephalic congestions, themselves  the con-
 sequence of general plethora.
   Noav it is really only necessary to read the list of symptoms belonging to
 chlorosis, in order to  be  convinced  that they are identical for  the two
 affections.
   This is easily explained, says M. Andral, by  observing  that if the mere
 passage of too great an amount of corpuscles through the vessels of the brain
 appears to account sufficiently for the cerebral disorders Avitnessed in ple-
 thora, it folloAvs  that too small an amount of corpuscles traversing the same
 vessels Avill  produce similar  disorders; so that too great or too small an
 amount of corpuscles  deranges  certain actions  of the  brain in the  same
 manner.  Therefore, the true cause of the symptoms is  not to be judged of
 by their external  characters, but only by the  changes in  the blood.  Now,
 the analysis of the blood of a large number of females, Avho complained of
 these supposed plethoric phenomena, has shoAvn a marked  diminution of
 corpuscles and an  increase of serum.
  Besides,  if Ave remember Avhat has already  been  said concerning the
 pathology of pregnancy, it will be found  that  there is hardly one of the
 functional disorders yet studied, which  is not  also observed in chlorotic
 women.  What is  more common than to find in  chloro-anaemic patients the
 want of appetite, disgust for  food, Avhimsical and depraved  tastes, cramps
 and  pains in  the stomach, nausea and vomiting, — in short, all those symp-
 toms of gastralgia Avhich render many pregnancies so suffering?  Are not
 also the headaches, toothaches, faintings,  and the facial, frontal, orbital, or
 temporal neuralgias, common, so to speak, to the tAvo conditions?  As re-
gards the circulation,  do  Ave  not  observe the same  modifications in the
strength of the impulse, the rhythm, and the clearness of  the pulsations of
the heart, and is  not a belloAvs murmur also heard in the principal vascular
trunks?
  Some of these various disorders, such as the nervous phenomena, are  moie
     31 
482
PATHOLOGY OF  PREGNANCY
particularly observed in the first half of pregnancy; others, such  as  the
pretended symptoms of plethora, trouble more especially those females who
have reached a more adAranced period.   It must, hoAA'ever, be  confessed,
that sometimes all of them appear at the beginning, and sometimes at  the
end of gestation, which fact some persons  have thought to militate against
my theory.   Why, said M. Jacquemier, should the same symptoms, which
are regarded as disorders due to sympathy with the uterus, if they appear
during the first half of pregnancy, be considered as caused by chlorosis, if
they appear during the second half?  Is there not something arbitrary and
artificial in this,—something Avhich  seems to have been devised  expressly
for the support of  a theory?
   In  the first place, I Avould  observe that I have only spoken of the un
comfortable sensations Avhich women  experience in the  latter months; but
in supposing  the similarity of the symptoms, there is nothing irrational in
attributing to them a different origin.  I may be allowed to  recall what
takes place in the  case of a young girl becoming chlorotic: it will be seen
that the succession of phenomena is absolutely the same as what I have
supposed for the  chlorosis of pregnant  women.   A  healthy  young  girl
reaches the age of puberty, when, under the influence of causes which we
often cannot appreciate, the menstruation  fails to betome established, or
takes place only in  an  imperfect or irregular manner.   The uterus, being
disturbed  in the exercise of its monthly functions, soon reacts upon all the
other organs.   The  appetite diminishes, the stomach  becomes capricious,
the tastes whimsical, the digestion painful;  and from the persistence of this
difficult digestion results incomplete assimilation,  and soon deficient nutri-
tion.  After  the lapse of a few weeks or months, the defective nutrition
produces an alteration in the composition of the blood, which, Avhen carried
to a certain  degree, produces  all the symptoms of chlorosis,—symptoms
bearing a  strong  resemblance to those  Avhich  preceded and  caused the
general disease of Avhich they are the expression.
   No one, certainly, will deny the truth of the picture just drawn.  Now, is
not the same succession of phenomena witnessed  in pregnancy?   In both
cases, is it  not the irritation of the uterus produced by'the neAV functions,
Avhich first  reacts upon the other functions of the economy, disturbing their
regular fulfilment, Avhich afterAvard interferes with the assimilation of nutri-
tive matters, and Avhich finally produces  chlorosis?  Is not .the latter con-
dition indicated  in the pregnant woman, as in the young girl, by the same
symptoms?  Where then is the difference?   And if it  be alloAved  that the
primary functional disorders  of  the young girl  are purely sympathetic,
whilst  those which occur later are attributable  to  chlorosis, Avhy should Ave
refuse to acknowledge the same as occurring during pregnancy?
   After thus recalling the fact, that all the functional disorders of chlorosis
are sometimes observed  during pregnancy, it  truly becomes a matter of
astonishment that the resemblance  betAveen the two should not have been
noted earlier, and that it should have been left for recent analyses to excite
the suspicion that the same symptoms might be due to the same cause.
   The pathological anatomy and symptomatology being then in accordance
with each  other, it remains to be seen Avhether the  treatment will afford
another evidence of the nature of the disorder. 
DISEASES OF  PREGNANCY.                  483
  Plethora Avas formerly considered  so  common, and so exclusively the
cause of the diseases of pregnancy, that blood-letting had become a general
practice.  So  strongly impressed  were many Avomen Avith the  idea of the
necessity of bleeding, that they thought themselves under an obligation to
have recourse to it by the time they had reached the fifth month of gestation,
and even demanded it before consulting their physician.  Most practitioners
declined performing these so-called  preventive  bleedings, though all  re-
garded venesection  as the best means of overcoming plethora, that is to say,
the assemblage of phenomena attributed thereto.   If the latter proposition
Avere true, it Avould  constitute an unanswerable objection  to  the theory  Ave
are endeavoring to  establish.  Fortunately, however, such is not the case.
  I certainly do not Avish to deny the amelioration  produced by bleeding
in certain cases ; but it  proves nothing  against the poverty of  the blood,
and  the chloro-anaemia.  The lessened proportion of the corpuscles does
not necessarily involve a diminution of the  entire mass of the blood, as the
word amemia applied to this alteration Avould seem to indicate.   Generally,
on the contrary, the amount of this fluid remains the same, and  sometimes
even  is considerably increased;  thus corresponding with Avhat M.  Beau
states to be habitually the case in chlorosis.  A true plethora, Avhich might
be styled serous, then exists, in which case, especially to the usual signs of
anaemia, are superadded  headache, vertigo, ringing in the ears, etc.; and
under these circumstances, bleeding may afford relief by diminishing the
amount of blood.   The same result is obtained in ordinary chlorosis, Avhen
bleeding is  practised for the removal of local  congestions.   But, in preg-
nancy as in chlorosis, this alleviation is but temporary, and if the propor-
tion  of corpuscles  be not brought up to the  healthy standard by proper
hygienic and therapeutic measures, the same symptoms will soon reappear,
and Avith greater intensity.   The  abstraction of blood  is, therefore, in any
case, but a palliatory measure, only to be employed in extreme cases, Avhen the
general symptoms  are very  severe, but Avhich might have been  avoided
by administering tonics  and ferruginous  preparations at an earlier period.
  An animal  diet, and  preparations of iron, have, for  six  years  back,
always appeared to  me to be quite as  useful  against the functional disorders
of pregnancy  as  against  those of chlorosis.  Unless they be very serious,
I no  longer bleed  for palpitations, pains in the  lead, or suffocations, nor
have  I  knoAvn them, in  a single  instance, to resist the use of the prepara-
tions of iron longer  than a couple of Aveeks.  Even  when the gravity of the
accidents has  obliged me to bleed to the extent of six or eight ounces at
the utmost, I begin  immediately with the use of ircm, and it is very rarely
that  I am  obliged  as formerly to recur to venesection.   Hemorrhage from
the boAvels might, in some cases, remove the necessity for phlebotomy, Mid
M. Blot was  certainly  right in  advising gentle purgatives under  these
circumstances.
  There is still another  condition, in Avhich I have associated iron and
bleeding with advantage; with Avhat propriety we shall next see.
  The excess of impoverished blood in pregnancy may, as in chlorosis, give
rise to local congestion, Avhich congestion,  Avhen  carried beyond certain
limits, explains the  occurrence of  epistaxis, and the  less  frequent haemop- 
484
PATHOLOGY OF PREGNANCY.
tysis and haematemesis, all Avhich seem to be the result of an effort on the
part of  nature to diminish the  vascular fulness.    These accidents are
unusual during pregnancy, or, at least, rarely occur to an alarming  extent.
The reason seems to be, that from  the moment of conception until delivery,
all the vital powers appear to be  concentrated upon a single organ, VA'hich
forms a  centre of fluxion, towards which all the  troubles of the organism
converge; this organ is the uterus.  The congestion, which in the chlorotic
patient  occurs in the head or the chest, here takes place in the womb; and
the extraordinary development of the vessels of the uterus, and their more
or less intimate connection with those of the foetus, sufficiently explain the
danger of an  over-determination  of fluid.  At a very early  period, the
congestion may occasion the rupture of  one of the numerous capillary
vessels distributed upon  the  internal surface of the mucous  membrane
[parietal or epichorial decidua) ; rather  later, the congestion may be great
enough to rupture one of the utero-placental vessels, and in both cases give
rise to an effusion, Avhich, by destroying wholly or in part the utero-placental
relations, proves fatal to the child.
  These  uterine  congestions, which are properly considered, in some cases,
as the consequence of general plethora, I have  witnessed  much  oftener in
feeble and anaemic women.   They almost ahvays appear at the menstrual
periods, as though  the  monthly periodicity excited  at those times  a more
active vitality in the uterus.  The woman complains of tension, of swelling
of the abdomen, of a feeling of weight in the pelvis, the groins,  and upper
part of the  thighs; she also soon suffers pain in the region of the kidneys
and in the loins.  If the proper  measures are not employed, the vascular
congestion, and the pressure upon the uterine Avails resulting from  it, irri-
tate the organ; slight  contractions occur, sometimes  even a little blood
floAA's from the vulva, and announces a threatened abortion.  These symp-
toms are almost always accompanied with  marked vesical tenesmus.  Can
the latter be  due to pressure on the neck of the  bladder, produced by an
increase  in the size and Aveight of  the uterus caused by the congestion ?
  It is evident that Avhen  these  symptoms of uterine  congestion appear,
prudence dictates a  recourse to all the means  likely to effect a revulsion.
Thus, sinapisms to the upper and posterior part of the back, seven or eight
dry cups to the upper  part of the chest, and finally, if these measures are
insufficient,  bleeding, to the extent  of six or eight ounces, as a poAverful
revulsive, is very useful.  But, even here, the bleeding may have  only a
momentary effect by destroying the local plethora, and by no means  enables
us to dispense Avith medicines capable of modifying the state of the blood.
We shall return to this* subject under the head of Preventive Treatment of
Abortion.  It  is proper, hoAvever, that I should say in this place, that many
of my patients who had suffered  frequent miscarriages, have been enabled
to attain their full period by the use of iron administered from the begin-
ning of pregnancy.
  We see, therefore, and I call the  attention of practitioners to  this point,
that if the medicament  which cures a disease  sometimes also  proves it*
nature, then the disorders  Avhich Ave  have  described  are  oftenest  due to
chloro-anaemia. ani not  to plethora.  The latter proposition, confirmed as 
diseases of  pregnancy.
485
 it is by pathological  anatomy and symptomatology, I hold  to be  incon-
 testable.
   I say oftenest, for I Avould not have my assertion regarded as absolute.
 Though  true  plethora, that Avhich is distinguished from serous plethora bv
 an increase in the amount of the corpuscles, be rare, it nevertheless is some-
 times met Avith, especially at a very early stage of gestation.  Females of a
 really plethoric constitution, Avhose menstrual discharge is habitually abun-
 dant and  high-colored, may retain this constitutional  peculiarity during
 pregnancy,  and sometimes even have it increased.  The  sixty odd analyses
 Avhich Ave  have quoted, show that, in several  instances, the proportion of
 corpuscles  undenvent no diminution in the earlier months, and that in the
 case of one woman Avho had reached  the end of the  second month, M.
 Andral found them increased to one hundred and  forty-five.  It is even
 probable that, Avhen analyses shall be more numerous, the same peculiarity
 will be remarked in some cases of advanced pregnancy.  For my OAvn part,
 I have certainly met with females Avhose antecedents, symptomatic expres-
 sion, and the physical properties of whose  blood  afforded  every indication
 of plethora.
   The fact of our having observed but feAV instances of the latter class, is
 explained by our practising in the metropolis,  Avhere all debilitating influ-
 ences are collected.  The hygienic conditions in Avhich women live in the
 country, dispose them less to chlorosis, and  it is exceedingly probable that
 their blood is not so much altered during pregnancy as in the cases we have
 noticed.  To this, I think, is certainly due their exemption from the func-
 tional  disorders, nervous or othenvise, Avhich so commonly affect the females
 of large cities.  This is an additional argument in favor of my theorv.
   Though such Avomen are exposed to  the general consequences of plethora,
 they present more frequently the  signs  of  local or uterine  plethora, espe-
 cially  during the first,  half of pregnancy,  at  the periodic returns  of the
 menstrual periods.   The local  phenomena, as tension, swelling of the  abdo-
 men, feeling of weight in the pelvis,  are  very strongly marked in their
 cases.  The circulation of the.foetus also, sometimes, appears to share in
 the troubles of the maternal circulation, for these signs of congestion are
 frequently observed to be folloAved by the Aveakening, diminished frequency,
 and even complete cessation of its active motions; and if the motions have
 not yet been perceived, the plethoric  condition may greatly  retard their
 appearance.  HoAvever  difficult the explanation of these peculiarities may
 appear, they are too common  to be doubted.'  The best proof that can be
 given of the effect of this local congestion upon the motions of the  child,
 is their prompt reappearance after a venesection made at the proper  time;
 and it very frequently happens that a Avoman Avho is five months, or five
 months and a half, gone, Avithout having felt them, perceives them suddenly
 after bleeding.
   It is unnecessary to state  that here  blood-letting constitutes the proper
 treatment, and that the quantity/ abstracted may be regulated by the cir-
 cumstances  of  the individual  cases.  It is,  hoAvever, better to practise
several small bleedings at short intervals,  than to depend upon a  single
copious one.  The production of syncope should  be  studiously avoided. 
486
PATHOLOGY  OF PREGNANCY.
   We shall have occasion, Avhen  treating  of abortion, to finish the study
of the therapeutical indications.   (See Abortion.)
   To recapitulate,  the functional  disorders  of pregnancy,  as  cephalalgia,
giddiness, vertigo, ringing in the ears, dyspnoea, palpitations, tx"c, are rarely
due  to true plethora, but most  generally to  chloro-anaemia.   We  might
indeed  distinguish  for pregnant  Avoinen a very rare sanguineous plethora,
and a very common serous plethora.
   Independently of this marked diminution of globules  and albumen, the
blood is sometimes considerably altered byr admixture Avith the elements of
the urine.   This  alteration, Avhich  has been  described of late  by the Ger-
mans under the title of urozmia, and  of Avhich Ave shall soon have occasion
to speak, is a capital fact in the etiology of several diseases Avhich are liable
to appear  in the puerperal condition.   We  merely  state the  fact for the
present, leaving further notice of it until we come to treat of the lesions of
the urinary secretion.

   § 2.  Hemorrhage.
   [Hemorrhage from the genital organs  is, unfortunately, but too common  during
pregnancy, and is an accident  much  to be apprehended.  The hemorrhage may
assume very different features according to the cause Avhich  produces it and the
time of  its  appearance.  On this account it would be so difficult to treat of it in a
single chapter,  that its  history  must necessarily be divided into several articles,
which we think it best thus to indicate at  the outset.  Sometimes the effusion of
blood  is confined to the placenta, and has already been described as placental apo-
plexy with the other diseases of  the placenta (see Diseases of the  Ovum).   Uterine
hemorrhage occurring during the first  six months of gestation should, if it be some-
what profuse, excite fears of abortion, which it often gives rise to or accompanies.
Under these circumstances it is impossible to separate the study of the hemorrhage
from that of the abortion.   (See Abortion).
  Hemorrhage occurring during the three last months of gestation presents, on the
other  hand, the same symptoms,  and requires the same treatment  as though  it
occurred during labor.  One description, therefore, suffices for both, and  Avill be
given  in connection with the history of  other accidents which are liable to occur
during labor.  (See Dystocia, article Hemorrhage.)
  Again, rupture  of varicose veins of  the vulva and vagina gives rise to  effusion
of blood in these organs.   Such  an effusion is  knoAvn  as a thrombus.   As it rarely
occurs except during labor, we refer the account of it also to the article on Dystocia.
(See Dystocia, article Thrombus.)
  We shall merely refer in this place to a rather rare and curious form of uterine
hemorrhage.  Some women have a discharge of blood from the vulva a few days
after conception.  It is small in  armount and is sometimes intermittent and some-
times  continuous; it is rarely attended Avith clots, but resembles  a moderate men-
strual flow.  It  sometimes lasts for three or four  months without  interruption, yet
neither gives rise to serious symptoms nor  interferes with the  course of gestation;
finally it ceases without  assignable cause.  In our opinion, the discharge  has its
source in the neck of the uterus, which, in these  cases, has appeared to  us both
large  and  softened.   The  explanation would  at least seem  probable, when we
remember how readily blood exudes from the os tincae Avhen a pregnant woman is
examined by means of a speculum.   An ulceration of the cervix viould facilitate
the discharge of blood.  It requires  no treatment, the greatest dar ger being that
it might lead to the belief of the non-existence of pregnancy.] 
DISEASES OF  PREGNANCY.
487
   § 3.  Varices. .Hemorrhoids.
   A varicose condition of the veins in the  loAver extremities, the vagina,
 and inferior parts of the rectum, is quite a common occurrence toAvards the
 latter part of gestation, though, as regards treatment, the varicose veins in
 the limbs only require the usual precautions  to prevent their rupture.  For
 this, methodical compression is  the  best  remedy, and every attempt at a
 radical cure should be discountenanced.

   [Varicose veins of the limbs sometimes burst during pregnancy, and  the  result-
 ing hemorrhage is almost always  serious  in consequence of  the pressure of the
 uterus on the iliac veins.  Though some cases are said to  have  proved fatal, any
 hemorrhage of this kind  is  generally easily  arrested  by well-regulated  pressure
 applied to the seat of the injury.
   The veins of the vulva, ahvays dilated during pregnancy, sometimes become
 varicose, giving the sensation of well-defined cords.  No annoyance usually results,
 though  some women  complain of a  very uncomfortable  feeling  of weight  whilst
 standing.  Moderate pressure by means of a T bandage almost always affords relief.
   Rupture of one of these varieo.se  veins may give rise  to severe hemorrhage or
 even death, as in the following case Avhich  came under our notice at the hospital
 of the Clinique.  A pregnant woman, in other respects in good health, Avas affected
 with varicose veins of the vulva. One evening, whilst about retiring, she attempted,
 whilst sporting with  some of the other women in the dormitory, to leap from her
 bed.  Falling backward, she found  herself seated upon a chair, the edge of Avhich
 had struck against the vulva.  A hemorrhage so severe as to prove fatal in a short
 time, Avas the immediate result.  At the autopsy, the only lesion  that I could dis-
 cover was a contused wound  about, half an inch in length  upon the external surface
 of the left  internal labium.  Water injected into the primitive iliac vein escaped
 rapidly  from the little wound just mentioned.  Had the cause of the hemorrhage
 been discovered as soon as the accident occurred,  the effusion could have been cer-
 tainly stopped by  pressure directly applied.
   As the rupture of the veins of the vagina  and vulva occurs most frequentlv dur-
 ing  labor, we refer for further  particulars to the  subject of Thrombus.  (See Dys-
 tocia.)]

   Hemorrhoids, like varices, are an ordinary  consequence  of  the  uterine
 pressure on  the  hypogastric vessels; but they may  likeAvise be frequently
 produced by constipation, and the attendant  accumulation of hard  matters
 in  the  rectum.  The bleeding piles  are generally less disastrous ;  but the
 others  are  more grave and very painful.  In  fact, it often happens that
 Avomen  affected Avith them can neither stand nor Avalk, and they are even
 troubled Avhen seated.
   The first indication is to combat the costiveness, and then to  assuage the
 pain by tepid  bathing, cataplasms, and  emollient and narcotic lotions,  or
 the poplar ointment may be applied to the tumors; and Avhere they are in-
 ternal, a suppository of cocoa-butter might be introduced into the  rectum.
 Liniments  containing  opium and belladonna  -will  frequently^  relieve the
 patients;  but this  is  all  that Ave could prudently  do under  the  circum-
 stances.
   When the inflammation and turgescence are very  great, bleeding in the
arm is advisable, as this is much  preferable to the application of lerches  in
the immediate neighborhood  of the tumor; true, the latter calms the  pains 
488                PATHOLOGY  OF  PREGNANCY.
temporarily, but then, in certain females, they might bring on an abortion.
I have  never known, says Desormeaux, the application of leeches on the
tumors, or the incision of the latter, to procure any durable relief.
  Where  the irritation  from the piles seems to react on the Avomb, and
threatens a uterine hemorrhage, M. Gendrin  has derived signal  advantage.
from cold applications around the pelvis.   In those cases, says  he, if the
hemorrhage, is  imminent, we augment the  activity of the topical remedies
placed directly over the parts affected, by using cold baths to the breech at
the same time, the temperature of the Avater never having been loAver than
12° or 15° (Centigrade, equivalent to  54°  or 59° Fahr.).  I have several
times employed cold injections  successfully.  The plan  is to take every
evening a large cold enema, which after being discharged  is  folloAved by a
small one, which ought to be retained.
  We shall speak  more fully of the varicose condition of the vaginal veins
under the article Thrombus of the Vulva.


                          ARTICLE  IV.

             lesions of the secretions and  excretions.
  § 1. Ptyalism.
  Ptyalism, or a  hypersecretion  of saliva, sometimes occurs during preg-
nancy.  It generally lasts but a short time, rarely more than two months.
One case, however, is mentioned by M. Brachet,  in which the salivation
commenced in the second month, and lasted for a month after delivery;
and I have quite recently observed a  similar instance  in the  case  of the
wife of  one of my  professional brethren.   It frequently returns in several
successive pregnancies.   I have  seen  it continue between six  and seven
weeks in  the two'first pregnancies of  a lady Avho has  since  had another
child  Avithout a recurrence of  the affection ; and M. Danyau, Jr., mentions
a patient Avho Avas  profusely salivated for five months in  her first pregnancy,
and still longer and more profusely in tAvo  succeeding gestations.
  HoAvever considerable the salivation may be, it is rather a disagreeable
inconvenience than a serious complication.   Though it has in no case mate-
rially affected the  health, some Avomen have been so annoyed with the con-
tinual spitting, and the Aoav of saliva which sometimes deluges the pilloAv at
night, as to insist upon being relieved of it.  Happily, in a large proportion
of cases, the  ptyalism ceases  spontaneously, for no great confidence can be
reposed in the measures generally resorted to for its  removal.   Some ad-
Arantage, however,  may be derived from the use of aromatic  infusions and
slightly astringent gargles.   Like Desormeaux, I have .found it useful to
recommend the patients constantlv to  keep a little piece of sugar-candy in
the mouth.   Others, again, advise lumps of gum arabic, and pieces of ice.
It is useful to be  acquainted  Avith these various  measures, if only to keep
up  the patience of the sufferer, by varying them  from  time to  time until
the disorder ceases of its own accord.
  Some authors seem to have dreaded the  effect of the  sudden suppression
of a profuse salivation.   Two cases are mentioned, in one of which apoplexy, 
DISEASES OF  PREGNANCY.
489
and in the other symptoms of suffocation, appeared to result from it.   I do
not think that the relation of cause and effect has been satisfactorily sIioavu
in these cases, and am tempted to  believe that here, as in many other in-
stances, it has been erroneously concluded, post hoc, ergo propter hoc.

   § 2. Excretion of the  Urine.
   The renal secretion is  rarely increased  during pregnancy;  those Avriters
who have stated the contrary, having been deceived by the frequent incli-
nations to urinate which females experience at certain periods of pregnancy.
These repeated desires are due to a true vesical  tenesmus, produced by the
compression exerted upon the body and neck of the bladder by the uterine
tumor.  They occur every hour, sometimes oftener, and are relieved by the
discharge of a feAV drops  of urine.
   The pressure of the uterus upon the neck of the bladder is  sometimes so
great as to obstruct the  emission  of urine, and render it  painful  or  even
impossible.   This difficulty in urinating may  occur  in  the  commencement
of pregnancy, either Avhen the pelvis is too large, and permits the uterus to
remain a long time in the excavation, or on the occurrence of  a prolapsus
uteri, or those other displacements of this organ known  as  anteversion and
retroversion.
   Most frequently, however, it appears towards the end of gestation, either
because the uterus,  from  being  pushed down  by the presenting part of the
foetal head, early engages in the excavation, or because the Avomb is forcibly
carried fonvards; in the latter case the body of the bladder is  pressed up-
wards and in front by the uterus, and its neck forced against the  superior
 margin of the symphysis pubis.
   When the anteversion is Avell marked, the body of the bladder forms  an
 angle of the neck ;  in some cases it is even loAver, whence tbje introduction
 of a catheter is then exceedingly troublesome.  After all, the difficulty of
 urinating still persists  until  term, whatever Ave may do; for Ave can only
 alleviate it by tepid bathing,  the horizontal position, and more particularly
 by the  use of a bandage to sustain the abdomen.
   Where the retention  is complete, the bladder, by becoming distended,
 may increase so much in size as to reach the umbilicus, and its excessh'e
 distention might produce an inflammation or even a rupture, especially
 during the throes of labor;  but where the neck is not altogether obliterated
 by the pressure, an incontinence  of urine may ensue, the fluid  dribbling
 away drop by drop; though, unfortunately, that is not ahvays the case, and
 the catheter  must then be resorted to.
   I have already said this operation is attended  by difficulties under such
 circumstances, and when it  is quite impossible to  perform  it, the distress
 may be relieved, in a measure, by pressing  back the uterus from the sym-
 physis  pubis with the tAvo fingers introduced into the vagina, and the Avoman
 should be taught to aid  herself in this Avay.
   In some instances, the female  suffers at the latter stages a considerable
 smarting or  pain in urinating, as  sharp as if  there Avas a stone  in the blad-
 der ; these symptoms arise from a true catarrh of the  body, or at least of
 the Lock of  this organ;  the urine, in fact, often contains Avhitish flakes of
 purulent  matter.  Such symptoms require the general  antiphlogistic  treat- 
490
PATHOLOGY OF  PREGNANCY.
ment,  local bathing, emollients, and mucilaginous drinks.   As a  general
rule, women only suffer from an incontinence of urine during the last three
months, and then the delivery is the only remedy;  however, it shows itself
in the  earlyT stages of gestation in certain females, being evidently produced
by the pressure which the uterus, that is still within the pelvis, makes on
the neck of the bladder, and it lasts until the Avomb rises above the superior
strait.   If the incontinence remains after the fifth month, the symptoms may
be relieved by injections of warm water, and by the internal use of  tonics.
   Though the  amount of urine is not changed, its composition sometimea
undergoes alterations Avhich it is important to be acquainted Avith.
   I shall not  return to the consideration of the  peculiar pellicle called
kyesteine by M. Nauche, and Avhose diagnostic value we  have already deter-
mined  ; but I shall proceed to notice a very remarkable fact, Avhich we shall
often  have occasion to  refer to;  I  speak  of the presence  of albumen,
which  is  found in greater or less amount in the  urine of some women at an
advanced stage of pregnancy.  (See Albuminuria.)

   § 3.  Albuminuria.   Uraemia.
   The  credit of having called  the attention of physicians to the presence
of albumen in  the urine  of pregnant Avomen belongs  to M. Rayer, whose
admirable and  laborious investigations  of the disease of the  kidneys have
throAvn so much light  upon the pathology of those organs.   He was the
first to endeavor, in his splendid Avork, to determine the  effect of this altera-
tion of the urinary secretion upon the health of the mother, and the regular
development  of the foetus.   Aftenvard, folloAved  the observations of Dr.
Lever  and of Dr. Cahen, Avho, by the advice of his master, M. Bayer, pub-
lished  a  good thesis upon the subject.   Next came the  interesting memoir
of AIM. Devilliers and  Regnauld, and  another thesis  by M. Blot.   More
recently,  tAvo manuscript  memoirs by  MM. Imbert Goubeyre, and Bach,
and the  researches of Frerich, Schott,  and Wieger, have shed  some light
upon this still obscure point of puerperal pathology.
   It is knoAvn that albuminuria is generally the symptom of an organic dis-
ease of the kidneys, Avhich almost always proves  fatal; hence,  it may be
readily understood, that when this change in the urine  is observed during
pregnancy, it becomes at once  desirable to ascertain Avhether it be neces-
sarily due to the same cause, or Avhether it be merely one  of the numerous
modifications produced in the economy by gestation.
  In the first case, it  is a very serious affection, calculated to aAvaken  all
the solicitude of the physician ;  in the second, it is but a temporary func-
tional disorder,  Avhich Avill most probably disappear with the cause that pro-
duced it.  Unfortunately, in the present state of our knoAvledge, it is very
difficult to decide the question.   For,  on the one hand, 1.   The  normal
diminution of the albumen in the blood of pregnant Avomen, Avhich diminu-
tion is much  greater in  patients  affected  with albuminuria, since  MM.
Devilliers and  Regnauld have observed it to descend to 56'39, would lead
to the supposition that the cases  under consideration were but  exaggerations
of what ordinarily occurs, and that the elimination of a larger amount of
albumen  than usual from the blood, be the cause Avhat it may, accounts for 
DISEASES OF  PREGNANCY.
491
 its evacuation by the urine.  2. The albuminuria of pregnancy is net gener-
 ally accompanied by the functional disorders and the symptoms to Avhich it
 gives rise Avhen connected Avith disease  of the  kidneys;  and the dropsy7 it-
 self, Avhich is  almost constantly observed in the latter  case, is  sometimes
 Avanting  in  pregnant Avomen affected Avith  albuminuria, as Avas twice ob-
 served  by MM. Regnauld and Devilliers, as I have myself Avitnessed, and
 as M. Blot  found to be the case tAventy-three times  out of forty-one.  3.
 Lastly, in the majority of instances, it disappears immediately  upon the
 termination  of the pregnancy which caused it; and Avhen Ave consider the
 obstinacy of albuminous nephritis, it  is difficult to  account for this  sudden
 disappearance of a  disease, Avhich, under  other circumstances than the
 puerperal condition, so  frequently has  a fatal termination.   On the other
 hand, however, observation shoAvs  that in  almost  all the  cases in Avhich
 women die of the convulsions Avhich too frequently complicate albuminuria,
 the kidneys present the anatomical  characteristics of albuminous nephritis,
 the more or less advanced degrees of alteration appearing to correspond
 with the duration of the disease and  the amount of albumen discharged.
 Many times  have I  had occasion to  observe this  fact,  and fearing lest I
 should  interpret the alterations erroneously, have  almost uniformly  pre-
 sented  the kidneys  to the  examination of M. Rayer, avIio generally recog-
 nized in  them the second, sometimes the third,  and only once the  fourth
 degree of alteration.
   The learned physician of La Charite considers the more frequent occur-
 rence of the, anatomo-pathological  characters of the second  degree  of the
 disease  to be due solely to the recency of the latter, and  by no means to a
 difference of nature.  It is no less the consequence of a renal  hyperaemia,
 which he  supposes may  be caused in many cases  by compression  of the
 emulgent veins by the enlarged uterus, and the  consequent obstruction to
 the  return of the venous blood.   That, in  simple  cases, it generally dis-
 appears promptly after delivery, is probably due to the  consequent cessation
 of the congestion of the kidney Avhich Avas maintained  by the pregnancy.
   We see, therefore, that the question  is far from being settled ; Avhilst M.
 Blot, for example, regards puerperal albuminuria as generally unconnected
 Avith  Bright's disease, M.  Bach, of Strasbourg (Memoir, croAvned by the
 Academy), thinks that it is only sometimes due to albuminous nephritis, and
 M. Imbert Goubcyre (Memoir, croAvned by the Academy i  endeavors to
 prove that it  is always a sign of Bright's disease.  jSToav,  is it impossible to
 throw a little light upon this question,  which is still  so  obscure?
   Healthy urine contains no albumen,  and the same is  true for the healthy
 woman  in the puerperal condition.  Albuminuria,  therefore, ahvays indi-
 cates a pathological condition of Avhich it is the symptom; for  every func-
 tional disorder, Avhether temporary or  persistent, supposes a  momentary or
 prolonged alteration of the organs Avhose office it is to accomplish the func-
 tion.  Therefore,  the investigation of the causes of albuminuria implies
 that  of the general or local affections  Avhich are  capable of producing it.
But  lest Ave should go astray in these researches, it is very important to
ascertain a jsriori, Avhat  are the organs upon  Avhich the  accomplishment of
the urinary secretion devolves.   The kidney is supposed to be exclusively 
492
PATHOLOGY  OF  PREGNANCY.
intrusted Avith this office, and thus it happens that the material explanation
of all the disorders of the secretion  is sought for in lesions of that organ.
Now, as M. Pidoux has very judiciously  observed, the secretion of urine is
not confined to the kidney, since it takes  place previous to the formation of
the latter.  (Uric acid and the other elements of the  urine have  been dis-
covered in the fluid contained within the allantoid.)  The process of assimi-
lation, which is so active in the foetus, can only be understood  by supposing
a contemporaneous process of decomposition.   The blood Avhich Aoavs to
the organ is  already charged Avith the elements of urine. Avhich are to be
separated from it in the passage.  The function begins in all parts of the
economy by this  admixture of heterogeneous elements with the blood, and
is completed in the  kidney by their elimination  from the  circulating fluid,
Avhich is returned in  a purified  condition.  M.  Pidoux Avas therefore right
in saying, that the secretion of urine is at once a  local and general function:
general, because it commences everywhere, and local, because it ends in the
kidney.   To  study the  latter organ  exclusively, when Ave wish to obtain a
physiological idea of the  function, is to neglect an  important element; so,
also, in pathology, always to expect to find the cause of the disorders of the
urinary secretion in alterations of the kidney, is to overlook a multitude of
other causes Avhich may have a corresponding influence.   The elements of
the blood conveyed by the renal artery exist, in health, in a fixed proportion,
and certain of them are destined to be eliminated by the kidneys.   Noav it
is easy to understand  that if an  alteration in the structure of these organs
is capable of modifying both the quantity and quality of the matters elimi-
nated, an alteration of the fluid, such, for example, as the diminution or in-
crease of its  solid or fluid parts, may also  have the same  effect.  Clinical
observation and post-mortem examination give constant support to this idea;
for though we sometimes find a material lesion  of the kidney to Avhich we
attribute the albuminuria, Ave are very frequently obliged to  recognize the
fact that it is very often absent.
  [In the present state of knowledge in respect to albuminuria it cannot be regarded
as the symptom of any one single  lesion, the passage of albumen being  due to
many different causes upon the nature of wliich  great light has been thrown by
physiological experiment.  The most striking experiment is that of Claude Bernard,
who, having injected a solution of the white of an egg into the veins of an animal,
found that albumen soon made its appearance in the urine.  The same result fol-
lowed the injection of serum of blood.  Albuminuria may also be  produced arti-
ficially  by feeding animals  Avith   albuminous matters  exclusively.    All  these
experiments  prove that an  excess of albumen in the blood is always followed by
albuminuria.   A somewhat similar excess is found in  the blood of pregnant women,
for, w*e have here to consider not the relative proportions  of the water and organic
matters, but rather the  comparative relations of the  tAvo.  Now Mr. Gubler states
that such a comparison shoAVS, as a general rule, a marked predominance of albumen
as compared Avith  the corpuscles (see page lo8).  He therefore regards the pro
portionate superalbuminosis of the blood as the common determining cause'of albu-
minuria.   During pregnancy,  continues this author, the mother's blool has t<i
supply the foetus with its nutritive materials, but only in  a soluble and  diffusible
form, inasmuch as  no inosculation exists between the maternal and fcetal vessels.
Albumen in its various forms is. therefore, required for the nourishment of the
new being, and whilst this is the case the maternal  organism has to provide for a
double expenditure. 
DISEASES OF PREGNANCY.
493
   In c mi sequence either of an  increased ingestion or a moie perfect appropriation
 of protein substances, or to both causes conjoined, a greater amount of albuminous
 matter is continually supplied.   Now, under the changes impressed upon the func-
 tions, a bad state of the economy or the perturbations produced by the first efforts,
 so to speak, in this novel direction, may cause the albumen to accumulate in pro-
 portions beyond the needs of  the two conjoined organisms.
   In  this vieAV, the albuminuria of pregnancy implies an excessive production of
 albuminous matters  in  relation to the requirements  of  both mother and child.
 Sometimes  it Avill be that the  former  produces too much, .and sometimes that the
 latter appropriates too  little ;  again, both these conditions may concur to  produce
 the same result.  Should the children,  when born, be of the usual size and weight,
 it would be fair to conclude that the  albuminuria resulted  from  disorder of the
 maternal economy ; should they,  however, be  small and puny, it would be equally
 just to suppose that their condition may have  caused the excess of albumen in the
 blood and its consequent filtration through the kidneys.   We would add, as a fact
 shown by experience, that children born of  mothers affected  with albuminuria
 are often of less than  the medium weight and development.   The remarks  of
 Danyau, Depaul, and  Blot put the truth  of the latter statement beyond a doubt.
 (Gubler.)
   In connection with the superalbuminosis just discoursed of, we should consider
 the effect of the pressure of the  blood  upon the Avails of  the vessels as of no less
 importance in the etiology of the affection.   If enough water be thrown into the
 vascular system to increase  suddenly the  mass of the blood and produce a strong
 vascular tension, albumen is found  to  escape immediately by the  urine.  A still
 more decisive  experiment is afforded by ligating the emulgent vein.  In this case,
 the sudden arrest of  the venous circulation determines a progressive stagnation in
 the capillary vessels and albuminuria results.   The same result is obtained if the
 ligature be gradually tightened, so that entire interruption of the  Aoav of venous
 blood is not produced for several hours or even days.  Whenever, therefore,' sufficient
 pressure is  made by a tumor  upon the renal vein or vena cava inferior to  slacken
 and obstruct the returning circulation in  the  kidney, the  urine is liable to contain
 albumen.   This, M. Jaccoud  states, is the most frequent cause of the albuminuria
 of pregnancy.   (Generally, indeed, it does  not  begin  until after  the sixth month
 of gestation (Rosenstein, Braun), but  then everything conspires to produce con-
 siderable obstruction of  the abdominal circulation;  that of the kidney is slackened
 as Avell as that of the  liver or spleen (Yirchow), and the pressure thus abnormally
 produced in the malpighian bodies leads to the passage of albumen into the urine.
 This view,  iioav universally received (Frerichs, Braun, Rosenstein, Wieger, Beck-
 maun, Krassnig, Brown-Seguard), is evidently not applicable to that kind of albu-
 minuria which appears  exceptionally during  the four last months of pregnancy.
 At this period  it can no  longer be attributed to obstructed circulation in the renal
 veins, the pathological process being entirely different.  (Jaccoud.)
   Superalbuminosis, therefore, on the one hand, and great distention of the vessels
 of the kidneys  on the other, afford a satisfactory explanation of the albuminuria of
 pregnancy; but are Ave to conclude that the kidneys themselves have nothing to do
 with the causation of tlie disease?  Evidently not, for the albumen would remain
 imprisoned  in the blood-A'essels indefinitely, did not the kidney undergo such changes
 ns would allow the protein matters to pass through it, that is  to say, did it not
 become  affected  with active  congestion  and  certain transient  parenchymatous
 alterations  which are the instrumental conditions of the disease.  Co-operative
circumstances, such as the impression of cold, might increase the hyperasmia to the
state of  inflammation  properly so called, and  thus  give rise  to what Gubler  has
termed secondary albuminous nephritis.   In this case, the albuminuria is maintained
by the kidney itself.
I 
494
PATHOLOGY  OF  PREGNANCY.
  But this is not all.  The kidney may also be the seat of the initial phenomena
of the disease ; which would then be due to a primitive albuminous nephritis.
  To recapitulate : the albuminuria of pregnancy is  produced by various causes,
the principal of which, in our opinion, seem to proceed from and be connected with
the three following conditions :
  1.  Superalbuminosis.
  2.  Over-distention of the blood-vessels of the kidneys.
  3.  Albuminous nephritis, which may be either primary or secondary.]

  This  succession of pathological phenomena seems to me to throw much
light upon the etiology and nature of puerperal albuminuria, and to recon-
cile  apparently contradictory facts  and opinions.  It Avere  certainly going
too far to say that all cases of  albuminuria during pregnancy are attended
Avith  albuminous nephritis ; it is an opposite exaggeration, on the other
hand, to insist that there very  rarely exists a connection betAveen  the albu-
minous  urine and the disease described by  Bright.   The true  statement, we
think, Avould be: that pregnancy generally  produces a  notable change in
the relative proportion of the elements of the blood, AA'hich  change consists
essentially in a diminution of the solid constituents,  Avith relative predomi-
nance of albumen.
  This  general alteration is of itself capable of  producing  the elimination
of albumen;  but  when existing in a slight degree only, and  therefore un-
equal to the production of albuminuria, may have its action assisted by the
active or passive  congestions to Avhich  the kidney may be exposed  during
pregnancy,  and especially during  labor.   Those  simple hyperemias of the'
kidney, which are so often seen after death,  and which are really the first
degree of granular nephritis, do not appear to have any other cause.
  The marked influence which a first  pregnancy appears  to have in the
production  of albuminuria (the  resistance  of the  Avails of  the  abdomen
increase greatly the pressure sustained  by the  parts  situated  behind the
uterus)  is thus explained, as  also  the  rapidity  with  Avhich  the  albumen
frequently disappears after labor.

  [According  to most authors, the  presence of  albumen in  the urine is almost
always coincident with diminution of urea,  which would even seem to lessen in
quantity  in proportion to the abundance of urine.   The urea being imperfectly
eliminated by the  kidneys, therefore accumulates in the blood.   For further dis-
cussion of this subject, see Urcemia, at the end  of this  article.
  Let us  now examine the  methods of detecting the  presence of albumen in  the
urine and the symptomatic troubles to AA'hich its existence there gives rise.
  NotAvithstanding all that has been  said respecting the appearance of albuminous
urine, its want of color, and the frothy bubbles which form on its surface, it would
often pass undetected if  care were not taken to examine it closely by peculiar pro-
cesses.   Many chemical reagents have been proposed  for its  analysis, but heat and
nitric acid are almost the only ones to be relied on.
  The simplest process for detecting albumen is as follows  : having drawn the urine
by a  catheter in order to  avoid  the inconvenience of admixture with vaginal or
lochial discharges, it should be poured  into a tube and heated to the boiling-point.
When ebullition commences, should the urine be  albuminous, it grows cloudy, and
a flocculent coagulum  precipitates.   It ought, however, to be understood that this
coagulum is not a certain indication  of albumen, since alkaline urine might pre-
cipitate its earthy salts.  An opposite error  might also occur, inasmuch as highly 
DISEASES  OF  PREGNA.NCY.
495
alkaline and at the same time notably albuminous urine contains but a sms.ll pro-
portion of earthy salts  and is  not clouded by heat.   In all cases, therefore, it is
indispensably necessary first to test  the urine by litmus-paper, and if alkaline to
acidulate it with  a small quantity of nitric acid ; after which it should be subjected
to boiling.
  The  testing by heat  is liable to another objection, to Avit, that urine which is
albuminous but  at the  same time very acid, may not yield a precipitate by heat.
The resistance to coagulation depends, in  this case, according to Gubler, upon the
presence of phosphoric acid.  Here a little nitric acid, by neutralizing the influence
of the  phosphoric acid, restores to the albumen the power of coagulation by heat.
On the other hand,  a still larger proportion of acid would precipitate  the albumen
directly, without the assistance of  an elevated temperature.
  Instead of having recourse to heat, albumen may be sought  for in urine by
allowing a few drops of nitric acid to flow down the sides of the glass containing
the fluid.  The acid coagulates the albumen and a flocculent precipitate soon forms.
  This method, unfortunately, is not decisive, for the action of nitric acid upon
cold  and  acid urine gives a precipitate of uric acid  resembling  considerably
that  of albumen.  Wo  may avoid deception, however,  by warming  the clouded
fluid, which, will  resume its transparency as the temperature rises in consequence
of the greater solubility of uric acid at high than at low temperatures.
   All the preceding considerations show :  1st, that albumen maybe  supposed to
exist Avhen  it is absent; 2d, that it may be overlooked Avhen present.   The testing
for albumen is not so easy as is generally supposed.  Therefore, it Avere better, for
greater certainty, to examine first by boiling and then by nitric acid.  All  the
difficulties  presented by the  analysis have  been thoroughly  stated by  Gubler
(Dictionnaire Eneyclo]>edique), Avhose work we refer to without being able to enter
at present into greater detail.]

   The urine, in Bright's disease, presents other alterations besides its admix-
ture with a certain proportion of albumen.  Thus, Avhen submitted to micro-
scopic  examination at a  certain period of the disease, it  is found to contain
mucous corpuscles, scales of epithelium derived from  the  bladder,  ureters,
and  pelvis of the kidney, besides elongated  cylindrical bodies formed of
amorphous fibrin, in  the substance  of Avhich  blood-corpuscles  may be  ob-
served, either singly or in groups.   These  have been termed fibrinous cylin-
ders, and are regarded by Frerich as pathognomonic of Bright's disease.
   According to some authors, all these peculiarities are observable in  the
urine of pregnant Avomen affected Avith albuminuria;  according to  others,
on the contrary, the fibrinous cydinders are very rare in the latter case, and
M. Blot has quite recently examined the urine of three eclamptic patients
without discovering them.
   I am not prepared to decide upon this point, though it seems to me very
probable that this difference of results is simply due  to the fact that,  in the
first case, the kidneys  Avere diseased, Avhilst in the second  the recent albumi-
nuria was connected only Avith a general alteration of the fluids.
  After the indications afforded by examination of the urine, the next most
frequent symptom of albuminuria is general infiltration  or anasarca,  Avhich
must not be confounded Avith bedema of the loAver extremities.  (See Dropsy
of the Cellular Tissue.)   The latter is occasioned simply by the mechanical
obstruction of the  venous circulation produced by the pressure of the gravid
uterus. 
496
PATHOLOGY OF PREGNANCY.
  General infiltration is not so uniform an accompaniment of albuminuria as
I thought  formerly.   In order to determine  its relative  frequency, it is
necessary not only to examine the urine  of infiltrated females, as Avas ray
practice, but to investigate carefully the  urine of all .pregnant  Avomen, as
was done by M. Blot.  It will then be  discovered that many patients Avith
albuminuria present not a trace of oedema.  M. Blot found it, Ave have said,
in 23 cases out of 41.
  It is proper to observe, that this absence of infiltration is also often noticed
in the ordinary Bright's  disease.   By a collection of  observations Avith
autopsies, derived from various authors, Frerich found that, of 220 cases of
Bright's  disease, 175  Avere accompanied  Avith  oedema,  and 45  Avere free
from it.
  Nervous disorders are sometimes attendant upon the anasarca.
  In the last edition of this work Ave stated that puerperal albuminuria did
not usually give rise  to the  symptoms  Avhich  accompany Bright's disease.
This is true for the light  cases, Avhich, happily, are the most frequent;  but
science has progressed, and modern researches have proved that  certain of
the affections of the pregnant female, whose cause and nature were entirely
unknown, coincide  Avith  albuminuria, and very  probably are, like it, the
consequence of extensive elimination of albumen from the blood.  Thus, in
several cases of amaurosis occurring during pregnancy, MM. Simpson, Im-
bert Goubeyre, and others, have detected albumen in the urine.  ' The same
is true of certain cases of obstinate headache, of lumbar pains and pleuro-
dynia, of paralysis (hemiplegia or paraplegia), (Robert Johns, Simpson, Im-
bert Goubeyre), and of contractions, hemorrhages (Blot), &c.  (See Urozmia,
and Paralysis.)
  Noav, M. Imbert  Goubeyre's remark  is very important, namely, that all
these phenomena are found in the symptomatology of Bright s disease,  Avhich
confirms  the comparison that we have made.
  To  the symptoms just mentioned Ave might add  eclamptic  convulsions,
which are, happily, quite rare, and hardly ever appear,  except  at an ad-
vanced stage of the disease.   We shall treat of them at length hereafter.
(See Urozmia,, and Eclampsia.)
  It is very difficult, not  to say impossible, to determine Avith certainty Avhen
the albuminuria commences; to do this,  it would be necessary to examine
daily the urine  of a large number of women  during the entire period of
pregnancy.  Hitherto, it has generally been observed only during the latter
months.  M. Bach, of Strasbourg, hoAvever, says that he has seen it at six
Aveeks in a  very nervous  person.  I once detected it at  four months in a
greatly infiltrated  primiparous female, who Avas delivered at six  months of
a still-born child, and Avhose  urine Avas slightly albuminous eighteen months
aftenvards, although the infiltration had disappeared since six months.  M.
Cahen mentions in his thesis three cases, recorded in the  fifth  and sixth
months, and M. Bach two others.  Perhaps, now that attention  is directed
to this point, such  facts Avill multiply  ; but those observed hitherto have
almost ahvays been noticed in the latter stages.   Sometimes it appears only
at the moment of delivery, under the  influence of the parturient efforts,
which are Avell  calculated to produce congestion of the kidneys. 
DISEASES  OF  PREGNANCY.
497
  When once begun, the progress of albuminuria is liable to great varia-
 tion ;  sometimes it continues  uninterruptedly until the commencement of
 labor, and increases during its continuance;  at others, it varies greatly in
 intensity, and may even cease completely for several days, then  reappear,
 and again stop at very indefinite intervals.
  When it begins  during  labor or shortly before, it often disappears a feAV
 hours or days after delivery;  but it  follows from the facts collected by M.
 Imbert Goubeyre,  that so prompt  a  cessation is not as common as I had
 thought, and as M. Blot had  stated.  Though there are cases, says M. Im-
 bert Goubeyre (memoir quoted),  in Avhich  the  albumen disappears Avith
 rapidity,  in  others it  continues,  and passes into  chronic and confirmed
 Bright's disease.   From a statement by this  author, it appears that, of 65
 cases of puerperal albuminuria unaccompanied Avith eclampsia, 21 proved
 fatal during pregnancy  and the lying-in;  and 6 from the third to the four-
 teenth month after delivery;  5 cases became chronic, and Avere found to be
 still existent, tAvo, eight, ten, and  fourteen months, and seven years after
 the labor.
  I but just  noAV mentioned a case  in which  albumen was  detected in the
 urine eighteen months after delivery.
  These differences appear to  me to  be due to the greater or less intensity
 of  the disease.  When the alteration of the  fluids is but slight, especially
 when it has existed for but a short time, and occurs towards the end of ges-
 tation, or only during the labor;  Avhen, finally, the active  or passive con-
 gestion of the  kidneys,  produced by obstruction of  the venous circulation,
 has had its influence in causing the albuminuria, Ave can understand how
 the removal  of one of  the  causes, by delivery, may leave  the other inca-
 pable of  sustaining the functional  disorder.   But  Avhen the alteration is
 slight,  especially Avhen it dates back  to the middle or first half of the preg-
 nancy, it may then continue for a long time after delivery.  In these latter
 cases, granular nephritis is often present; but I am much inclined  to believe
 that sometimes the kidney  is  unchanged, or A'ery slightly altered, notAvith-
 standing the persistence of the albuminuria.
  In respect to the prognosis, the coexistence of an alteration  of the kidney
 is of the highest importance;  unfortunately, hoAvever, the diagnosis during
 life of this organic lesion  is  extremely difficult,  inasmuch as none of its
 symptoms are  pathognomonic.  It  Avould appear,  hoAvever,  from  the re-
 searches of M. Pickard  (thesis, Strasbourg, 1856), that great  light may be
 throAvn upon the question by analysis of the blood, since, Avhen the kidneys
 are  diseased, the blood contains an amount of urea much greater than in
 any other cases of  albuminuria; moreover, the quantity of urea is propor-
 tionate  to the greater or less  advanced degree of renal  alteration, a A'ery
 small proportion of urea in the blood generally coinciding Avith simple con-
 gestion of the kidneys.
  Has  the albuminuria any  effect upon the progress of the pregnancy, and
 upon the life  and development of  the foetus?   M. Blot thinks that  it has
not, Avhilst MM. Cahen,  Rayer, and some others, hold the contrary opinion.
  I  still regard the vieAV of M. Blot as entirely correct for the slight cases,
which are, I repeat, the  most common; but it does  not appear to me well
      32 
498
PATHOLOGY  OF  PREGNANCY.
founded as regards  those complicated Avith  anasarca, or Avhich begin before
the latter half of gestation.  I  am very much  inclined  to consider it  aa
being then a  frequent cause of abortion, of premature labor, and of death
to the foetus.
   We have noticed the views of Simpson and others respecting the frequent
occurrence of albuminuria in numerous puerperal disorders.  M. Blot con-
siders it a cause of hemorrhage.  It is, therefore, as relates to the prognosis,
a sign Avhich is ahvays calculated to excite solicitude.   As a diagnostic sign
it is certainly destined to reveal the nature and  etiology  of a multitude of
affections hitherto of very difficult explanation;  therefore, it is noAV indis-
pensable, in obscure cases, to examine carefully the urine of pregnant Avomen,
even Avhen unattended Avith dropsy.  It may possibly be shoAvn in the future
that albuminuria is a central point toAvards Avhich converge a multitude of
diseases of various  characters, and these  researches may throAV light upon
their treatment, which is still so obscure.
   If we have succeeded  in shoAving that an altered  state of the blood is the
principal cause of puerperal albuminuria, and that this  alteration  consists
chiefly  in a diminution of its solid constituents, we shall  have no occasion
to insist strongly  upon the advantages  of  a reparatory treatment.  Unless
very evident symptoms of general plethora or renal congestion be  present,
bleeding Avould be rather hurtful than useful,  in a disease attended  Avith  so
great impoverishment of the system;  therefore a tonic medication should
be resorted to from the outset.  A good animal  diet, assisted by the use of
Avhatever feiruginous  preparation will be  most  readily  supported by the
patient, ought evidently  to form  the basis of the  treatment.  The prepara-
tions of Peruvian bark,  and other bitters,  may be added with advantage.

   [Uraemia. — We  have just said that albuminuria is often accompanied by various
nervous disorders (amaurosis,  paralysis, eclampsia), the production of which it is
very difficult to explain satisfactorily.  It will  not, however,  be forgotten that
albuminous urine contains but little urea (see page 494), which being no longer
eliminated by  the  kidneys, must necessarily accumulate in the  blood.  This fact
is supposed  to  account for the nervous disorders in  question, by giving rise to a
peculiar poisoning  to which the name uraemia is applied.  We  propose now to state
the principal points and successive phases of the doctrine of uraemia, premising,
however, that it is  liable to numerous objections.
   Wilson first, and  afterwards Rayer, attributed the  nervous  complications  of
albuminuria to the presence of urea in the blood.  At first accepted without limi-
tation, this opinion was soon attacked in its very foundation.   Cases were cited in
which urea Avas present in large amount in human blood Avithout being  attended
by any  of the so-called uraemic symptoms.  Finally, CI. Bernard, from experiments
made by injecting  urea into the blood of animals, came to the conclusion that urea
is incapable of producing the nervous accidents  of albuminuria.  Thus  Wilson's
theory Avas ruined.
   Frerichs came, for a while, to the rescue of the doctrine of uraemia by explaining
the facts differently.  According to him, urea is, of  itself, innocuous, the danger
arising  from the fact that  it is easily decomposed  in the blood, giving rise to car-
bonate of ammonia, which really is poisonous.  Frerichs' experiments appeared tn
be decisive.  He injected  carbonate  of  ammonia into  the veins of dogs in good
health,  and after a very short time the expired  air contained carbonate of ammonia,
and the animals were soon taken Avith convulsions and coma.   The symptoms thus 
DISEASES  OF PREGNANCY.
499
 artificially produced bore a strong resemblance to eclampsia, and Frerichs' position
 Beemed for a time to be thoroughly established,   ft was  thus  presented in a favor-
 able light in former editions of this work, but since then it  has lost ground and
 its partisans become daily less numerous.  The fact is, that the  theory is  not free
 from objections ;  and out of a great number of experiments which go to contravene
 tho-e of Frerichs, I again cite the opinion of Bernard,  which  is far from being
 favorable.   This celebrated physiologist asserts that carbonate  of ammonia is almost
 always present in human  blood, whether in health or in disease, and the experi-
 ments which he undertook satisfied him, moreover, that  it is  far from being pro-
 ductive of the terrible nervous symptoms which have been attributed to it.  " If,"
 says the learned professor, "carbonate of ammonia be injected in small quantity,
 it produces no effect.   When thrown in larger amount into the blood of a  dog, the
 animal cried and was  extremely agitated for  a considerable time: nevertheless it
 recovered."  From these experiments Bernard concludes that eclampsia cannot be
 explained by carbonate of  ammonia.  The same opinion  is given in the excellent
 thesis  for the Concours, of my colleague Dr. Fournier ;  and, for my own part,  I
 would say Avith him that  Frerichs' doctrine, ingenious and learned though  it be,
 will not bear severe scrutiny.   (Fournier, These de Concours pour  VAgrogation,
 1803.)
   At  present, the position can no longer be sustained that uraemic symptoms are
 due to the presence in  the blood of any  single principle, whether  urea or carbonate
 of ammonia.  Scliottin assumes  that  substances  imperfectly known as yet. and
 vaguely styled  extractive matters,  may accompany the urea, remain in the blood,
 and give rise to a poisoning which Gubler  proposed to  call urimvmia.  This last
 mode of interpreting the facts is an approximation, perhaps,  to  the truth, though
 it is far from proven that it represents it precisely.
   "If the  doctrine of uraemia or of urinosniia be accepted as true, how shall the
 nervous troubles which it produces be explained?  Here come in what have been
 termed the  nervous theories of uraemia.  Certain authors, as  Traube and  See, re-
 gard the nervous phenomena of  uraemia as somewhat analogous, as respects the
 intrinsic mode of production, with the pathogenic process which Kusmans,  Tenner,
 and others  assign to epilepsy.  Through some change in the  blood an excitement
 is produced of the vaso-motor nerves and  the cerebral  arteries.  These  arteries
 contract, and there result  either oligosmia of the medulla oblongata giving rise to
 convulsions, or the same condition of the encephalon giving rise to coma."   (Four-
 nier, The\se de Concours.)
   In short, the clinical facts are real, and all  physicians have occasion to see how
 frequently nervous troubles arise in the course of an attack of albuminuria.  How
 shall they lie explained?  Though the question seem at present to  be unanswerable,
 I have deemed it  my duty to exhibit the present state of knowledge on the  subject.
 Should the doctrine of uraemia be false and that of urinaemia doubtful, plausible
 hypotheses Avould  still remain  whereby to explain the nervous disorders  compli-
 cating  albuminuria.  Other changes in the blood, altered nutrition of the nervous
 tissue (Gubler), hyperaemia or  anaemia of  the encephalon,  serous effusions upon
 the surface of or in the cavities of the brain (Rilliet, Nat-alis Guillot), and oedema
 of the  cerebral  substance, are all circumstances capable  of explaining the  convul-
 sive phenomena  and  concomitant symptoms  observed in certain forms of  albu-
 minuria.  (Gubler.)
  One  other difficulty remains to  be mentioned.   What are the  nervous disorders
 observed in cases of albuminuria?  In the first place AAre would mention cephalalgia,
 troubled vision and hearing, vomiting, coma and eclampsia.  Up to this point there
 is no disagreement.  But are cases of paralysis like hemiplegia or paraplegia over
 witnessed?   Here is a case of controversy : Churchill and Imbert Goubeyre on the
one hand, admit that puerperal paralyses are not uncommon, whilst  on the other 
500
PATHOLOGY  OF  PREGNANCY.
 almost all pathologists, Addison, See, Lasegue, Fournier, and Grisolle, remarfc that
 paralysis has no place amongst the nervous disorders of albuminuria.  When here>
 after we come to study puerperal paralysis and include  uraemia in their etiology.
 we shall not lose sight of the difference of opinion upon  this subject.
   In short, various nervous affections occur in women affected Avith albuminuria,
 to explain which the doctrine of uraemia and urinaemia has been invoked, although
 confidence in it has become A'ery much shaken.  All our knowledge on the subject
 is hypothetical, and further investigation is indispensable to reduce it to any cer-
 tainty ;  therefore, whenever Ave shall mention uraemia in explanation of any patho-
 logical condition, our  reservation on the matter will be brought to recollection.]

   § 4. Dropsy of  the  Cellular Tissue.
   Another  affection of quite frequent occurrence, and  one which is often
 connected with what  accoucheurs call  plethora,  of which,  according to
 Chaussier, it is a variety (serous plethora), is serous infiltration of the cellular
 tissue.  This infiltration  begins in the feet, then  extends to the legs, thighs,
 genital  parts, and sometimes rising above the lower  extremities, invades the
 trunk, face, upper extremities, and is sometimes even accompanied by effu-
 sion into the great serous cavities.
   These dropsies, upon Avhich MM. Devilliers and Regnauld have published
 an interesting memoir,  are by them divided  into:  1, simple  oedemas; 2,
 oedemas connected Avith  affection of the central organs of respiration and
 circulation; 3, oedemas with albuminuria.
   The oedema connected  with lesions of the organs  of circulation generally
 increases  during  pregnancy, but  this increase is especially due to the  un-
 fortunate  influence  which gestation has upon all organic lesions, and Ave
 have no occasion to speak of it further.  As regards the two  other species,
 we think it  proper, in order to avoid repetition, to include them in the same
 description;  for though  they have some special characters upon which we
 shall have to insist,  they  resemble each other in a great many  particulars.
   The causes of the serous infiltrations which occur  during pregnancy, may
 be divided  into general  and local.  As first  in  importance of the general
 causes, Ave must rank the decrease in the proportion  of albumen; a decrease
 Avhich has been discovered by all  observers in the blood of pregnant Avomen.
 According to M. Andral, this special alteration of the blood is the only  one
 which necessarily produces  dropsy.  The amount of effusion  is dependent
 upon the  extent of  the alteration, Avhich, if considerable, is  often attended
 Avith albuminuria.
   ITydraemia,  or  serous  plethora,  which also produces oedema in certain
 chlorotic  patients, may also  give  rise  to the  same  symptom  during preg-
 nancy,  and assist in the production of serous  infiltrations.   When these
 general alterations of the economy are but slight, they usually would be
 unequal to the production of oedema, did not the development of the Avomb
 add its local action to their own.
  The pressure of the Avomb upon the surrounding parts from  early preg-
nancy, and the obstruction Avhich it occasions to the performance of  the
functions of the central organs of respiration and circulation at an advanced
stage, Avhen by rising into the epigastric region it forces up the diaphragm
and thus diminishes the thoracic cavity, explain Avhy the oedema commences 
DISEASES OF PREGNANCY.
501
in the loAver extremities, and Avhy it generally does not extend until a much
later period to the trunk and upper extremities.
   Progress  and Symptoms.—Generally speaking,  the oedema  makes  its
appearance within the last  three months of pregnancy, especially when it
appears to be due simply to  a mechanical  obstruction of the  circulation.
But when it results from one of the general causes before mentioned, it may
commence with the pregnancy, or in the third or fourth month.  HoAvever,
as hydraemia, the  diminution of the albumen  of the  blood, and the albu-
minuria, are most generally observed in the latter half of gestation, we may
understand  that  the dropsy to which they give rise should  also be more
eommon towards the seventh, eighth, or ninth month.
   The progress of the oedema  of pregnancy  is generally slow and chronic ;
sometimes, hoAvever, it advances rapidly in a  feAV Aveeks.  Whatever may be
the case in this respect, it generally begins by the lower extremities; some-
times affecting one of them, at  others both.   At first it is limited to the feet
and neighborhood of the ankles;  sometimes  even it never  gets farther than
the loAver part of the legs, though quite frequently it reaches the knees, the
thighs, and external genital parts.  Occasionally it invades the integuments
of the loAver part of the trunk, and  in some rare cases, generally attended
with albuminuria, it affects  even the face and hands.
   In the early stages, Avhile limited to the  loAver part of the legs, it  dis-
appears at night, in consequence of the horizontal position, and is only well
marked towards the close of the day.   But when the disease has advanced
farther it continues, whatever  position the patient assumes;  and although
the horizontal posture seems to diminish the SAvelling of the legs, it it only
because the infiltrated fluid is displaced to the lower part of the trunk.
   The amount of fluid extravasated varies betAveen a slight  puffiness and
the extreme swelling which makes standing and Avalking impossible.   In
the latter case, the parts affected are generally the seat of pain, of sensations
of pricking, and sometimes  of  burning and extreme tension.
   The oedema rarely disappears  before delivery; on the  contrary, it gen-
erally increases until near the  end of  pregnancy.  Sometimes, hoAvever, as
MM. Devilliers  and  Regnauld have  indicated, it  undergoes remarkable
variations.  Thus,  it may disappear entirely and finally, or  it may return
shortly after; sometimes it  is observed to  leave one member and fix upon
the other, Avhich had been but partially affected.  These changes are doubt-
less OAving to mechanical  causes,  the action of Avhich varies  or  ceases Avith
alterations in the  situation of  the uterus (Devilliers and  Regnauld);  but
they certainly may also be occasioned  by fluctuations in the albuminuria,
which may be suspended for a short time and then reappear, as I have wit-
nessed in one case after labor.
   Terminations. — The dropsy' of pregnant Avomen, hoAvever caused, generally
disappears quickly after labor;  and in cases of albuminuria, the secretion of
albumen often ceases "with equal rapidity.
  Prognosis. — If  the dropsy be viewed as a simple fact, independent of the
complications A\hich so often attend and folloAv it, it assumes the position of
a  merely troublesome affection ; but to  appreciate the prognosis rightly, it is
important to remember that some authors regard the oedema as favoring 
502                PATHOLOGY  OF  PREGNANCY.

abortion and premature labor.  They also suppose it to be almost unit jrmly
connected Avith the  etiology of eclampsia, and often Avith the development
of puerperal fevers; and finally., that sometimes the disappearance of the
effusion after delivery has been folloAved by a frequently fatal serous conges-
tion of the nervous centres or respiratory organs.  The  facts related by M.
Lasserre leave no doubt in my mind of the truth of the  latter proposition.
It is especially important to  bear  in mind, that although these dangerous
complications are possible as a consequence of simple oedema, they have been
chiefly observed in cases of albuminuria with infiltration,  and consequently
that the presence of albumen  in the urine adds greatly to the gravity of the
prognosis.   Hence  the  interest which then attaches to  the examination of
the urine.
  The treatment of the dropsy of pregnant females should be conducted "with
the double  purpose of overcoming the  organic  cause Avhich  so  frequently
produces the oedema, and to  stimulate the absorption of  the effused fluids.
The preparations of iron and  a tonic regimen appear  to me to be especially
called for in a disease which is so frequently connected Avith hydraemia.  The
presence of  albumen in  considerable quantity, even supposing it  due to  a
nephritis, does not contraindicate this treatment.  The antiphlogistics recom-
mended by  some authors seem to me  likely to be more  hurtful than useful;
and unless  the patient suffers very severe lumbar  pains, or to the general
infiltration  are superadded dyspnoea, palpitations,  extreme giddiness, and
especially evident indications  of  uterine congestion, threatening abortion,  I
should think it right to prescribe bleeding.  Even under the latter circum-
stances, I would employ it less as an antiphlogistic than as a  revulsive, nor
would I discontinue the use of the iron.
  To assist  the absorption of the  effused fluids, mild laxatives, diuretics, and
dry frictions may be used.  To these may be added vapor-baths, provided the
patient is able to bear them Avithout danger of cerebral  congestion.
  If the distention and size of the loAver extremities is so great as to make
walking impossible  and  cause great suffering, and if the genital parts are
greatly SAVollen, their disengorgement may be facilitated by practising small
incisions, or, at  least, a number of punctures, Avith  the  lancet or  a needle.
In  several cases I have derived benefit from keeping compresses, saturated
with cold Avater, applied to the limbs for several day^s.   Levret advises blisters
betAveen the thighs and external  labia, aided by slight punctures on the feet;
but inasmuch as the application of  blisters upon a highly oedematous limb
is sometimes attended Avith  serious consequences, I  think  it prudent to ab
stain from them.

  § 5. Ascites.
  We have already stated, that dropsy during pregnancy Avas so far from
being limited to the subcutaneous cellular tissue, that collections of fluid of
variable amount might take place in the great cavities of the  body.   The
effusion Avithin the  abdomen may occupy different locations: thus, it may
accumulate within  the amnion, and constitute dropsy of the  amnion;  or
betAveen the membranes of  the ovum and the internal surface of the Avomb,
in which case it furnishes the  fluid that gives rise to hydrorrhoea ; finally, by
collecting Avithin the cavity of the peritoneum, it forms  a true ascites. 
••
                    DISEASES  OF  PREGNANCY.                  503

  Either of these varieties of dropsy may occur separately, or tAvo of them
may coexist in the same female, as is often the case%^th ascites and hydram-
nion.   We shall treat first of ascites.
  This affection sometimes makes its appearance in the first half of the preg-
nancy, though usually tOAvards the fifth or sixth month, rarely later.  When
the accumulation begins very early, it sometimes progresses so rapidly that
the abdomen  is larger  at the  fifth  month than at the  usual term of ges-
tation, and as the infiltration of the lower extremities generally keeps pace
with the effusion  in the abdomen, the patients find it impossible  either to
Avalk or pursue their occupations.
   The progress of the ascites increases rapidly; the face is puffed and livid;
the abdominal Avails, much  thickened by infiltration, add to the size of the
belly; the skin covering them, although  distended and shining, sometimes
has a  tuberculous appearance, as  in elephantiasis.   The  umbilicus usually
forms a smooth, rounded, translucent tumor, of the shape and size of a hen's
egg, at the base of AA'hich the umbilical ring may be felt, though it is too
much distended to produce any circular constriction.
   The greater labia share in the general infiltration, are enormously SAvollen,
and affected  with a painful irritation, produced by their constant friction
against each  other, and contact Avith the urine.
   The skin of the loAver extremities is so distended as to seem readA' to burst
at several points, and is exceedingly painful.
   The progressive accumulation of fluid in the cavity of the peritoneum soon
obstructs the  regular performance of the  thoracic functions; the dyspnoea
becomes extreme, the respiration very short,  Avheezing,  and  painful;  the
patient is obliged to remain seated night and day;  yet, notwithstanding this
position, the haematosis  is so imperfect that she seems threatened with suffo-
cation at every instant,  and  has frequent attacks of faintness.  The suffering
condition is aggravated by almost constant insomnia, intense headache, ex-
treme thirst,  and disgust for food.
   Percussion of the abdomen detects readily the presence of a large amount
of fluid in its cavity, though the fluctuation is not equal  in all parts of it.
As Searpa remarks, it is slight or absent in the hypogastrium and tOAvards
the flanks, is manifest near the hypochondriac regions, and very well marked
in the left hypochondrium, near the edges of the cartilages of the false ribs.
   The enormous  distention of the parietes of the abdomen  frequently pre-
vents the uterus from being felt, and its elevation determined Avith precision.
 Ihe motions  of the child, though generally obscure, are,  hoAvever, still per-
ceh'ed by the mother.
   Ihe prognosis of ascites complicating pregnancy is grave in proportion as
it dates farther from the term of gestation.  When  it appears only in the
latter nunths, there is every reason to hope that, notAvithstanding its rapid
progress, it will be arrested  by delivery, before producing such disorders as
seriously to compromise the life of the mother, and that,  as in the observa-
tion of M. Prestat, the recency of the  effusion will render  its absorption easy
after delivery.  But Avhen the ascites begins Avithin the first half of the preg-
nancy, there is great cause for fear, should it progress rapidly, lest paracen-
tesis should be demanded long before the  ninth month.   It Avere  useless to 
t*
    504                PATHOLOGY OF  PREGNANCY.

    add, that the prognosia^vill be  far  graver, if, as  unfortunately very ofteD
    happens,  the  ascites sjiimld coexist  Avith dropsy of the amnion.  If,  says
    Scarpa, there should fortunately be no uterine dropsy, the paracentesis  may
    alloAV the pregnancy to  progress favorably through its  usual stages;  but,
    under the opposite circumstances, it almost always happens that the Avomb,
    being excited by sympathy, contracts, and delivery follows.
       Treatment.—The  general bleeding, purgatives, and  diuretics, employed
    with the design of retarding the advancement of the disease, have not seemed
    to influence its later progress, and it is conceivable that a too long-continued
    use of them might be prejudicial to the pregnancy.   They should, therefore,
    be resorted to with the greatest reserve, and relinquished as soon as found
    to be unsuccessful.
       When the disease  has increased to such an extent as \o threaten the life
    of the patient, it is evident  that the only resource consists in the evacuation
    of the fluid.   But where should the puncture be made?
       The development of the uterus makes it impossible to insert the trocar at
    the place of  selection  in ordinary ascites.  From  the  circumstance of the
    fluctuation  being particularly  well marked in the left hypochondrium, the
    prominence of which was greatest near the  edge  of the .false ribs, Scarpa
    introduced  his instrument between the uppermost part of the external
    border of the rectus muscle and the edge of the false ribs in the left hypo-
    chondrium.   The patient aborted tAvo days after, and recovered.
       George Langstaff made  an incision two inches above the umbilicus, ex-
    posed the peritoneum, and punctured it with a medium-sized trocar, being
    careful to introduce it  but a short  distance so as not to wound the uterus.
     He had thus given issue to  about ten pints of fluid,  AA'hen the Avomb came in
    contact with the end of the canula, interrupting the Aoav, and occasioning so
     much pain as to  oblige him  to withdraAV the instrument.  As the patient
    was unable to endure any pressure, he introduced a  medium-sized gum-
    elastic catheter by the opening, directing it betAveen the peritoneum and the
     anterior surface of the uterus.  Peritonitis followed eight hours after the ope-
     ration; three  days subsequently to  the operation she aborted, and three
     Aveeks later she was well.
       Finally, in a case in which a considerable tumor existed at the umbilicus,
     Ollivier,  of Angers, was decided by the tension and  thinness of the skin at
     the part to make use of the lancet simply.   This instrument was introduced
     in the same manner and to the  same depth,  as  for bleeding, at the middle
     and front part of the tumor, at the distance of half an inch from the circum-
     ference of tbf ring.  The  water floAved immediately to the amount of six-
»     teen pounds.
       For twelve days, the  serum continued to Aoav by the  little wound, Avhich
     was closed hermetically on the thirteenth.   The patient, who  had been  re-
     lieved at once, experienced a  return of the accidents with  the  fresh  accu-
     mulation of fluid.   Twenty-eight days after the first puncture,  it became
     necessary to repeat it; eight pounds  of fluid Avere discharged, and  the  same
     alleviation followed.  TAvelve  days after this,  the Avoman Avas delivered of a
     living, though feeble child, and  in fifteen days Avas discharged cured.
       This simple process, consisting of  a small puncture with the lancet, seema 
DISEASES  OF  PREGNANCY.
505
 to  me  preferable to Scarpa's operation in the hypogastrium.   The  latter
 might,  in some cases, endanger  important organs, and could  only be pre-
 ferred on account of the existence of an old umbilical hernia with adhesions
 of the intestines to the sac.  The  presence of this complication can be readily
 discovered by holding a candle behind the thin and transparent Avails  of the
 umbilical tumor, as for the diagnosis of hydrocele, when the opacity of the
 exomphalos will be  at once detected.
   There is  no advantage in  placing a foreign body in the  small  opening,
 since the Aoav of serum  keeps the  sides separated, and the density and ex-
 treme thinness of the Avails of the tumor prevent infiltration of the abdomi-
 nal parietes.  The observation of  Langstaff,  aboA'e cited,  as  also another
 fact related  by M. Danyau, prove that the introduction of  a foreign body
 exposes to peritonitis.
   When the pregnancy has made but slight progress, the only resource evi-
 dently consists in the puncture; but Avhen the ascites endangers the mother's
 life only at the eighth or ninth month, is it allowable to think of premature
 artificial delivery?
   If the uterine dropsy, of which Ave are about  to speak in detail, compli-
 cates the ascites,  and Ave are able to  ascertain that the  sufferings  of the
 patient are in good measure due  to the extreme size of the uterus, I think the
 tapping Avould be insufficient, and that the artificial induction of labor may
 be  attempted Avith advantage; still, though common, the hydramnion  is not
 a necessary complication, and it seems to me that ascites can very rarely
 require premature delivery.
   In the eighth, and especially the ninth month, the evacuation of the peri-
 toneal fluid will  afford sufficiently lasting  relief  to enable the Avoman to
 reach the regular term of pregnancy ; or, at least, it will rarely be necessary
 to repeat the operation more than once.  Such was the case Avith  the patient
 of Ollivier.   The only fault to be found Avith the puncture is that  of  being
 merely palliatory, Avhilst it exhausts the strength if frequently repeated.
 But should the relief afforded be such that one or tAvo punctures enable the
 patient to reach the end of the ninth month Avith  moderate suffering, I see
 no  reason for not  preferring it to premature  delivery, Avhich ahvays  places
 the child in unfavorable conditions.

                           ARTICLE V.
                       LESIONS  OF INNERVATION.
  [I 1. Eclampsia.
  On  account of its danger and  the nature of the convulsions which characterize
 it, eclampsia takes the foremost  rank in the diseases of women.  It  is liable to
 appear suddenly either during pregnancy, at the moment of delivery, or subsequent
 to the removal of  the  placenta;  it occurs, however, more frequently during  labor,
 and will, therefore,  be studied in connection with the accidents of dystocia.   (See
 Dystocia.

  12. Vertigo.   Giddiness.  Lipothvmia.   Syncope.
  These  affections are due  to various  causes.  Usually they seem to depend upon
greet nervous susceptibility, occasioned by pregnancy and heightened by chlorosis; 
506               PATHOLOGY  OF PREGNANCY.
less frequently they result from plethora, in which  case blood-letting becomes, ex-
ceptionally, the best method of treating them.  Sometimes, also, vertigo and giddi-
ness accompany  albuminuria, and  precede eclampsia.  (See Albuminuria,  and
Eclampsia.)  In the majority of cases, neither plethora, albuminuria, nor eclampsia
are observed in connection, so  that the above-named affections seem to be due
simply to a perverted action of the nervous system ; an unsatisfactory explanation,
but really the only one Avhich can possibly be given.]

   Thus some delicate, nervous women  are subject to faintings, from  the
most trifling  cause, when they are pregnant; any strong moral impulses,
such as joy, or anger, and sometimes even  an odor that is a little too pene-
trating, or the sight of an unpleasant object or person, may give rise to  this
condition.  Gardien relates an instance, where the simple movements of a
child produced swoonings; and I have attended a lady who fainted three or
four times a week, during the second, third, and fourth months of her gesta-
tion, Avithout any satisfactory cause being discovered for it.
   Ordinarily, the syncope attacks  the  woman Avhen standing, and she at
once experiences a ringing in her ears, vertigo,  dimness of vision, Aveakness
in the knees, and she has scarcely time to sit down, before she faints aAvay.
Some  females, however,  are  Avarned  of the attack by  the occurrence of
yawning,  and a  sensation of heat in the precordial region; soon after, the
extremities  become cold, the  face grows pallid, and is covered with a cold
sweat; the senses and intellectual  faculties are almost lost, the pulse  and
respiration have nearly ceased, though  a total loss  of the intelligence  and
sensibility is very rare.  For my own part,  I have never seen any Avoman in
this  latter state, since nearly all those whom I have carefully  questioned on
the subject have  stated that they had a confused idea of  what Avas passing
around them; and therefore, if there really be any instances of a complete
abolition of the faculties, they certainly are not so frequent as the authors
would have us helieve.
   While the syncope  lasts, we should employ the ordinary means, such aa
ammonia, vinegar, cold water, &c, &c. The  tonics combined  with anti-
spasmodics  have been recommended for its prevention:  for  instance, Van
Swieten highly  extols the use of orange-peel Avith  canella, or  lemon-rind
and  canella; in the proportion  of two or three drachms to three pounds of
sherry-Avine, of Avhich  three or four tablespoonfuls are to be taken daily.
Chambon has employed an  infusion of peach-blossoms with  success.   All
these nervous disorders are  more  alarming than serious.   We  have never
known  them  to  endanger the life of the mother, or to disturb the regular
course of  gestation.
   The attacks of fainting, though generally short, are sometimes quite pro-
longed.  In the latter case, they are frequently accompanied or folloAved by
some hysterical symptoms, as sense of oppression, hypogastric pain, constric-
tion  of the fauces, and sometimes true hysterical convulsions.  In the case
of a young lady, a patient of M. Rayer's, these symptoms occurred almost
every evening after dinner, during the last  three months of her  pregnancy.
They had no serious consequence, unless a  threatening of premature labor
toAvards the  end of  the eighth  month be so  regarded, which, hoAvever,
yielded to a small bleeding and opiate injections. 
DISEASES  OF  PREGNANCY.                  507
   [g 3.  Various Forms of Neuralgia.  Odontalgia.
   Various forms of cephalalgia and obstinate hemicrania are often observed during
 pregnancy.  Other neuralgias may also occur with their usual syirptoms in various
 situations.   The sensibility of the  skin  sometimes  becomes  sc  acute  that the
 slightest touch gives pain ; again there may be the sensation of intense heat in the
 feet and hands, or  else an  impression of cold Avhich nothing will remove.   (Jacque-
 mier.)  The Avails of the  abdomen are often affected with neuralgic  pains, Avhich
 will  be studied  hereafter in an article devoted to  the subject.   (See Abdominal
 Pains.)
   Odontalgia is the most common of all the neuralgias of pregnant Avoinen.  The
 lower jaw is the one usually affected, the pain sometimes invading one side, some-
 times both sides together.   It usually occurs during the first half of gestation, not
 unfrequently commencing shortly after conception,  of which it is sometimes the
 first sign.  It commonly ceases from the fourth to the sixth month.
   It Avere not  exactly correct  to  say that every case  of odontalgia is a true
 neuralgia, inasmuch as it is often  occasioned by  a  carious tooth.  It therefore
 becomes necessary, in view of treatment, to make a correct diagnosis,  and in order
 to do so, to give  the mouth a very careful examination.  (Churchill.)
   Mauriceau considered bleeding the  best remedy for the toothache of pregnant
 women, yet  it is a measure by no means certain, and  in some cases entirely inad-
 missible.  It is  recommended to guard against constipation by the use of mild
 purgatives  taken  at short intervals, and as local applications, the use  of gargles
 containing opium,  and plasters of opium and hyoscyamus.  Internally, some of the
 preparations recommended for facial neuralgias may  be tried ; such as  pills of
 cvnoglossus  or Merlin's  pills.   Should the  paroxysms  and remissions  be well
 marked, and more  especially should there be an actual  intermission, the best effects
 might be anticipated  from the  use of quinine.  No active^measures  should be
 resorted to unless the pain be very great, depriving the  patient of sleep and render-
 ing mastication almost impossible, for  the contact of foreign  bodies with the teeth
 is sometimes insupportable.   (Jacquemier.)  Capuron says that toothaches which
 had resisted all kinds of remedies have been known to  subside spontaneously about
 the third or  fourth month  of gestation.
   Should the  gums be inflamed, one or more leeches might be applied.  If the
 trouble is occasioned by a carious tooth, efforts should be made to relieve  it by the
 measures commonly employed, the best being cauterization of the offending tooth.
 As most authors think that extraction might cause  abortion, it would  be well  to
 advise patients not to undergo the operation.

   § 4. Paralvsis.
   Pregnant  Avomen are not exempt from the causes Avhich produce paralysis under
 ordinary circumstances, but are  even  more  liable thereto than other females of
 their age.  That such is the fact the recent researches of FleetAA'Ood Churchill and
 Imbert-Gourbeyre  have established bey-ond a doubt.
   Churchill  reports 34 cases of paralysis derived from various authors or observed
 bv himself.  In  22 of them, the attack occurred  during  pregnancy, and in the
 remaining 12, either during or after labor.  The location of the paralysis is noted
 as follows:  17  cases of complete  hemiplegia and 1 in Avhich it Avas partial; 4 of
 paraplegia, in 2 of Avhich  but one leg was  paralyzed; 6 of facial  paralysis, 3 of
 amaurosis, and  3 of deafness ; in some of the latter cases, however, the local affec-
 tion was connected with hemiplegia.  Of these 34 cases, 4 were fatal.
  Of the 22 cases occurring during pregnancy there were 12 of hemiplegia, 1 of
 paraplegia, 4 of facial  paralysis,  2 of amaurosis, and 3 of^deafness.  Analysis of
these  cases  shoAvs  no  regularity in  regard to the period of gestation  at which the
attack occurred, though it  seems that the patients were more liable  to the  affection 
508
PATHOLOGY OF  PREGNANCY.
during the latter months.   Most of them recovered before or after delivery, though
some continued to be affected for a considerable time.  But one case was fatal, anq
in this it was evident that the result was due to a disease of the brain antecedent to
the pregnancy rather than to the paralysis which had  increased during the latter;
so that this single case by no means invalidates the conclusion as to the relatively
trivial character of these attacks during pregnancy.
  It is often very difficult to determine precisely  the influence which pregnancy
may have in the production of the paralysis.  In our  brief exposition of the state
of knowledge on the subject, we shall have in view only such cases as occur during
pregnancy, and' thus endeavor  to  avoid being  led  off into the general subject of
internal pathology.
  The causes of puerperal paralysis are various ; in the first place we would men-
tion cerebral apoplexy, which is  not very uncommon in pregnant women.  Meniere
reports in his  excellent treatise  several  cases of  the kind, and, at a  later date,
M.  P. Dubois, whilst discussing  the  subject in a clinical lecture, came to the con-
.clusion that the frequency of its occurrence proves the  existence of some connection
between it  and the pregnant  condition.   How  then  shall the  connection be ex-
plained?   By  plethora or  hypertrophy of the heart?   Botli these views could
doubtless  be well defended, but M. Imbert-Gourbeyre believes thaA  the apoplexy is
due to albuminuria, which is well known to be common during gestation.  He cites
in support of his  A'iew several cases of Bright's disease Avhich terminated in cere-
bral hemorrhage, and calls to mind that it is by no means a rare attendant upon
eclampsia.  More well observed cases are  necessary to enable us to determine con-
clusively the value of this opinion,
  According to Churchill and Imbert-Gourbeyre, uraemia is almost the only cause
of puerperal paralyses,  such as amaurosis, deafness, and  hemiplegia.   As regards
amaurosis and deafness, we freely accept their opinion,- but have  some doubt as
regards hemiplegia.  Most authors, in fact, think that  uraemia never occasions
either  hemiplegia or paraplegia (see Uraemia), but however  this  may be, the so-
called  uraemic  paralyses sometimes accompany an attack of eclampsia  or else  are
preceded  by it.
  After cerebral hemorrhage and uraemia,  anaemia deserves to be mentioned, as also
hysteria, a reflex  action whose point of departure is located in the uterus, but whose
influence  extends to the spinal marrow; — rheumatism, etc., may also  be noted as
causes.
  We  have thus endeavored  to show that the causes of puerperal paralyses are
both  numerous and variable, so  that  it Avill be evident that the  prognosis and
treatment will  have to  be  modified  in the different cases.   The ordinary rules of
pathology must serve as a  guide in the course of medication to be folloAved.
  1. Amaurosis, — which is of  common occurrence in cases of albuminuria.
  It varies in degree from the slightest  amblyopia to perfect blindness.   It usually
affects both eyes, though Imbert-Gourbeyre says  that he has known but one eye
to  be  involved.  Though generally of short duration, it may  sometimes become
permanent and incurable.  It  may also be the first symptom to call the attention
of the physician  to  the  possible  existence of albuminuria, and is therefore of the
greatest A'alue as  a premonitory symptom in  the diagnosis of eclampsia (see
Eclampsia).  It may make  its appearance  before, during, and after  labor, and
recur in several successive pregnancies.  If the eyes be examined with the ophthal-
moscope, the retina will sometimes appear to  be healthy, whilst  at others a fatty
alteration will be observed or an effusion of blood; regard will be had to the latter
in the formation of a prognosis.
  2. Deafness. — Puerperal deafness is less frequent than amaurosis, and like it is
connected with albuminuria and  caused  by unemia.  The deafness  is  generally
imperfect and almost always preceded by roaring in the ears.   Like amauroris, it 
DISEASES  OF PREGNANCY.
509
 may be intermittent, permanent, periodical, single or bilateral; may cnange  into
 exaltation of the sense of hearing, be connected with other symptoms of albuminuria,
 or  exist alone, although it accompanies amaurosis as it were by preference.  We
 shall learn hereafter (see Eclampsia), that buzzing in the ears and deafness often
 precede and announce an attack of eclampsia (Imbert-Gourbeyre.)
  3. Facial Paralysis. — In  connection  with  amaurosis  and  deafness  may be
 olaced paralysis of the third and seventh pairs of nerves — although it is much less
 frequent.
  4. Hemiplegia. — Hemiplegia during pregnancy is of common occurrence, and M.
 Imbert-Gourbeyre has reported a large number of cases in his memoir.  Sometimes
 it is caused  by cerebral apoplexy;  at others, no lesion of the nervous centres is dis-
 coverable at the autopsy, whilst  the numerous  examples of rapid and permanent
 recovery seem to prove that there could have been no grave lesion of the brain or
 Bpinal marrow.  Albuminuria alone and often eclampsia have been observed with
 hemiplegia,  so that Imbert-Gourbeyre feels no hesitation  in saying  that uraemia is
 the usual cause of  this form of paralysis.  As has been said, Ave do not partake
 wholly of this view (see  Urcemia).
  Hemiplegia may sometimes also  be caused by anaemia, as  shown by the following
 case: A young lady had, during the early months of her pregnancy, an imperfect
 hemiplegia  characterized only by  weakness and numbness.  The symptoms were
 of  short duration and recovery rapid and complete.  In the absence of any other
 appreciable cause, the affection seemed to be due to a well-marked chlorotic condition.
  Paralyses are  not  rare  in hysterical women.  There is  nothing to prove that
 pregnant females enjoy any immunity in  this respect, so that  should any of the'
 symptoms peculiar to hysteria exhibit themselves, it would be reasonable to attri-
 bute the paralysis to the pre-existing neurosis.   In some patients even, the hysteria
 may  appear for  the  first  time  during  pregnancy and be  attended  by  various
 paralyses.   It ought, however, to  be noted that hemiplegia  is rarely  dependent
 upon hysteria.
  Finally, Avhen no cause can be discovered, we si\  in order to conceal our igno-
 rance, that the paralysis is  essential.
  5. Paraplegia. — Beside the usual causes of paraphgia, and independently of all
 those above  noted, this paralysis may  be occasioned by pressure of the fcetal head
 upon the nerves  of the pelvic cavity or by reflex action.   Paraplegia from pressure
 upon the nerves  by the head ought to be rare during pregnancy ; it has been more
 commonly Avitnessed during labor and after delivery, especially Avhen the labor has
 been severe  or attended Avith hemorrhage ; we have nothing further to say in regard
 to this cause.
  It is acknowledged, as stated,  that paraplegia  may be caused by reflex action;
 but how, in  these cases, can its production be  explained?   How can a partial ex-
 citement of the uterus so react upon the spinal marrow as to suspend its functions?
 Without pausing before the various theories proposed  by modern physiologists, we
 would  say that, according to M.  Jaccoud who wrote a  remarkable work  upon the
 subject, parahsis is occasioned by exhaustion of  the  nervous system,  an<I that
 numerous  experiments upon  animals tend, at least, to prove the correctness of his
 view: "Along continued, abnormal, excitement is transmitted to the spinal cord
 by the uterine nerves:  after a longer or shorter time it exhausts the excitability
 peculiar to the corresponding region of the organ, and the inertia of these nervous
 elements under  the action of the  brain closes the avenues  by which  the motor
 impulse is  transmitted; as a necessary consequence of this  state of things there
 results paralysis  of all parts situated below the affected points."
  Tlie following case of Echeverria's, which the  author and others after his example
have given as a type of the  so-called reflex  paraplegia is, to my mind, an  absolute
demonstration of the  theory just stated, — allowing the finger to be laid, as it were, 
510
PATHOLOGY  OF  PREGNANCY.
 upon the pathological  mechanism of the paralytic affection.   A woman who had
 miscarried three times, continued to suffer  after the last one severe pain in the
 hypogastrium accompanied  by a slight metrorrhagia.   Seventeen days after  +he
 abortion the  uterus was found to be anteverted ; it Avas soft and A'oluminous, rising
 an inch above the pubis; the neck was  sensitive, bled easily, and admitted  the
 finger ;  the anterior lip was covered by a  painful ulcer of a violet-red color.
   Having determined these facts, Echeverria, with the double object of exciting
 the contraction of the uterus' and hastening the cicatrization of the ulcer, had re-
 course to electricity by placing one pole of the apparatus upon the pubis, the other
 in the orifice of the  cervix, and then  transmitting a current of  low poAver.   In-
 stantly  violent pain was experienced in the womb, loins, and loAver  extremities,
 which were  seized with convulsive  tremors.  The current  was immediately sus-
 pended, when  it was found that in place of the convulsion  there was complete
 paraplegia which lasted  for fourteen hours (Jaccoud).   Is it not  evident  that we
 haA'e here a  case in which  extreme excitement exhausted  the irritability of the
 spinal cord?   Loss of motion  resulting and continuing until  the functions of the
 nervou6 centre had been restored by  adequate  repose.
   The causes of paraplegia  may be various and  combined, of which the following
 case is an example.  A young primiparous lady, of extremely lymphatic tempera-
 ment and affected with  general oedema, had a tedious labor requiring the use of
 the forceps.   Extensive  laceration of the perineum occurred, and  profuse hemor-
 rhage attended the delivery of the placenta.  The lying-in was also complicated by
 a  double phlegmasia alba dolens, pleuritic effusion, and ascites.   I attended  this
 patient  with  my friend Dr. Siredey, now hospital physician, and we  assured our-
 selves at Ararious times that the urine contained no albumen.   When convalescence
 was established, it Avas  found  on getting the  patient up that  she had  paraplegia.
 For  several months she Avas unable  to  stand, but the  poAver of motion gradually
 returned until at length walking was possible with the assistance of a cane.  Whilst
 this improvement Avas in progress the paraplegia suddenly became complete, the
 aggravation being afterward found to have coincided with tlie time of her becoming
 again pregnant; and throughout the gestation  no improvement took place.  During
 labor the limbs Avere thrown wildly about in a Avay which the patient Avould have
 been incapable  of doing by any  exertion  of her will.   After delivery the power
 of motion was again wanting.   The paraplegia continued for several months with-
 out  much amelioration, but finally disappeared  under  the use of strychnine  and
 electricity, the  recovery having been now for  a  long time perfect.  In this case,
 thus briefly related, it would be reasonable to  refer the beginning of the paralysis
 either to pressure by the head of the child during the first labor,  or to the hemor-
 rhage attending the delivery of the placenta ;  but hoAv shall Ave explain the recur-
 rence of the affection during the next pregnancy? In my opinion, the cause of the
 new phase of the disease must be regarded as an instance of reflex action.]

   §  5. Intellectual  Disorders.   Insanity.
   Those physicians who may be Avilling to admit  the truth of the analogy
 AA'hich we have endeavored  to establish betAveen  the sympathetic disorders
 of pregnancy, and those observed in young girls suffering from  difficult or
 irregular menstruation  (p. 462), will readily understand  the functional aber-
rations  of the intellectual  and  sensorial faculties so often observed in preg-
nant Avomen.
   The pre-existing alterations of certain organs of the senses are sometimes
very happily modified by the occurrence  of pregnancy.  A  young Avoman,
 whose imperfect vision had  obliged  her  to use spectacles from  childhood,
 found her sight so much improved immediately after the beginning of preg- 
DISEASES  OF  PREGNANCY.                  511
 nancy as no longer to have need of glasses.   (Obs.  de Salmat,  Cent, III.
 Obs. 270
   At other  times there is greater or less disturbance of the affective and
 intellectual  faculties.   I knew  a young lady  pregnant for the  first  time,
 whose former love for her husband Avas replaced  by an antipathy AA'hich she
 was barely able to overcome.  Another young  AA'oman, when five months
 gone, was suddenly seized with such an aversion  for  her apartment, that
 after many fruitless efforts, and notwithstanding all the force of her reason,
 she had  to be left in the country for the remainder  of her  pregnancy.
   Some  exhibit  a peculiar  tendency  to  sadness,  Avhich  is  mentioned by
 Burns, and of which I have observed tAvo  cases.   Certain individuals, avIio
 are usually of a gay disposition, suddenly become sad and. morose; refuse all
 the enjoyments tendered to them,  and entertain the belief  that they will not
 survive  their labor, with  a tenacity that nothing can overcome.   A young
 American lady, recommended to my care by M. Rayer, exhibited a profound
 melancholy for the last six Aveeks of her pregnancy.  Although surrounded
 by her  family, she declined  all  the pleasures  of the capital.  She  Avept
 unceasingly over  her  inevitable end, Avhich Avas  so near at hand,  and Avas
 constantly expressing  her  distress at being obliged  to leave all  Avhom  she
 loved.   She had  a happy labor, and from the next day  her  usual gayety
 Avas resumed.

   [Disorders of intelligence  may proceed even  to insanity;  although this form is
 more common with newly-delivered females than with pregnant Avomen.  Maree's
 excellent book, which shall be our guide in the preparation of this article, gives as
 the result of several collections of statistics, that of 310  cases of puerperal insanity
 27 came on during  pregnancy, 180 after delivery, and 103 during lactation.
   Puerperal  insanity may date from the time of conception,  or may  appear during
 the course of gestation.  In  19  of Marco's cases it  commenced with  conception
 eight times, and in the remaining eleven during pregnancy.   It began  th-ree  times
 in the third month, once in the fourth month,  three times in the sixth month, twice
 in the seventh month, and twice at times which  could  not be clearly ascertained.
 Melancholy seems to be the most common form of  this  insanity. Analysis of the
 above-mentioned 19 cases shows  that the duration  of the disease is very variable.
 Seven times  the recovery dated from  delivery;  twice only did it occur  during the
 course of gestation  ; nine times the disease continued, or else did not subside until
 long after delivery; finally, in one case, the delirium  was exasperated by delivery,
 and death occurred  shortly after.  The physician ought, therefore, to be very guarded
 in his statements when questioned in  regard  to the probable  result.   It is well
 also to know  that when a AA'oman becomes insane during gestation, there is reason
 to fear a recurrence, should she again become  pregnant.
  .Montgomery mentions the case of a Avoman who became insane at the com-
 mencement of three successive  pregnancies.   In another case, the derangement
 recurred  in  eight  pregnancies,  and ceased onl}-  after delivery.   By a curious
 anomaly,  hoAvever,  it happens that some Avomen suffer from this affection in one of
 their pregnancies only.
  Hitherto we have studied  the  influence  of  pregnancy as productiA"e of mental
alienation; but  there remains another question,  the  discussion of which Avill  not
be devoid of interest, to A\it: What  are the effects of  pregnancy occurring in a
woman who  is already  insane?  In  regard to this, Esquirol says, "Pregnancy,
labor,  and lactation are sometimes used by nature as a means  of curing insanity,
though, in my opinion,  this  resu.t is rare."   Almost  always,  indeed,  preguancy 
512                 PATHOLOGY  OF  PREGNANCY.
 gives to mental alienation a character of extreme gravity, either as regards its form
 or its duration.  It  is evident, therefore, that the practice of some physicians who
 recommend pregnancy for insane women cannot be too strongly censured.
   Labor itself, in its  last stages,  especially when the pains are extremely severe,
 may occasion disorder of the  intellectual faculties.  All accoucheurs, indeed, have
 described  the excitement of  mind which  occurs under  these circumstances, and
 Avhich in some rare cases assumes the form of maniacal delirium.  To the examples
 already noted on page 300, we add the following. A woman in the hospital of the
 Clinique was suddenly, when near the termination of her labor, afflicted with a
 complete hallucination ;  she saw a spectre  at the foot of her  bed, endeavoring to
 injure her, and which she made strong efforts to drive away.   The illusion lasted
 hardly two minutes before her mind became perfectly sane.   The transitory in
 sanity  occurring thus during labor is doubtless caused by the excessive  pain.
 NotAA'ithstanding its apparent gravity, it is rarely followed by serious consequences
 if care be taken, by sufficient watchfulness, to prevent  the lamentable acts to which
 the patients  might be  impelled.  It subsides spontaneously, and very rarely passes
 into long-continued mania.
   The part of the physician, in these cases, is easily pointed out. Generally every-
 thing will be left to nature ; but should the labor last too long,  delivery should be
 effected by the forceps.   Blood-letting at a later period, should  it be indicated by
 the signs of  plethora,  antispasmodics and  judicious expectant  conduct, Avill suffice
 for  the successful management of  an  occurrence which in itself presents but little
 gravity.
   There remain a few observations to be made upon the subject of the insanity of
 lying-in wcunen and nurses, known as puerperal insanity. As predisposing causes of
 this affection may be mentioned inheritance, numerous pregnancies, advanced age
 of the subjects, previous  attacks of insanity, eclampsia, and the return of menstrua-
 tion.  Sometimes the  disease  commences  suddenly,  but is often preceded by an
 accelerated pulse, heat of skin, dryness of tongue, thirst,, and the entire assemblage
 of pyretic symptoms.
   The various forms of mental  alienation  are far from occurring with equal fre-
 quency  under these circumstances, but may be represented in the following order:
 first, mania; secondly, melancholia and partial insanity.
   The  mania of lying-in Avomen ends in recovery, incurability, and, in some rare
 instances, death.  Of  these, recovery is by far the most frequent termination, and
 may be said  to include about  two-thirds of the entire  number of cases.  Cases are
 mentioned in Avhich the  affection subsided  in  less than three days, though it more
 commonly terminates  within  the first month folloAving the commencement of the
 attack.  Again, recovery may be postponed as late as  the sixth month, or not take
 place until after one, tAA'o, or more years.  The prognosis is most favorable in mel-
 ancholia and monomania.
   A great variety of remedies  have been recommended  in the treatment of puerperal
 mania.  Warm baths, purgatives, and  narcotics  are the most available at the out-
( set.  It is of the greatest importance to Avatch the patients, and not  lose  sight of
 them for a moment.   The children should  be taken away (Marce) ]


                             ARTICLE VI.

                           diseases  of the  skin.
   § 1. Itching.
   The skin, during  pregnancy, is sometimes affected with extreme  itching
 without any appreciable lesion.   M. Maslieurat-Lagemart has published a
 remarkable case of a lady who, in eight successive pregnancies, was afflicted 
DISEASES  OF  PREGNANCY.
513
 with itchings so violent as to produce premature labors.   On four occasions,
 they began in the sixth month, twice at eight months and a half, and  twice
 in the  seventh month.   They appeared  almost instantly over the entire
 cutaueous surface; the legs, thighs, genital parts, the whole trunk,  the  neck,
 face, scalp, were all affected;  nothing escaped  but the palms  of the hands,
 and even they Avere  invaded  at a  later period.  So  severe were they, that
 the violent rubbings of the poor sufferer excoriated the skin.   Hardly was
 she delivered when they vanished entirely.   The skin  retained its  natural
 transparency, color, and brightness throughout.  Simple and alkaline baths,
 ammoniacal and  camphorated frictions to the spine, preparations of opium,
 bismuth, valerian, hyoscyamus, belladonna, and bleeding, were all employed
 without advantage.
   Three cases of general itching which I have had occasion to  treat, yielded
 quite promptly to alkaline  baths.   (Five ounces of carbonate of potash  to
 an entire bath.)
   [I 2. Pigmentary Spots.  Pityriasis.'
   The skin during pregnancy often becomes affected with yellowish spots known
 as ephelidae, chloasma, and pityriasis versicolor.  When they appear on the forehead,
 cheeks, and chin, they receive the common name of mask.   These spots  affect by
 preference the face, especially the forehead; they vary in size, are almost symmet-
 rical in form,  and  never extend to the roots of  the hair, from which they always
 are separated by a border of healthy skin.  It Avould seem that the action of light is
 one of the principal conditions of their formation, and that the shadow of  the hair
 is sufficient to arrest their progress.
   M. Hardy, physician of the Hospital St. Louis, classifies them as  ephelides and
 pityriasis.
   The ephelides make no projection from the surface, and are  attended by neither
 itching nor desquamation; their examination would almost lead one to say that the
 "igmentary matter had left the healthy parts and collected in the spots, on account
 of the apparent bleaching of the skin around them.  They are the result, simply,
 of an accumulation of pigment within a circumscribed space.   Ephelides often ap-
 pear in women at the menstrual period, and  more especially during pregnancy:
 they usually vanish  after delivery, though, much to the chagrin of  those affected,
 this does  not  always happen.  When they continue, a special treatment, having
 for its object the  production of a superficial inflammation  of  the skin, will  often
 prove successful.   To effect this, M. Hardy recommends frictions to be made  twice
 a day with the folloAving lotion:
        R.—Water,......fgiv.
             Corros. Sublim.,     ....      gr. v.
             Sulph. Zinc,    .       .      .       .      .  3ss.
             Acetate of Lead,   ....      3ss.
             Alcohol,        .       .       .       .      .   q. s.
                      to dissolve the corrosive sublimate.
  Shoald the lotion fail, sulphurous douches, especially with  the mineral waters
of Luchon and Bareges, applied to the affected parts, may be used with advantage.
  Pityriasis versicolor, also termed hepatic spots and chloasma of pregnant women,
appear in the form of spots bearing strong resemblance to the ephelides.   In  pity-
riasis, however, the spots  project slightly from the surface of the skin, and  the epi-
dermis  becomes detached in the form of little scales, either spontaneously or by
scratching.  They are always accompanied by itching, which  is generally slight.
The characters just mentioned will suffice to distinguish pityriasis versicolor horn
      33 
514
PATHOLOGY  OF  PREGNANCY.
ephelides, in which there are neither elevation, desquamation, nor itching.  Pityri-
asis versicolor is a parasitic disease, so that the microscope affords another means
of diagnosis by exhibiting the spores and numerous ramifications amidst the epithe-
lial scales.
  The pityriasis of pregnancy usually declines after delivery, though in some casea
it remains and offers great resistance to the treatment employed.
  The therapeutic  measures are very simple.  Sulphurous waters, by lotion or
douche, and ointments containing sulphur, are often effectual.  The  above lotion
(see formula) and nitric acid ointment produce similar results.]

                          ARTICLE  VII.
                lesions  of the pelvic articulations.
  § 1.  Relaxation of the  Pelvic  Articulations.
  The question has long been agitated whether the  ligaments which unite
the bones of the  pelvis are ever softened, and whether  the articulations  are
movable.  Ambrose Pare himself, that great  surgical luminary, did  not
adopt the opinion of Hippocrates until  after' Severin Pineau made a dissec-
tion, in 1569, of a woman recently delivered, in his presence.  But, at  the
present day, this  question is determined  by a  very great number of cases,
and  it is noAV generally admitted  that  a ramollissement of the symphyse3
actually  occurs in most females during gestation.
  This softening may be and generally is slight; though it may be carried
to so great an extent as  to admit of considerable separation between  the
articular surfaces, constituting then a true pathological  alteration.  Hunter,
Morgagni,  and some  others, cite  instances where  the  relaxation Avas such
that the pubes could be drawn more than an inch apart.                      «
  With our present knowledge on the subject, it is impossible to explain  the
cause of this softening; for, when trifling, it generally escapes the notice
both of the Avoman and her physician;  but if well  marked, a separation of
the bones takes place as just stated.
  Authors do not agree  as to  the manner in  which the separation is pro-
duced; since, according to some, the cartilages are softened and thickened
by the liquids that  penetrate them, acting like a piece of prepared sponge
placed betAveen tAvo bones to absorb the effused  fluids; whilst others imagine
them to  resemble the  roots of the ivy, which insinuate themselves into  the
little crevices betAveen the stones of a Avail, and finally overturn it.  Louis
thinks  they act more like dry and porous wooden  wedges  placed  in  the
fissures of a rock, which, by  imbibing moisture,  swell up and ultimately
split the rock, — or like polypi in the nasal fossae and  frontal or maxillary
sinuses.
  M. Lenoir supposes that a slight degree of this relaxation is due simply to
serous infiltration of the pelvic ligaments resulting from the pregnant con-
dition ; the articular surfaces are, therefore, not separated, though separation
is possible under the influence of actions tending to produce it.   In the more
advanced stages, he adds to this softening a hypersecretion of synovia, which
distends the articular cavities, and separates the bones that constitute them.
Mobility in these cases is great, and if the joints be opened in the dead body,
a viscid fluid is discharged abundantly, as Avas  once observed by Morgagni, 
DISEASES  of  pregnancy.
515
  This relaxation,  may, according to Baudelocque, oppose the spontaneous
termination  of the labor, by destroying the point d'appui which the abdo-
minal muscles  derive from the bones of the pelvis;  and  perhaps, also, the
distress produced  by the engagement of the head, forces  the woman to re-
strain the pains as much as possible; though, on the other hand, from the
observations of Desormeaux, Smellie, dkc, Ave learn that this  circumstance,
so far from being a cause of dystocia, has actually permitted a spontaneous de-
livery in some cases Avhere the disproportion betAveen the size of the head and
•the dimensions of the pelvis Avould have otherwise rendered it impossible.

  [The attention of physicians has, of  late years, been again called  to  the study
if the relaxation of the pelvic symphyses  by a work of  M.  Ferdinand Martin,
Avhich was soon followed by M. Danyau's report.  A special article was devoted to
the subject in the previous editions of this work, so  that M. Trousseau was Avrong
in supposing that it had been omitted.  (Legons CUniques sur le Reldchement des
Symphyses du Bassin, May, 1865.)  Nevertheless, as the affection is still  badly
understood, frequent errors in diagnosis are the consequence.
  The pains  in the  back which many pregnant women suffer, are due  simply to
relaxation of the  symphyses.   To be convinced of the fact  it will be sufficient to
examine the lumbar region  by pressure over the sacroiliac articulations when, if
they be diseased, decided pain will  follow.  The same remark  applies to the sym-
physis pubis, which is often the seat of the vague pains complained of in the lower
part of the abdomen.
  In all these cases it is the more  easy to be deceived, as  the patients, on being
questioned, are rarely able to define  clearly the seat of their suffering, and the real
affection is OA'erlooked if care be not taken  to make a direct examination.  How
often is the uterus regarded as the source of  the pain, when the lesion is precisely
located in the pelvic articulations!
  The spontaneous pains produced by relaxation of the pelvic symphyses are more
particularly aAvakened by motion of the lower extremities,  as in  walking and stand-
ing, and usually subside upon lying  down.  In slight cases walking is difficult, the
patients are soon fatigued, drag their  limbs, and are unable  to stand  upon  one
foot.  In a more advanced stage, walking becomes increasingly difficult, painful, and
finally, impossible.  When the patient would stand, the sensation is as though the
sacrum descended between  the iliac bones, or as though the body would drop be-
tween the thighs.  It is then quite possible by moving  the loAver extremities to
perceive  the motion of the  ilia, and sometimes even a very sensible crackling or
clicking can be detected.   In one of M. Trousseau's  patients the end of the fore-
finger could  be readily inserted between  the two  pubic bones  and a softened con-
dition of the interarticular cartilage perfectly detected.
  Relaxation of the pelvic  symphyses is often greater after delivery than during
gestation,  and though more evident during the lying-in,  is still often overlooked,
and the pains Avhich it occasions attributed to metritis or uterine displacement.   In
all  these eases, however, the symptoms are the same and require similar treatment.
  The prognosis is variable; in slight cases no treatment  is required and the affec-
tion disappears after delivery.  In a more advanced stage, rest in bed is insuffi-
cient, and an appropriate treatment becomes necessary.   Sometimes  three, six, or
eight months, or several years, are required for the consolidation to take place.  In
one of M. Martin's  patients the cure was  postponed until after another labor.
There are facts, indeed, which go to prove that relaxation  of the  symphyses may
continue  through life in spite of the best treatment  Finally, in the following
article Ave shall speak of inflammation and  suppuration  of the symphyses, which
may also occur and lend fresh gravity to the affection. 
516                PATHOLOGY  OF PREGNANCY.
  As soon as the relaxation is discovered, the patient should be put to bed aid kept
strictly at rest, with the pelvis held motionless by means of a compressor} bandage.
For this purpose a  towel passed  around the  pelvis and drawn very tight, may
answer in the simplest cases.   The procedure is at once a rational treatment and a
means of diagnosis,  inasmuch as relief  is generally immediate, and if successful,
leaves no doubt as to the nature of the disease.  Bandages of linen or ticking are,
however, liable to stretch and  loosen in a very short time, in which case a good
substitute  is found,  according to Boyer, in a leather  belt quilted internally and
caused to surround the pelvis between the great trochanter and crest of the ilium
and buckled in front.  The best apparatus, however, is the one recommended and
used by M. Martin.   It is composed of a strong circular piece of metal two inches
wide, open in front,  and large enough to embrace  the entire circumference of the
pelvis.   It is padded and quilted like the spring of  a truss  and provided  at one
end with a. strong strap and with a buckle at the other, Avhereby the ends are
brought together and  held firmly.  This  apparatus  has  the  advantage of being
applicable during pregnancy without  interfering with the  development of the
abdomen, and is even more useful after delivery.  Although its  weight is consider-
able, the patients soon become accustomed to its use.  It secures immobility of the
bones so fully that absolute quietness is no longer  necessary, and the patients may
walk every day Avithout the recovery being interfered with.
  "We owe," says M.  Danyau, "the acknowledgment to M. Martin, that his belt
fulfils all the indications, and that none other does so  more  effectually.  Not only ia
it, like Boyer's, narrow enough to clasp the pelvis where the pressure can produce
neither interference  nor injury and be at the same time really  effective, that is to
say, between the crests of the ilia and  the great trochanters, but what is not less
important, it is so strong and stiff that when once applied and the bones brought in
contact by it, separation afterward becomes impossible."]

  When to relaxation of the  pelvic  articulations, inflammatory symptoms
are added, they should be met by the appropriate means;  in their absence,
we  may apply gentle pressure around the pelvis, and make use of some
topical applications, general and local tonics, and astringent and  resolvent
lotions.  After  the total disappearance of  the lochia, Desormeaux highly
extols  the employment of douches,  sea-bathing, a good  diet of  nutritive
articles, the Spa and Seltzer  waters, Avearing  flannel  next to the skin, and
dry frictions.   We cannot  recommend too highly the use, in these cases,  of
the steel girdle of M. Martin,  which, when tightly drawn around the pelvis,
immediately restores a portion of its normal solidity, and facilitates the cure
wonderfully.
  These measures should be continued for a long  time, and even when con-
valescence is fully established, the  greatest possible care must be  exercised
in rising, Avalking, &c.

   § 2. Inflammation of the Pelvic Articulations.
   Inflammation of the pelvic  articulations, which is  sometimes  observed
after labor, may also occur, though  more  rarely, during  pregnancy.  Drs.
Hiller, Monod, Danyau, and  Professor Hayn, of Konigsberg, have  men-
tioned instances of it.
  •The disease  generally begins without appreciable  cause with sudden,
acute, sometimes lancinating, though  usually heavy pain, hi one or several
of the pelvic articulations.  The pain is increased by pressure, standing, and
especially by attempts at walking, Avhich is sometimes altogether impossible. 
DISEASES  OF  PREGNANCY.
517
   These pains often extend  into the lower extremities, and especially into
the thighs.  Swelling can sometimes be detected over the inflamed articula-
tions,
   These articular  pains are sometimes  attended  by a febrile movement,
which is occasionally severe, though generally  quite  moderate.   In some
cases, indeed, there is almost no general reaction.
   The  inflammation,  Avhen  moderate, usually  yields promptly  to proper
treatment; the cure is almost perfect after  tAvelve or fifteen days, and  the
delivery and lying-in seem to experience no unfavorable effect from it.  In
some cases, however, whether in consequence of the intensity of the inflam-
mation, or because  the proper means Avere not  employed Avith sufficient
energy, the disease ended in  suppuration, and in tAvo instances proved fatal.
In these cases, the articular surfaces were found denuded of cartilage.  MM.
Hiller and Monod mention tAvo cases which proved fatal in this manner.
   If  the pains  are very acute, and  the general  reaction  decided, general
and local bleeding may be  employed at the outset.   But Avhen there is no
fever, and the local symptoms are moderate, Ave may be content Avith  resol-
vent applications, restricted diet, and absolute repose in the horizontal pos-
ture.   Narcotics may be added to the resolvent applications, if  the  pains
are too severe.

                         ARTICLE  VIII.

                DISEASES OF THE VULVA  AND VAGINA.
   [Various lesions of the vulva and vagina impede delivery, and are therefore dis-
cussed in the article on Dystocia.  At present we shall describe only pruritus of
the vulva, leucorrhcea, and vegetations, as  they occur in pregnant women.

   § 1. Pruritus of the Vulva.
   Pruritus of the vulva, though not peculiar to, often occurs during pregnancy. It
is characterized by intense itching of the  external genital  parts, the labia majora
and minora, and  often extends even into the vagina.   The itching is irresistible,
obliging the patients to scratch  themselves, and thus, in consequence of the  relief
afforded, leads to a sort of masturbation.
   Examination of the affected parts discovers no appreciable alteration :  sometimes
there  is redness,  at others some exudation of serum with  superficial ulcerations
reminding one of eczema.  (Hardy.)]

   The itching Avas so insupportable in a young married lady under my care,
that she  could not refrain from continual scratching, and the general irrita-
tion resulting therefrom almost threw her into convulsions.
   In another instance, a young  girl, Avho Avished to conceal her pregnancy,
was so tormented by this disease,  that  it was absolutely impossible to hide
her distress from the observation of her family;  and when I examined her,
I found the internal face of the labia externa, and the nymphse, both SAVollen
and inflamed from the constant scratching; the nympha on the  right side
had been so  long, and so strongly  dragged  upon, that it had acquired  twice
the usual length at least.   Generally speaking, the frequent use of bathing,
and of the vcge to-mineral lotions  applied five or six times a day,  Avill calm
the itching;  an 1 as it is often greatly aggravated by walking, perfect rest is 
518
PATHOLOGY  OF  PREGNANCY.
of course indicated.   Some advantage  is often to be derived from a fine
compress  dipped  in  oil of sweet almonds, and then  placed in the vulvar
fissure; or still better, if the compress be soaked in lead-Avater.
  Dewees  states that he examined a young lady who complained of this
excessive itching in the genital parts, and he found  the internal face of the
vulva, as also the inferior part of the vagina, covered by numerous aphthae;
and  that the  application of a strong solution of borax, four or five times a
day, caused them all to disappear in the course of twenty-four hours.
  Dr. Meigs has always found the folloAving preparation useful: —
     R—Borax,..........3ij.
          Sulph. of morphia,   .......    gr. ivss.
          Dist. rose water,........foviii.
  Apply tSiree times a  day to the  affected parts, by means of a sponge or
piece of linen, taking care to wash the parts beforehand Avith soap and water,
and to dry them well aftenvards.   The  folloAving solution of bichloride of
mercury may also  be used Avith  advantage:  Add a drachm and a half  of
corrosive sublimate to four ounces of distilled water, and of this solution  let
the patient add a dessert-spoonful to a pint of very warm Avater, and use for
injections and lotions.  Hot water alone will answer in many cases.  (Trous-
seau and Pidoux.)
  [Pruritus of the vulva is often very obstinate.  In the rebellious cases mentioned,
M. Dubois advises that the entire mucous surface of the vulva be cauterized with
the solid nitrate of silver.   A great objection to it however is,  that it is extremely
painful and almost always produces but temporary alleviation.   We have generally
succeeded with a solution of corrosive sublimate, as follows:
          R.— Bichloride of mercury,.....gr. xxxi.
               Alcohol,.......f3iij.
               Rose water,  .    .    .     .    .    .    .  f,^iss.
               Distilled water,.....f^xv.
  This is used as a wash, undiluted, morning and evening, as follows: After using
warm water for the purpose of removing mucous secretions  from  the vulva, and
drying the parts well with a piece of fine linen, a small  sponge saturated with the
fluid is passed rapidly over the  entire itching surface, so as to moisten it thoroughly.
A smart burning sensation is the first effect of the application, which is alleviated
by a few minutes washing with cold water.  Subsequent applications are less and
less painful, and the cure is generally rapid.  We prefer this treatment to all others.]

   §  2. Leucorrhcea.
  We shall limit ourselves to  a short notice of the profuse leucorrhcea with
which women are  very often  affected during pregnancy.   This  discharge,
which is sometimes white and  sometimes of a yellowish-green  color, usually
makes its appearance during the second half of gestation, though  I have
seen some persons affected Avith it from  the  early months.   It is generally
coincident with the development of numerous granulations,  which, as  we
have already said, sometimes  cover the. vaginal  mucous  membrane, and
constitute Avhat  has been described of late as granular vaginitis.   When it
is very  profuse,  an examination  by  the speculum  frequently  discovers
numerous  ulcerations of the neck of the uterus.  We shall  ha ve occasion 
DISEASES  OF  PREGNANCY.
519  .
 to speak of these ulcerations hereafter.   I am convinced that the vaginal
 granulations and ulcerations of the cervix are very rarely as serious during
 gestation as they appear to be under  some  other circumstances, since they
 generally disappear with the pregnancy, during Avhich they are developed.
   Sometimes the discharge is so abundant as to react upon the functions of
 the stomach, and I have seen several  patients with symptoms of gastralgia,
 evidently connected Avith the  leucorrhcea, inasmuch as  they increased or
 diminished  according as the latter Avas more or less profuse.
   This affection often produces, in addition, great irritation, a burning heat,
 and sometimes an almost insupportable  itching of the  lower part of the
 vagina and external genitals.   A  profusion of small vesicles appear  upon
 the internal surface  of the  greater and lesser labia, Avhich,  by  constantly
 rubbing against each  other, finally  give rise to excoriation, aijd render
 Avalking very  painful.
   Frequent baths, lotions, and injections of cold water, to  each quart of
 which a dessertspoonful of subacetate  of lead  has been  added, repeated
 several times daily, according to the  degree of pain, are the best  remedies.
 It -will also  be  found advantageous  to separate the  parts, by introducing a
 piece of fine linen between the labia, so as to prevent friction Avhilst Avalking.
 It is unnecessary to say that the introduction of  the speculum during preg-
 nancy requires that especial care be taken not to press it too  far.
 • Though the  patient's sufferings may easily be alleviated in this manner,
 it is more than probable that the granulations will continue, and that the
 discharge will  not cease entirely;  in spite of all  that can be  done, it gener-
 ally lasts until the end of  pregnancy,  and in the great majority of  cases
 only terminates after delivery.

   [Would any disadvantage attend the insertion in the vagina of tampons formed
 of carded cotton and alum?  Would  they  be likely to occasion  abortion or pre-
 mature delivery?  During my present temporary service at the Lourcine hospital,
 I have found quite a number of pregnant women affected with vaginitis and profuse
 leucorrhcea,  and in all such cases  it is the practice there to use the above-named
 tampons, notwithstanding the  fact of pregnancy.   I  continue them as  they have
 been used heretofore,  though  not without apprehension;  still no accident hai
 occurred as yet.   I should desire, however,  a longer experience, before I could feel
 willing to advise them.
  Vaginal injections, especially if  used indiscreetly, may excite contraction of the
 uterus  and abortion, if the fluid be thrown upon the os tineas.

  § 3.  Vegetations.
  The external parts of generation, particularly in women affected withblennorrhcea,
 vaginitis, or  uterine catarrh, often become covered with vegetations, which  were
 long supposed to be of  a  syphilitic character.  They  seem always  to be connected
 with the presence  of a discharge in non-pregnant females;  that their  production
 may also be favored by pregnancy, is a fact  established, as I  think, by the treatise
 of M. Thibierge.
  The  vegetations may appear in pregnant women  at  any period of  gestation.
They consist  of tufts of a rosy hue, attached by a pedicle, and spreading nut like
a caulifloAver. In  respect to number and size they vary greatly.
  They may  be either scattered or so grouped as to form large masses.   A patient
in the Hospital of  the Clinic had them in the form of  a tumor as  large as the fist. 
520
PATHOLOGY  OF  PREGNANCY.
They affect more especially the mucous membrane of the vulva, though they also
form on the external  surface of the labia majora, in the  furrow between the but-
tocks, about the region of the anus and the genito-crural folds: sometimes, even,
they sprout from the walls of the vagina or the os tincae, though in these situations
they are generally small.
  They are attended with itching, considerable pain, and a discharge.  They also
exhale a very unpleasant odor, but are really devoid of danger, and occasion no
obstruction to  delivery, even when of large size.  In the majority of  cases they
disappear spontaneously after delivery; the pedicle dries up, and they fall like a
ripe fruit.  This favorable termination is not, however, universal.
  One of their peculiarities is that of continuing to sprout during gestation in spite
of all kinds of treatment.  Still, M. Thibierge thinks that the use of local appli-
cations during  pregnancy may dissipate them when  small and few in number.
Under other circumstances they are almost certain to return.
  In regard to treatment during pregnancy, an attempt may, in the first place, be
made to  destroy them by local applications, as of alum,  nitric  acid, or the acid
nitrate of mercury applied drop by drop.  Excision, and even  crushing, are liable
to occasion obstinate hemorrhage, so that radical operations ought not  to be per-
formed.  After delivery, should the trouble  persist, any of the methods of treat-
ment used in such cases become applicable.]


                           ARTICLE  IX.

                    ABDOMINAL  AND UTERINE PAINS.                  »

  Beside the numerous functional  disorders just studied, some  pregnant
women suffer, in various parts of the body, pains whose  intimate cause  is
imperfectly understood,  and to which they sometimes call the  attention of
the physician.  Some of these pains  appear to  be seated in the abdominal
parietes, the lumbar region, the groins, and the internal part of the thighs;
others, again,  appear to affect more  especially the walls of the uterus, or
the annexes of that organ.

  § 1. Abdominal, lumbar, and Inguinal Pains.
  These pains, which are sometimes confined to a quite limited space of the
abdominal parietes, do  not  often  appear before the latter months of gesta-
tion. t They  are  frequently felt  at the lower part of the breast, near the
upper insertions of  the  abdominal muscles, or, less  often, in  the inguinal
folds near their  inferior attachments.   The  pains are  much  increased by
motion, the least  pressure, and  sometimes, also, by the movements of the
child, if violent.   As already stated, they are generally limited in- extent,
sometimes  not affecting a space  larger than a silver dollar, the  parts sur-
rounding being entirely  free from pain.
  Since lumbar and inguinal pains, occurring in the first  half of  gestation,
may be the preludes of  an abortion near at hand, they claim special atten-
tion.   At this early period  they are almost uniformly the sympathetic ex-
pression  of uterine disorder, itself due to a local congestion, though perhaps
still oftener to a special  irritability of  the Avomb.  They  then  resemble
precisely the lumbar and inguinal  pains which are so often experienced by
young girls affet ted with dysmenorrhoea or amenorrhcea, and are effectually
overcome by opiates, small revulsive bleedings, and sometimes  also, in very 
DISEASES  OF  PREGNANCY.                  521
 nervous women, by warm bathing.   If, as is  often the case, the pains seem
 to be increased by sexual intercourse, too long a walk, or riding in a carriage,
 it were useless to say that abstinence from all these causes, and repose in the
 horizontal posture, are the first indications to  be fulfilled.
   These  pains most  commonly  appear  toward the end of pregnancy, but
 their cause, that especially of the lumbar pains,  is very  obscure.   Some-
 times, hoAvever,  it can be ascertained  that they  are  seated  in the pelvic
 articulations (see  page 515).  Dragging  upon the broad ligaments, com-
 pression  of the  lumbar  nerves, extreme distention  of  the  uterus,  and
 engorgement of the  pelvic  and  uterine vessels, have  been successively ad-
 duced  in  explanation ; but  though  the relief obtained from  bleeding, in
 some cases, Avould seem to  show that  they might sometimes be caused by
 local plethora, there  is no  evidence of  any such  influence as  is attributed
 to the other causes mentioned.
   The  inguinal pains have generally been referred  to traction  upon the
 round  ligaments.  I  do not say that this traction may not produce them,
 but I am convinced that toward the  end  of pregnancy they are  oftener
 due to the pressure of the  uterus upon that region, in the vertical  as  Avell
 as in the  sitting posture.   They generally disappear, indeed, in  the hori-
 zontal  position,  and the best  means of relieving the patients is to support
 the abdomen, and at the same time raise it a little by means of a Avell-made
 corset, or of a large abdominal belt, the central portion of which embraces
 the sub-umbilical region, and whose tAvo ends are attached to the back  part
 of the corset.

   [Having for some time made a special study of these abdominal,  inguinal, and
 lumbar  pains, we are convinced that very often  they are due to neuralgia of the
 cutaneous nerves from the collateral  branches of the lumbar plexus.  To be  assured
 that such is  the case, it is  only necessary to  test carefully the sensibility of the
 skin in  these regions, either by rubbing it rudely with the end of a pencil, or by
 raising  it in the form of a fold which is to be  gradually  pinched between the
 fingers.   Pressure ought also  to  be made  all along the crest of the ilium in the
 direction of the genito-crural nerve.  Should Ave be satisfied with merely question-
 ing the  patients, or depressing the  walls of the abdomen by the hand, we would
 incur the  risk of obtaining very little information, or of suspecting the existence
 of a deep-seated visceral pain when  the skin only is affected.  This mistake, which
 we see committed every day, would be avoided by taking the trouble to make the
 above-mentioned examination, and we cannot recommend it too highly.
  The principal parts affected by this neuralgia are the lumbar, iliac, hypogastric,
 and inguinal  points, though the pain may  appear  in some other portion of  greater
 or less extent of the skin of  the abdomen.   Sometimes confined to a circumscribed
 point, it  occasionally invades  an entire half of the abdominal walls.   It very
 rarely affects both sides at the same time with equal intensity.
  The local  application of narcotics constitutes the treatment par ^excellence, of
 these neuralgic  pains.   We have almost always succeeded with very small  blisters
 sprinkled with  one  of the salts  of morphia.  Subcutaneous  injections are  also
 clearly indicated, and none of these  methods are  liable to effect unfavorably the
 course of the pregnancy.
  What  we have just written  applies especially to  the abdominal neuralgia of
pregnant wo nen ;  but before leaving the subject, we desire to say that the same
affection is also extremely common  after  delivery.  In the latter case, however, 
522
PATHOLOGY  OF  PREGNANCY.
instead of being the chief pathological  element, it is almost altf fiys symptomatio
of a  lesion of some one of the pelvic organs.   Its investigation  is not,  on  this
account, less  important, because,  generally, the intensity of an inflammation  is
estimated by the  acuteness of the  pain which it produces.  Under these  circum-
stances,  if the skin be raised carefully between two fingers, and the  fold thus
formed be pinched, it is often found that the pain is seated partly  in the skin and
not in the uterus or its appendages. The physician is thus better informed, since a
slight metro-ovaritis may be attended by a violent cutaneous neuralgia  more
alarming by far than  dangerous.
  The lumbo-abdominal neuralgia  which is symptomatic of a metro-ovaritis or of
a met>ro-peritonitis, also  enables us to understand certain facts which would be
inexplicable without it.  Suppose a newly delivered female to  be attacked by
metritis; the uterus is  examined by depressing the walls of the«abdomen by the
hand, and several examinations carefully conducted assure us that pain is produced
about the fundus  of the organ.   The usual treatment  in such  a case consists in
the application of  leeches directly  over the seat of pain, and, we must say, almost
ahvays affords relief.  Is it not surprising that  such a result should be produced?
How could we suppose that an abstraction of blood from the skin  of the abdomen
near the umbilicus would act directly  upon the fundus of the uterus when all
vascular  communication between  the two parts is prevented  by the interposition
of the peritoneum ?  We bow before the  facts, yet believe that  the bites of the
leeches,  when they afford relief,  do  so by acting directly upon the  cutaneous
neuralgia  which  is  symptomatic of the  metritis, and have no  effect upon the
vascular engorgement of the uterus.  The same result would follow the  applica-
tion of a blister dressed with a' salt of morphia.  As soon  as  time shall permit,
we intend publishing several cases which go  to prove what we have just  said
respecting the part played by lumbo-abdominal neuralgia during pregnancy and
in the diseases of  lying-in women.]
   The pains in  the internal parts of the thighs, the numbness and  cramps
of both legs, though more  commonly of one only, are usually attributed to
pressure of the head on the lumbar and sacral nerves.  But, as Tyler Smith
remarks, since they mostly occur at night, Avhen the women are in the hori-
zontal posture, or whilst they are sitting, in both which positions the pressure
should be much less than whilst standing, it seems very probable  that com-
pression of the nerves is not the cause.   Perhaps we may accept the  idea of
the English  accoucheur, that, like the corresponding affections in cholera,
they are connected with some irritation or difficulty of the large intestine, or
with a  morbid  condition of the uterus.   It Avould not be the only instance
of visceral  irritation producing spasmodic  contraction of the muscles of
animal  life by reflex action.
   According to this hypothesis, the best means of preventing the recurrence
of the cramp is to keep the boAvels free,  and allay the irritability of the Avomb
as much as possible by baths, opiates, &c.   The surest means of counteract-
ing it is to contract voluntarily, the very moment it appears, the antagonistic
muscle  of the affected one; thus the thigh should be strongly extended when
the flexor muscles are contracted, and the  foot should be  flexed on the leg
when the cramp  affects the muscles of  the calf.

   § 2. Uterine  Pains.
   1. Beside the  uterine  pains which sometimes  accompany  the outset of a
disordered pregnancy, also beside those which seem to herald the  approach 
DISEASES OF  PREGNANCY.
523
of labor  in  the  latter Aveeks  of gestation, females experience, at variable
periods and  intervals, pains AA'hich are sometimes very acute, an l evidently
seated  in the Avails  of the uterus itself.   It is  impossible  to determine  the
cause and nature of these pains; for though they may be attributed, in some
rare instances, to partial spasm of the muscles of the uterus, or to  a more
or less extensive inflammation, most frequently nothing* of the  kind is to be
discovered.  Sometimes they are limited to a single circumscribed point,
whilst at others they affect the entire Avomb.  In the first case they are con-
tinuous ;  in  the  second, they are irregularly intermittent, and their recur-
rence, or rather  their paroxysm, appears to  coincide Avith a motion of  the
female, pressure  upon the abdomen, an attack of coughing, or sudden move-
ments of the child.  At the same time the uterine tumor may almost ahvays
be felt to become denser and harder: in short,  a true contraction  takes
place, which continues as long as the paroxysm lasts.   If, struck Avith this
condition of the  body of the Avomb, an  examination be made per vaginam,
the cervix will be found unchanged, having undergone no alteration which
could excite solicitude on account of the long-continued previous contrac-
tions.  Usually,  there is very slight general reaction, and little  or no fever.
   When the pain is both circumscribed and moderate,  emollient and nar-
cotic applications may be found sufficient; but when more severe, it Avill be
necessary to  prescribe the most absolute repose, injections Avith camphor and
laudanum, baths, maniluvia, and even bleeding from the arm.  It generally
yields to these measures Avhen properly employed, though, unfortunately, it
returns Avith some individuals very frequently.  I  have, at this  moment, a
young lady under care, Avho is at the eighth month of her pregnancy, and
Avho has had  five attacks  within three months,  two of  them  lasting  for
twenty-four  hours.  The first time she Avas bled; but as her general condi-
tion seemed to  contraindicate a repetition of this measure,  and she Avas
very averse  to bathing, I Avas obliged to content myself  with prescribing
rest and opiate injections.   Noav, there is every prospect of her  reaching  her
full term.
   2. The sensibility of the uterus is sometimes singularly increased  by con-
stant and violent motions  of the foetus.   Some children, indeed, seem  en-
do Aved Avith  such activity that they  are  hardly ever  quiet, and their con-
tinual movement becomes a cause of irritation to the Avomb, Avhich, by re-
acting upon  the Avhole economy, may produce insomnia, general excitement,      i
and nervous and sometimes even convulsh'e  movements.  I have seen two
instances of  these disordered motions of the child;  especially Avas it marked
in the  case  of the Avife of one  of my professional  brethren.  This poor
lady avus delivered  at  term, notAvithstanding she  had been almost entirely
deprived of sleep during the eighth and  ninth months.   Burns says, that
patients  under  these circumstances are delivered rather  before the  ninth
month.   The bleeding and  opiates Avhich he recommends may indeed lessen
the irritability of the uterus, but evidently can have no poAver to diminish
the activity of the motions of the child, which  is the first  cause of  the
uterine pains.1
  1 Dr. Tyler  Smith endeavors to show, in  a very interesting memoir, that the  active
motions of the child amount to almost nothing, and that the sensations perceived by 
524
PATHOLOGY  OF  PREGNANCY.
  3.  Some authors state  that  metritis,  or metro-peritonitis, are possible
during pregnancy, but they are so rare that it has never fallen to my lot to
see them.  Besides, they seem to me to belong to the same category as all
the acute  affections which  may arise during pregnancy;  and though the
usual gravity of the prognosis be heightened by the condition of the female,
the treatment would be the same as after delivery.

  § 3. Rheumatism  of the Uterus.
  Rheumatism of the uterus, although studied for a long time in Germany,
was scarcely knoAvn in France, until M. Dezeimeris published in his journal
(PExperience) a series of facts that Avere previously known to, and put forth
by, the  German  authors.   About  the  same  time, M. Stoltz,  who Avas ac-
quainted Avith the works of our neighbors ®n the  subject, devoted particular
attention to this affection at the Clinical  Hospital of Strasbourg, and com-
municated the result of his observations to his  pupils.  One  of them, Dr.
Salathe, has quite recently defended a thesis on this  subject;  and from his
work, as also from the bibliographical researches of M. Dezeimeris, I extract
the following account of this disease, Avhich is unknoAvn to French nosologists.
  According to Radamel, rheumatism may attack the uterus in  the  non-
gravid state; but we have only to  study  it here as  occurring in pregnant
females, in whom it may appear at all stages of the puerperal condition.
Therefore,  after some general remarks on the disease itself, it will be neces-
sary to point out the influence that it may have over the gestation, the par-
turition, and the lying-in.
   Causes. — Every circumstance calculated to favor the development of the
rheumatic  affections in general, may likewise prove a source of rheumatism
of the uterus: thus, a momentary or a  prolonged  exposure to cold and
moisture, inadequate clothing, or sudden changes from a very high to a very
low temperature, and all those other atmospheric constitutions Avhich have
been enumerated by medical authors, either as predisposing or as determin-
ing causes of rheumatism, may likewise  produce that of the  womb.   But,
besides  these general causes, there is one peculiar to the disease under con-
sideration ; that is, the susceptibility of this organ to the impression of cold
under the attenuated integuments of the abdomen during the latter months
of gestation ;  for the belly is only covered at that particular point by very
light  clothing, which is far from fitting closely, and the lumbo-sacral region
is often but imperfectly protected by the short jackets worn by the patient.
  Symptoms.—Rheumatism of the  uterus very often occurs in persons who
are constitutionally predisposed to the rheumatic affections; and it may co-
exist  with  a general disorder of the same nature, though in the majority of
cases  the  womb, together  with its  appendages  and  the adjacent parts, ia
alone affected.  Again, it has oftentimes  resulted from a sudden  cessation

the mother and accoucheur, hitherto attributed to  the muscular  contractions of the
child,  result simply from partial contraction of  the muscular fibres of the uterus. Not«
withstanding the seductive character of the reasons adduced by Dr. Smith, we hold to
the generally received opinions, though entirely disposed to think that the views of
the English accoucheur may be applicable to  the ex "eptional cases of which we ara
speaking 
DISEASES OF  PREGNANCY.
525
of a rheumatic pain at some other point, which is speedily transferred to the
uterus.   But, whatever may have been  the mode of its attack, this disease
exhibits some Avell-marked peculiarities, by which it can easily be recognized.
The principal  symptom is pain, or a distressing sensation, Avhich  involves
the whole, or a part of the womb, Avithout any violence having been exerted
on the organ;   its intensity varies from a simple  feeling of heaviness to the
most painful dragging sensation ; and it may occupy either the entire Avomb,
or only one of its parts, such as the body, the fundus, or the inferior segment.
When the  rheumatism is fixed in the fundus uteri, the pain is particularly
apt to be felt in the sub-umbilical region ; it is augmented  by pressure, by
the contraction of the  abdominal muscles, and sometimes even by the simple
weight of the bedclothes ; and in  many cases  the patient is unable to bear
any movement whatever.   If seated somewhat  lower, she suffers from acute
dragging sensations, that  run from  the  loins toward the pelvis, the thighs,
the  external genital  organs, and the sacral region, along the uterine liga-
ments.  Finally, when the inferior segment participates in the affection, the
seat of it can be detected by the vaginal  exploration, which gives rise to the
most acute  sufferings.  But, of all  the  causes that may exasperate these
pains, there are none  more distressing than the incessant movements of the
child.
   Like all.  rheumatic pains, those of the  uterus  are metastatic, and they
occasionally pass rapidly from one  point of the organ to  another;  often,
indeed, they disappear at once, and pass off to some other organ.  This  is
particularly apt to occur when the pain Avas originally located at some other
point, and measures have been employed to recall the affection to  the part
primitively attacked.
  They present frequent and variable exacerbations in their duration and
intensity, according to the stage of the disease;  sometimes they are followed
by remissions,  during which the patient  experiences only a vague sensation
of weight in the part.   The  uterine pains are usually accompanied  by a
recto-vesical tenesmus, which is the  more distressing as the  former are the
more energetic, and are seated near the inferior segment.   The patient is
then tormented by a continual desire to empty  her bladder; the emission of
urine is attended by a smarting sensation, and sometimes by acute sufferings,
while at others  it is even Avholly impossible; and in many cases the attempts
to move the bowels  prove equally ineffectual.   Most of the German authors
attribute this double recto-vesical tenesmus to a rheumatic affection that is
not ahvays exclusively limited  to the womb,  but which also  invades the
neighboring organs.  But M. Stoltz  appears  disposed to believe that it  is
rather the result of the close sympathy existing between these adjacent parts;
for, if these  neAV pains Avere occasioned by a  rheumatism of  the rectum or
bladder, those of the uterus ought to  disappear altogether, or at least should
be diminished.  (Salathe's Thesis.)
  Analogy Avould lead us to suppose that an unusual heat and tumefaction
must exist in the affected parts; but the  difficulties in detecting these char-
acters are self-evident, although their existence  is quite probable.
  Such acute pains, seated in so important an organ, would  naturally pro-
duce considerable general reaction ; and it is found that this disease, like 
526
PATHOLOGY OF  PREGNANCY.
the greater number of the inflammatory affections, most usually commences
by a slight  chill, Avhich  lasts for a quarter of an hour or tAventy minutes;
the fever that follows it diminishes, and  sometimes disappears altogether,
during the interval between the paroxysms;  but, pending their duration, it
is usually quite intense, the pulse is frequent and hard, the face excited and
flushed, and the tongue is red and dry; the patient complains of thirst, the
skin is hot, and she often suffers from an extreme agitation and restlessness.
Towards the end of the paroxysm, a profuse perspiration  generally breaks
out, which seems to be the prelude of a notable amelioration.   Then  these
general phenomena become  moderated, together Avith the uterine pain, but
they reappear with the latter, after a variable  period, ranging from a few
hours to several days.
  1. Influence of Rheumatism over  the Progress of Gestation.—The parox-
ysms are apt to be folloAved by uterine contractions  in those cases in which
they have persisted for some time, or have been very severe;  and in this
manner they may serve  to bring on a premature  delivery.  The patient
experiences  some acute and tensive pains, but this feeling of tension is not
uniform;  for it attains, in turn, a high degree, and then becomes Aveaker in
the same proportion, progressing in this Avay Avith shorter and shorter inter-
vals.   At first the  uterus is indurated to  a  partial extent, but aftenvards
throughout;  the os uteri dilates, though its  dilatation is at first  slow and
difficult, and its ulterior  progress does not  seem to correspond  Avith the.
intensity of  the pains. An abortion  is then  imminent, but it is  far from
being so frequent as might be supposed;  and when it does  occur, it is  more
frequently observed in the febrile than in the apyretic form of rheumatism.
The orifice has been known to dilate to the extent of an inch  in  diameter,
and then the bag of  Avaters, that had previously engaged in this  opening,
insensibly retreated, the os uteri again closed up, and  the delivery did not
take place.   Consequently, so long as the dilatation  of the os uteri does not
amount to tAvo inches, Ave may reasonably hope to make the labor retrograde.
These uterine rheumatic  pains may simulate those of parturition, and thus
lead the accoucheur to suspect that  labor  has regularly commenced,  Avhen
in fact such  is not the  case.  The characters of the rheumatic pain, furnished
in the folloAving paragraph, will aid  in preventing such an  error.  It  is
probably to  some mistakes of this kind that Ave must refer  those pretended
instances of prolonged gestation, as Avell as  those  cases in  Avhich genuine
labor Avas developed,  and afterwards  suspended during several weeks, and
even months.
  2. Influence of Rheumatism over the Labor. — As a general rule, a  rheu-
matic affection of the  Avomb retards the progress of the labor, and sometimes
even  renders the  spontaneous  expulsion  of the  child Avholly impossible.
Besides the  general phenomena already pointed out, the disease here gives
rise to the folloAving peculiarities :
  1st.  It is Avell knoAvn that the normal uterine contraction only begins to
be painful Avhen it has accomplished the greater part of its course, and Avhen
it  is at the  point of  distending and dilating the uterine orifice; in  other
Avords, the true labor-pain only  commences at the instant when the power
of the body  of the  womb overcomes the resistance of the neck.   In rheuma- 
DISEASES OF  PREGNANCY.
527
tism, on the con trary, the uterine contraction is painful from  the very first,
and prior to any action upon the cervix; hence the cause of the pain is not
in the violent distention of this orifice, but rather in the uterine contraction
itself, in the other morbid  conditions, and in the altered relations of the
nerves and contractile  fibres of the uterus.
   2d. In a normal labor, the contractions begin  at the  fundus, and termi-
nate at the inferior segment of the Avomb ; in rheumatism, instead of starting
at the fundus, they begin in the painful point, and are not regularly propa-
gated toAvards the cervix.  Again, the rheumatic pains exist prior to the
contraction of the Avomb, and then speedily acquire a high  degree of inten-
sity under the  influence of  this latter.   At times their violence promptly
arrests the contractions, even before they have traversed their ordinary cycle.
They are then rapid, short, and become more and more distant.
   3d. Towards the end of labor, at the time Avhen the uterine action ought
to  be aided by the  voluntary contraction of the abdominal  muscles, the
woman  refrains from exerting these under the fear of augmenting the pains.,
whereby an excessive sloAvness in the labor results.  The patient is found in
a state of extreme anxiety, and the frequency of her pulse, the heat of the
skin, the thirst, and vesical tenesmus, are  all greatly augmented.   Where
these sufferings  are much prolonged, she falls into a state of swooning, Avhich
often proves serviceable, as  the pains are suspended while it  lasts; a pro-
fuse perspiration has then been observed to take  place, Avhich had the most
salutary influence over the  ulterior  progress of the  parturition.   But at
other times the uterus  becomes more and more painful,  and it is rather in
a  state  of permanent contraction, or of fibrillar  vibration, than of normal
contraction; the pulse is accelerated,  and the Avoman is affected with a me-
tritis Avhich renders the labor extremely painful.
   ^ Influence of Rheumatism  over the  Puerperal Functions. — The reader
Avill anticipate from the foregoing, that rheumatism of the Avomb may prove
a  source of difficulty  in  the delivery  of the after-birth,  by determining
irregular or partial contractions of the organ  immediately after the expul-
sion of  the  child; but that subject  does  not claim our attention at the
present  time, and it will be reverted to hereafter.   In the healthy state, the
uterus retracts after the delivery, and thereby prevents the development of
hemorrhage.  But in rheumatism, this retraction of the organ is very im-
perfect,  and it remains much larger than  usual; the  after-pains are  then
very distressing, and are prolonged for some time; the uterine vessels are
less compressed than usual,  and profuse floodings may thence result.   On
the other hand, the suffering state  of the organ diminishes both the lochial
discharge and the lacteal secretion; and this, together Avith the persistence
of the abdominal pains, and  a  manifestation of the  phenomena of general
reaction, may be mistaken for a peritonitis which does not really exist.
  Prognosis. — Rheumatism of the Avomb is not a disease capable of deter-
mining  the  loss of the mother's life; nevertheless, from the  pain  that it
occasions,  and the errors it may give rise to in practice,  it does not the less
merit a  careful study ; because, during pregnancy,  it  may prove  to  be  a
source of abortion, and  though it is not often manifested until after the sixth
month, yet it is  always an unfavorable circumstance to the child to  be born 
528                PATHOLOGY  OF PREGNANCY.
before term.  We have already spoken of the unfortunate influence it may
have over the course and character of the labor-pains;  in fact, it has often
rendered an artificial delivery imperative.  It may also complicate the de-
livery of the after-birth,  and disturb the order of the phenomena that con-
stitute the lying-in.  At that period it has often  been mistaken for true
inflammatory symptoms,  and, consequently, has been combated by measures
that Avere more dangerous than useful.
  As regards the period of manifestation, it is generally more unfavorable
when it occurs at an early stage of the gestation; both because it then has
a greater influence over the pregnancy, which has not become firmly estab-
lished, and because  it  has a tendency to return several  times before term.
Besides which, most women, who have been affected during the gravid state,
likewise  find it to  reappear again in the course of parturition, which is
thereby rendered laborious.
  Treatment. — 1st.  The measures that have most frequently been attended
with success Avhen administered for this disease  during the gestation are:
general venesection; the intestinal revu Isives, such as castor-oil and ipecacu-
anha ; bathing, narcotized lotions over the abdomen, opiated mixtures, and
sudorific drinks;  and in those cases in which  the uterine affection had suc-
ceeded the sudden disappearance of a rheumatic pain in some other organ,
the application of revulsives over the part primarily affected.   2d. During
the labor, the same means are employed ; but if they fail, and the degree of
dilatation of the os uteri be such as to permit an artificial  intervention, either
the forceps  or version  should be resorted to, according to circumstances.
3d.  After the delivery, sudorific drinks, opiated unctions over the belly, and
baths; and when the lochial discharge has failed, leeches to the vulva, and
ipecacuanha combined  Avith opium.

                          ARTICLE  X.
of  displacements of the uterus considered in reference to the
           accidents  they may cause during pregnancy.
  § 1.  Prolapsus of  the Uterus.
  We  have already seen, in studying the situation of the uterus at the dif-
ferent periods of gestation, that at first this organ  sinks  loAver in the exca-
vation, and that its  orifice approaches the vulva.  Now this first degree of
depression may be considered as  physiological, but it cannot  pass beyond
that without giving rise to some accident or other.   Hence, laying aside all
causes foreign to pregnancy, the uterus descends the more in the earlier
months of gestation in proportion to the larger size of the pelvis, and the
greater  relaxation of the ligaments.  In  some women it rests on the floor
of the pelvis, Avhilst in  others, the neck, or  even the  body, may protrude
through the vulva and become visible externally.
  We see, therefore, that either a simple descent or an  incomplete or com-
plete prolapsus may occur during pregnancy,  as Avell as in the non-pregnant
condition.  The complete prolapsus, that in  Avhich the  entire body of the
iterus is external to the genital parts and hangs betAveen the thighs, is ex-
tremely rare.  It were Avrong, hoAvever, to deny its  possibility, since this is
proved by a case reported by Vimmer. 
DISEASES  OF  PREGNANCY.
529
     Tnese  displacements may occur  either slowly  or suddenly,  th mgh the
   female may have had nothing of the kind previously;  sometimes, hoAvever,
   thcv are  but the continuation or exaggeration of a pre-existing prolapsus.
   Although the progressive development of the uterus generally removes the
   incomplete prolapsus about the fourth or fifth month, by causing the organ
   to rise above the superior strait, the die-placement, in some cases Avhere the
   pelvis  is  spacious, may continue, and  even  increase,  notwithstanding the
   progress  of  gestation.  I have, quite recently, had  under care  at lihe Clin-
   ique, a very remarkable case  of incomplete  prolapsus, in which the entire
   neck of the uterus projected  beyond the external  parts, the whole excava-
   tion being occupied by the lower part of the body distended  by the fcetal
   head.  The displacement continued until delivery Avithout  any serious  acci-
   dent supervening.1  It had existed for several years.

     1 The following are  some of  the details of this interesting case: Marie ----, aged
   twenty-seven years, entered  the  hospital  October  18th, 1849.  She was then at the
   beginning of the ninth month of her pregnancy.  Four years  previously, she  became
   pregnant for the first time, and when near delivery, she both felt and saw a small red
   tumor, of about the size of a  walnut, escape through the vulva.    It projected but
   slightly, incommoded the patient  but little, and did not interfere with the labor at all,
   since the latter was accomplished quite rapidly.  After her confinement,  she continued
   to feel the same tumor, less prominent, indeed, than during pregnancy, projecting and
   disappearing  according as she was quiet  or took long, fatiguing  walks.  Under the
   latter circumstances she suffered  much from sensations of dragging  in the groins and
   upper part of the thighs.  She was habitually and obstinately constipated, and some-
   times had great difficulty in urinating.
     Two years ago, the same person  became pregnant the second time, and during the
   first three months the tumor became gradually more projecting, and hung very low,—■
   bo low, she says, that a midwife,  after having returned the parts,  applied a pessary,
   which produced discomfort, and  was retained  but two days.  Eight days after the
   introduction of the pessary, she  miscarried, at about three months and a half to four
   months.  The midwife who attended her could not extract the  placenta, and, two days
   afterwards, a physician endeavored  to deliver it, first with the hand, and afterwards
   with forceps, but could obtain only some fragments.
     She recovered entirely; the tumor remaining within whilst quiet in  her chamber,
   but appearing externally after much walking.
     Becoming pregnant for the third time, the tumor  did not incommode her much  more
   than usual during the first three months, but after the fourth, it projected  much  more
   from the vulva, and towards the  last three  months it was impossible to restore it for
   several days, even after observing the most  absolute repose in bed.  At present, the
   patient being eight months and a  half gone, the following may be observed:
     A  cylindrical tumor, two inches in length, projects from the  vulva; it  is five inches
   in circumference, and rather larger and harder at. its lower than at its upper  extrem-
   ity.  Its external surface is marked at the union of the two upper thirds with the lower
   one by a whitish circle, dividing two surfaces of different color and  appearance.  The
   superior is of a  rosj' hue and  smooth, being only  the internal surface of the vagina
   inverted from above downwards, which thus forms the external surface of the tumor.
   The  inferior portion is of a deeper red color, and presents wrinkles or folds, directed
   from above downwards, and from  within outwards, and separated,on the  median line
   by apparently longitudinal fibres.   These folds are merely the  arbor vitee of the  neck
   inverted from below upwards, so that the  internal  surface of  the cavity of the  neck
"  has become a part of the external  surface of the tumor to the extent o;' five-eighths of
   an inch.   The somewhat swollen lower extremity of this tumor p -ese ats an opening,
   with rrinkled edges, resembling  the drawn mouth of  a  purse, ind into which the
         34 
530
PATHOLOGY  OF  PREGNANCY.
   In some  cases the displacement increases considerably, and either as an
effect of its  own Aveight,  or in consequence of exertion  or violent exercise, the
lower part of the body  of the  uterus projects beyond the vulva, the upper
part of  the  organ being still Avithin the pelvis.
finger enters  with  ease.  This is the cavity of the neck, forming a  canal two inches
and three-quarters in length, through  which the membranes and a hard body, recog-
nized as  the head of the foetus, may be felt.   The internal orifice  is quite largely di-
lated, that is, nearly to the size of a one-franc piece.   The entire head is discovered
to be in the excavation, and altogether behind the symphysis pubis, by which it seems
to be arrested.
   If it be attempted to enter the vagina, at the same time traversing the circumference
of the upper  part of the tumor, a cul-de-sac is reached at a depth of from two inches
and three-quarters to three inches and a quarter on  the  sides, from  two and a half
inches to three inches and a quarter behind, and from only two to two  and a half in
front, when the examination is stopped  by the walls of the urethra, which are thickened
and curved, as it were, posteriorly.
   This cul-de-sac is formed by the vagina turned inside out from above downwards;
and any  effort to push it upwards is soon arrested by the foetal head, which is plunged
into the excavation, and rests upon the floor of the pelvis.
   The patient suffers from obstinate constipation, and sometimes only from difficulty in
passing urine, which escapes by jets.
   To recapitulate, we find:   ]. A descent of  the womb, which seems to be retained in
the pelvis only by the floor of the latter, and the pubic arch and symphysis, against
which it rests; the rectum and urethra  are also compressed.  2. Prolapsus of the neck
of the uterus  outside of the vulva, carrying with it the vagina, which covers its upper
part like  the  inverted finger of a glove, and which is itself inverted from below upward
to the extent  of five-eighths of an inch, so that its internal surface forms the external
surface of its lower extremity; this extremity of the neck  forms the expanded and
wrinkled portion of the tumor.  3.  Constipation and difficulty in urination caused by
pressure.
   The tumor  increased about three-quarters  of an inch in size, from  the 20th of Octo-
ber to the  3d of November; but its volume was much greater in  consequence of the
oedematous condition of  the prolapsed parts.
  After  some fruitless efforts to reduce the prolapsus, I concluded  that it would" be
best not to  try any further, but to limit treatment to evacuation of the bowels by mild
laxatives,—the patient being unable to receive enemata,—a bath every two or three
days, and frequent lotions  and injections.   Assisted by the  horizontal posture, these
measures completely relieved the patient of her sufferings.
  At noon on the 3d of November, the waters came away without pain, after efforts at
defecation.   The internal orifice of the cervix was of the  size  of a one-franc piece;  the
neck Avas rather longer than before the 3d, and rather softer. During the last  ten
days the  patient felt her abdomen  become  harder from time to time, but without ex-
periencing  the least pain.
  From  noon until 10 p. m. the  pains were very weak and distant.  From 10 o'clock
to 3  a. m. (of the 4th), they became greater, more powerful and frequent.  Finally,
the labor terminated at  3 a m. the  4th of November, after  a  labor of fifteen hours, if
the time be reckoned from the rupture of the membranes and discharge of the waters,
and only of five hours, if counted from  10 p. m., at which time there  was no change in
either the length or dilatation of the neck, though then it  was that  the pains becamo
well marked and regular.
   The following are the principal phenomena which accompanied the expulsion of the
foetus: At the commencement of labor, the neck remained external precisely as before,
and when the head came to be expelled, it  dilated visibly, and was the last obstacle
vrhich  this part had  to overcome.  No resistance was offered by  the vulva, which'
"■ as traversed before the external orifice of the neck of  the uterus. 
DISEASES  OF PREGNANCY.
531
  The disorders resulting from this displacement vary in intensity according
to its extent and the stage of pregnancy al^Avhich it occurs.  When the pelvis
is too spacious, the excess of size affecting chiefly the excavation, whilst the
straits preserve their normal dimensions, the uterus may remain much longer
in the lesser pelvis than is usual in Avell-formed women.  It then incommodes
the neighboring parts, pressing upon and irritating the rectum and the blad-
der; the patient suffers from a feeling of weight at the anus, and painful
tractions in the  groins, lumbar regions, and  umbilicus.  A more  or  less
abundant and fetid discharge also comes on;  the woman  can neither stand
nor Avalk Avithout suffering, and  she falls gradually into a state of marasmus.
  When the gestation is more advanced, and the Avomb increased in size, or
even if less voluminous, but more depressed, the symptoms, such as com-
plete retention of the urine, very obstinate constipation, &c, are  still worse;
finally, the pressure of the  uterus on other organs may react on  itself, and
the consequent irritation thus prove a cause of  abortion.
  When the retention of the urine is complete, either the catheter should be
at once resorted to, or the womb be pressed up by one or tAvo fingers pre-
viously introduced into the vagina; but even  this assistance will not  be
necessary, if the Avoman lies doAvn and elevates her hips considerably Avhen-
ever she Avants to urinate.  All these symptoms, however, disappear  about
the fifth month, Avhen  the uterus, on  account of its great  development,  can
no longer remain in the excavation,  and therefore rises above the superior
strait.
  In cases of simple and incomplete prolapsus, some authors recommend the
introduction of a pessary, in order to sustain  the uterus, and prevent  its
prolapsing completely.  I regard the pessary as  ahvays useless  and often
dangerous.  Rest in bed, and proper cleanliness, seem to me capable of pre-
venting the precipitation of the organ, and of alleviating the painful  irrita-
tions Avhich the displacement produces.
  Certain instances of success  seem  to  authorize  attempts at reduction in
cases of incomplete and complete prolapsus occurring at an advanced stage
of pregnancy.  In  both circumstances, I think that these attempts should
be moderate, since  they appear to me likely to compromise the gestation.
When the prolapsus is complete, the danger to which the woman is exposed

  The child, Avhich was a male, was born alive.  Its weight and  dimensions were as
fc lows:
      Weight,   .       .     .     .      .       .     .  5£ lbs. (Troy).
      Total length,  .      .      .     .       .      .      1 ft. 6 inches.
      From the crown to the umbilicus,       . *    .     .       9  "
      From the umbilicus to the heel,    ...          9  "
      Occipto-frontal diameter,       .       .      .     .       4  "
      Occipito-mental    "       .     .      .      .          5  "
      Bi-parietal         "   .      .       .      .     .       3f "
      Sub-occipito-bregmatic diameter,   ...          3J "
  The day following the labor, the cervix projected to the same extent  outside the
vulva,  and the parts were rather more flaccid; the engorgement being dissipated, the
neck was returned within the vagina; the patient continued in the horizont il position,
»nd a month after left the Clinique without the neck having appeared at the vulvar
opering. 
532                  PATHOLOGY  OF  PREGNANCY.
by the nature  of the displacement itself would certainly authorizt rather
greatei perseverance; but it  is easy to  see that in the latter months it will
rarely be possible to return the uterus within the pelvis.
  When the reduction is impossible, the uterine tumor should be supported.
by a proper bandage, and the female confined to the horizontal position.
  In Avomen who have had a  falling of the Avomb before impregnation, there
is reason to fear  that it may  persist and augment during the first three oi
four months of gestation, in consequence of the great laxity of the ligaments;
and it is therefore  prudent  to advise such  persons to keep the horizontal
position  during all this time, and not to permit  them to get up until after
the fifth  month.   After  the delivery, they should again  remain  in bed six
weeks or two  months at  least; for by such precautions, not only may the
patient escape  the dangers attendant on a prolapsus uteri during the earlier
periods, but sometimes even a radical cure of the  disease she had before the
gestation took  place may be effected.

  §  2. Retroversion.
  The mobility of the uterus in the pelvis, which is still observable in the
early stages of  pregnancy,  notAvithstanding its  augmentation in volume,
exposes it to another variety  of displacement, that is not so  common as the
preceding, but  more disastrous in its consequences.  Thus, in some instances,
the Avomb seems to execute a see-saAV movement, by which its  long vertical
axis is brought into  a nearly horizontal line in the excavation, in such a Avay
that the fundus remains either  a little more elevated, or else somewhat more
depressed than the neck.   This displacement is called retroversion, Avhen the
fundus uteri is carried backwards into the hollow of the sacrum, and ante-
version, when it is directed towards the symphysis pubis.   These tAvo varieties
may  occur  in  different  degrees;  but  the displacement will  be much  more
considerable in retroversion than in anteversion, on account of the anterior
concavity of the sacrum ; the former is also more frequent and serious than
the latter.
   Finally, in  the latter part of gestation, the uterus may  incline more or
less to the right or the left, so as to constitute what have been termed lateral
obliquities.
   [If we may credit M.  Salmon  (of  Chartres), who has published an excellent
thesis for the "Concours" on the subject, retroversion of the uterus during preg-
nancy is not a very uncommon  occurrence.  Having already met  three cases in our
own practice, we are  the more ready to accept his opinion as  probably correct.  It
usually happens between the third and fourth months, and is rare before the third and
after the fifth months.  The observed cases occurred much more frequently in those
who had already borne children, than in those who were pregnant for the first time.
   As the displacement may be gradual or sudden, we may describe it  according to
its character in these respects.
   The causes of gradual retroversion are: the normal inclination  of the fundus
 uf the womb toward the hollow of the sacrum in early pregnancy;  the more rapid
 development of its posterior surface at  the same period;  a spacious pelvis, aa
insisted on by M. Chailly; the  constant pressure upon the fundus by the abdominal
 viscera;  and above all, a collection of fasces in the sigmoid flexure, of the colon, and
 retention >f urine. Numerous discussions have taken place in regard to the effect 
DISEASES OF PREGNANCY.
533
 of retention of urine in the production of this displacement, some thinking that
 the retention is an effect and not the cause, whilst others believe that distention of
 the bladder, so far from producing, would actually prevent the occurrence of retro-
 version.  We agree with those who regard retention of urine as the principal cause
 of the  gradual displacement, basing our opinion upon the  fact that,  by frequent
 emptying of the bladder  by the catheter, the displacement will  be spontaneously
 removed.  As other causes of this occurrence during pregnancy, we have noted
 a previous retroversion, the growth of abdominal tumors and adhesions resulting
 from an old peritonitis, &c]

   When the retroversion occurs suddenly, it  is produced by the same mech-
 anism, only a more vigorous and energetic impulsion is then requisite ; and
 such an impulsion is usually given by a rapid,  violent  contraction of the
 muscles:  thus, after a severe retching, or vomiting, or after the strainings
 at stool, in Avomen Avho are habitually  constipated, or in  urinating, in cases
 of retention, the Avomb  is often  found displaced.
   M. Moreau relates an instance of a Avoman Avho lifted a weight of fifty
 pounds, for the purpose of placing  it  on the balance, Avhen  she  Avas imme-
 diately attacked by pains in the hypogastrium, vomiting, syncope, &c.   On
 his arrival, he found the uterus completely turned backAvards; but all these
 symptoms disappeared immediately after the  reduction was effected.   A fall
 backAvards, or  bloAvs, or a strong pressure below the navel, have very fre-
 quently caused the same result.   (Naegele.)  In  one of Hunter's cases, the
 retroA'ersion appeared soon after a severe fright.
   "A  Avoman," says M.  Martin, of  Lyons, " Avas  taken in her third month,
 after a violent straining effort, Avith  pains, accompanied by loss of blood;
 at first, the os tineas Avas found in the centre of the vagina; but  the patient
 renewed her efforts, and then the uterus became completely retroverted, that
 is, the  neck avus placed  behind the pubis and a little to the right, and the
 fundus of the organ rested against the  sacrum.   In  this instance the retro-
 version evidently  resulted from the conjoint influence of the uterine  con-
 tractions and the  expulsory efforts  of  the abdominal muscles."  (Martin,
 Memoires, p. 142.)
   Where  the displacement is effected sloAvly, the Avoman is but little incom-
 moded at first; and the necessity for reduction is only apparent after it has
 become considerable.   Originally,  there are  only  some  painful dragging
 sensations in  the groins  and  lumbar  region;  a  feeling  of  Aveight and
 pressure on the neck of the bladder;  some  vesical  tenesmus, and  a little
 difficulty in the emission of urine.  But when the uterus attains a certain
 degree of development, all these  phenomena increase,  and Ave are then
 obliged to interpose the  resources of our art; for Avhen  matters  reach this
 state, the Avomb becomes Avedgcd, as it were, in the middle of the  pelvis, and
 even more firmly so  afterwards, because its volume  augments rapidly; for
 Qot only does the foetus continue  its  growth, but  also  the uterine walls
 become engorged, tumefied, and inflamed, and the symptoms caused by this
 inflammation are  added to those previously  existing;  and,  further, as the
space then occupied and filled up by the uterus is larger  than the superior
strait, the reduction becon es very  difficult,  .or even impossible.  Htinter
relates  a case in Avhich the   eduction could not  be  made, and the  Avoman 
534                PATHOLOGY  OF  PREGNANCY.
 died in consequence;  and at the autopsical examination it was fo ind neces-
 sary to cut through the symphysis, in order to disengage the womb from the
 excavation.
   When the displacement  takes place suddenly,  all  these  symptoms are
 speedily manifested, and should it happen at an early stage, they are shortly
 carried to the highest  degree, or even may soon prove fatal, for their per-
 sistence may give rise to so great a  distention of the bladder, as to produce
 its rupture.1  Again, the accumulation  of fecal matters in  the  intestine
 occasions so imperious a feeling of tenesmus, that  the female gives Avay to
 the most immoderate strainings ; and the pain caused by the  displaced and
 inflamed uterus may create a convulsive agitation of the abdominal muscles
 and the vaginal Avails, so great as to cause a rupture of the vagina, and an
 escape of the fundus of the uterus from the vulva;  as happened in the case
 communicated to M. Dubois, by M.  Mayor.
   [" Palpation of the  abdomen," says  M.  Salmon, " is usually the first thing
 resorted to by physicians when  called to a case  of retroversion.   The patients
 generally both know and say that they are pregnant, so that when the abdomen is
 examined in order to  ascertain the cause of suffering, a large tumor reaching from
 the pubis to the umbilicus  is almost always detected.  This tumor is superficial,
 fluctuating, and dull upon percussion.   It may bear no inconsiderable resemblance
 to the uterine globe, especially  should it harden at  intervals, as in one case which
 came under our notice.   That the tumor is formed by a greatly distended bladder,
 is proved by the use of the catheter: it is important, however, not to be deceived
 by the statements of patients, who often believe that the bladder is empty because
 they are able to discharge a small quantity of water.
   " Palpation of the abdomen is also useful in those rare cases unaccompanied by
 a distended bladder;  for here the displacement of the uterus is indicated by the
 impossibility of deteoting the fundus of the  organ on a level with or  below the
 superior strait of the pelvis."   (Salmon.)]

   The vaginal examination,  in  such cases, will enable us to detect the par-
 ticular variety of displacement Avhich  causes the symptoms, for the finger
 encounters  a  tumor just Avithin the vagina that fills the Avhole excavation,
 which is  the  posterior surface of the womb.   In passing over this surface,
 which is of greater  or less extent according to the stage of pregnancy, the
finger reaches the fundus of the uterus, which it finds directed toward the
 anterior surface of the sacrum, and in more  serious cases toward the point
 of the coccyx.  Pursuing the  examination  anteriorly, the neck is discov-
ered to be turned directly fonvard,  toward the middle of the posterior sur-
face of the pubis, and sometimes even raised above the upper edge of the
symphysis.  The displacement may indeed be so great that the axis of the
organ is almost completely  overturned  and  the finger  cannot reach  the

  1 The greatly distended bladder may then doubtless form a very considerable tumor,
capable of increasing  the retroversion  mechanically,  and  of opposing the reduction.
 But the very intimate adhesions, by which the anterior  and posterior surfaces of the
aterus are connected with the posterior and inferior walls of the bladder, tend espe-
 cially to augment the difficulties.  The abnormal size of the latter organ keeps it very
high in the pelvis, and the neck of the uterus  evidently can only be brought down-
wards and backwards, after the relieved bladder has itself descended  into  the exca-
 vation 
DISEASES  OF  PREGNANCY.                  535
external orifice.   Sometimes, hoAvever, the neck is  very accessible  to  the
touch, although the  retroversion is carried to the  greatest extent.  This is
owing to the fact of the cervix being bent round on the body, like the beak
of a  retort.  In  this case, the uterus Avas retroflexed before being overset
backward.
  In  retroversion, a rounded tumor, varying in size Avith the volume of  the
displaced organ, is found  in  the vagina.  This tumor spreads  out more
behind than in front, whereby the posterior vaginal Avail is depressed, Avhilst
the anterior is distended and  elevated.   Sometimes  the perineum is  promi-
nent,  and the vulva  SAVollen, the rectum is pressed doAvn and almost oblit-
erated by the tumefied organ, and the  anus  often  dilated  and  bulged
outwards.

  [Unpleasant to the patient as is examination by the rectum, it must be had re-
course to when the indications derived  from  the  above  described measures lead
one not merely to suspect, but to  feel  certain that  the retroversion exists.  It is
the only method by which the uterine tumor can be explored over a considerable
extent of surface, as there is  nothing  to prevent the finger from passing deeply
behind it.  Another advantage is,  that whilst the vaginal touch enables us to
appreciate better the position of the cervix  at the bottom of the long  cul-de-sac,
behind the pubis, examination by the  rectum affords precise knowledge  of  the
character of the tumor formed by the fundus of the womb.   (Salmon.)]

  A particular variety of retroversion has been described  by M. Martin,
of Lyons, in which the  os  tineas protrudes from the vulva, and the fundus
uteri  is  pushed to the  side of the sacrum ; the uterine neck, being curved
like the spout of a eAver, is  situated beloAV and a  little in front of  the  pubis;
the body of the organ is retained in the sacral excavation, and lies close to
the perineum.   But, after  carefully reading his  description, I do not think
it can be justly considered as a  neAV example of retroversion.  I  believe it
was merely a falling of the womb, which  had existed prior to  pregnancy,
and had  been aggravated  by this  latter  condition; there was at the same
time an anteflexion of the neck, Avhich explains how  the curve in the latter,
described by M. Martin, might  be  formed below and in front of the pubis,
from  the depressed body forcing it beyond the vulva.
  A retroversion could  scarcely be confounded Avith simple prolapsus; for,
in the former, the vaginal  Avail  is ahvays situated betAveen the  finger and
the tumor, and the neck is  high  up behind the. pubis, Avhilst, in a prolapsus,
the cervix is always the most dependent part, and the tumor can be perfectly
isolated from the vagina; in the latter case, the reduction is generally easy,
but it is  usually quite difficult, sometimes even impossible, in the former.
Further, the symptoms of retroversion are ordinarily much more  severe
than  those  of  prolapsus.

  [Without going into any detail on the subject, we would point out the possibility
of mistaking  a retroverted pregnant  uterus  for an intra-uterine  fibrous  tumor,
abdominal tumors, or tumors of the cavity of the pelvis.  The differential diagnosis
between the unimpregnated  uterus when retroverted  and the same  organ when
similarly displaced during pregnancy may also  prove somewhat difficult; still,
the  fact of the case may be generally arrived  at by judging carefully  of the size
»f the womb, and  interrogating the patients  in regard  to the time of the last- 
536                PATHOLOGY OF  PREGNANCY.
menst;ual flow.  It would be easier to make a mistake in cases of extra-uterine
pregnancy developed in the utero-rectal cul-de-sac, or of retro-uterine hematocele ;
in this case, however, the  entire uterus is crowded out of position without being
tilted, and it is often easy to feel its contour above the margin of the pubis.]

  As a general rule, the prognosis  in these displacements is very grave;  it
varies, however, with the period of pregnancy,  the volume of the  uterus,
the alteration in the neighboring parts,  and the violence of the attendant
symptoms.
  Cozteris paribus, a retroversion is usually more unfavorable than an ante-
version ; because,  in  retroversion, the constipation and retention of urine,
which thus far have been  considered as comparatively unimportant,  soon
become aggravating  circumstances of the disease.  In fact, the bladder can
only enlarge and ascend  into the abdominal cavity, by pushing the uterine
neck  upwards and towards  the front; and  hence, its body acting  on the
uterus by its  size  and weight, necessarily increases the displacement.  The
stercoraceous  matters accumulated in the rectum, above the part in contact
with the fundus uteri, act in a similar manner;  and, again, all the woman's
expulsory efforts have a constant tendency to  further  depress the fundus,
after  the displacement has once commenced.   In anteversion, on the con-
trary, all the  causes just  enumerated operate in a favorable manner.  Thus,
the distended bladder constantly has a tendency to press back the body of
the womb, which is then carried forwards, and the accumulated matters of
the large intestine, pressing from above downwards on the posterior part of
the neck, contribute  to the same end.
  [Sudden retroversion is  more threatening in appearance than the gradual form.
Both cases are serious in proportion as  the pregnancy is in a more advanced stage,
because the  accidents which are liable to occur and the  difficulty  of reduction,
increase with the size of the uterus.   Independently of the accidental or gradual
cause which  produced it, and of the period of gestation at which it occurred, the
danger, says M. Salmon, is in proportion  to the importance acquired by one of
the principal phenomena of the affection, viz., retention of  urine.  If the latter be
complete, the symptoms become urgent in seven or eight hours, but if incomplete,
the displacement may continue for fifteen,  twenty, or  twenty-five  days  without
causing any serious results.
  Retroversion generally terminates in recovery, though it may give rise to abortion.
In some cases death may ensue from peritonitis, beside which  rupture or gangrene
of the bladder, or rupture of the uterus or its partial destruction by gangrene, may
be apprehended.
  Treatment. — In  the first place the bladder must  be emptied, as in its distended
condition it would interfere with the attempts at reduction.   It sometimes happens,
indeed, that  after the  urine is withdrawn,  reduction occurs spontaneously.  Many
practitioners have very justly insisted upon the advantage  of catheterism repeated
several times daily through the course  of several days, as the only method of treat-
ment; it has very often proved successful, insomuch that Burns felt authorized to say
that retroversion would rarely last over  a week, if the bladder were emptied three or
four times a day.   It  is a  course, therefore, which  may be followed whenever the
symptoms are not urgent.]
   Treatment. — After having emptied the bladder and rectum, and combated
the inflammatory symptoms by the appropriate means,  the accoucheur should
proceed at once to reduce the  uterus to  its  natural  position, and secure it 
DISEASES OF PREGNANCY.                 537
 there.   The best position  for the female to assume is  one in which all the
 muscles are throAvn into  a state of relaxation ;  tAvo fingers are then to be
 ntroduced into the vagina, Avith which the  body is first to be pushed up,
 ifter Avhich the index should be hooked over the neck so as to depress it.
   The reduction may sometimes be effected on a single trial, but usually we
 are compelled to repeat the attempt after an interval of a few minutes : and
 just at the instant of the resumption of its ordinary position  by the Avomb,
 a noise is heard, in some instances,  like the click of  a spring.   It  must not
 be supposed, hoAvever, that this operation is ahvays  an easy one.   For the
 difficulty  in using  the  catheter, so often experienced, the  impossibility of
 emptying the rectum, and especially the voluminous tumor formed behind
 the uterus by the faeces collecting in the sigmoid flexure of  the colon, the
 violent strainings made by the  patient under such  circumstances, and the
 size of the tumor, and its  adhesions to surrounding  parts, are so many em
 barrassing circumstances  to the practitioner.  Although it is very seldom
 that we cannot succeed  in introducing the catheter, by time and patience,
 yet in  some cases this has been found altogether impossible;  indeed, much
 prudence  is requisite in the measures  then adopted, and if they all prove
 useless, a moderate pressure  made over the hypogastrium may,  perhaps,
 slowly compress the bladder, and thus make the Avoman urinate, so to speak,
 by disengorgement.
   The retroverted fundus sometimes compresses  the rectum to such  a degree
 that an injection cannot be made to enter the large intestine.
   Such cases  demand some precaution  in the administration of the enemata.
 There  may be a collection of indurated matters above the  fundus of the
 retroverted uterus, in Avhich case it  is evident, that, as the latter compresses
 the upper part of the rectum, an injection given in the usual manner cannot
 reach high enough  to bring away the faeces accumulated in the descending
 colon.   It then becomes necessary to use a long gum-elastic tube, Avhich may
 be inserted to the extent of seven  or  eight inches.   This simple expedient
 has often disencumbered the intestine of matters  which an ordinary injection
 could not have reached, Avith the effect of producing spontaneous reduction.
   Even Avith  the use of the tube just recommended, the injections are some-
 times ineffectual.   In such cases, if  the palpation and the abdominal percus-
 sion lead  us to suspect a considerable accumulation of fecal matters in the
 descending colon, Ave should exhibit purgatives  by the mouth.  Again, the
 necessary  introduction of the hand  into the vagina, to effect the reduction,
 is at times so  painful to the female,  that," notwithstanding all persuasions to
 the contrarv, she gives Avay to  the most violent bearing-doAvn efforts, Avhich
 neutralize those of the operator.   If baths, or emollient and narcotic injec-
 tions, should not assuage this acute sensibility, the advice of Dewees might
 be taken, and  bleeding  practised to the extent of producing syncope; still
 better,  in my opinion, Avould be the  administration of chloroform before the
 operation.
  The  abnormal adhesions that are occasionally established betAveen the
uterus an I adjacent parts, will certainly add another to the serious difficulties
 just  mentioned; but even  this should  not give rise to despair.  Amussat
reports a  case Avhere he distinctly felt  some bridles in the  bottom of the 
538
PATHOLOGY OF  PREGNANCY.
vagina, and to the left of the tumor, into which he could ho k the forefinger,
but after a careful examination  he acquired the conviction that the uterus
was free on the right side.  He then renewed his attempts, by acting in such
a way as to turn the uterus from  the  opposite side towards that Avhere the
adhesions existed; that is, from  right  to  left, and he thereby succeeded in
replacing the organ in its natural position.  But if, after having adopted all
suitable precautions, the simple procedure just described should not succeed,
one of the following plans should then be resorted to, namely, to act simul-
taneously by the vagina and rectum, as some  have advised; but the most
simple plan, however, is that of M. Evrat, quoted by M. Moreau, as follows:
The woman must  lie upon her side, and the accoucheur then takes  a  rod
eight  or ten inches long, covered at one end  by a tampon of linen smeared
over Avith some fatty matter,  Avhich he introduces into the rectum so as to
press, through the recto-vaginal septum, the fundus uteri from beloAV upAvards,
whilst the two fingers passed  into the vagina  hook the neck, and simultane-
ously draw it downwards  and  backAvards.   The force  necessary for  this
reduction is very variable, though in effecting it we need  not be restrained
by the fear of  producing an abortion;  for, even if this Avere to result from
such efforts, the dangers to the mother Avould be far less than from the con-
tinuance of the retroversion.   In a case of this kind, M. Halpin, after having
emptied  the bladder, and endeavored  unsuccessfully to reduce the uterus,
came  to the conclusion that the only mode of curing the patient Avas by the
employment of an instrument that Avould bear equally on all parts of the
displaced Avomb; and he imagined that the pelvis could be filled up Avith a
bladder,  and thus all the contained organs be pressed up  together into  the
abdomen.   With this vieAv,  he  placed an empty one betAveen the fundus
uteri and the rectum, and then by cautiously distending it, he actually suc-
ceeded in pushing the fundus upAvards.
  Attributing, as they did, the difficulty of reduction to the pressure of the
viscera upon the anterior surface of the uterus, Hunter, Boyer, and others,
have recommended that the patient should be placed in such  a position that
the Aveight of the intestines may be supported  by the upper part of the
abdomen.   Acting upon this suggestion, M. Godefroy adopts the  folloAving
position :  the patient rests her head and  hands upon the floor, whilst  the
anterior part of the thighs and legs repose upon the edge  of the bed, Avhere
they are supported by assistants.   The surgeon then acts either through the
vagina or the rectum upon  the fundus of the uterus in such a Avay as to effect
the reduction.   In three very grave" cases, success was  complete.  (Joum.
des Conn. Med. Chir., August, 1846.)
  This position is very fatiguing, painful, and disagreeable to the patient.
I Avould,  therefore, much prefer, in these  difficult cases, simply to place the
female on  her knees  in bed, Avith the  upper part of the body supported on
the elboAA'S. I have  thus  been able,  in  two cases, to reduce retroflexions
A'hich had resisted every other means.
  In  an  obstinate case, Ave might resort to a procedure recently employed
by Amussat, Avith a prospect of  success: that is, to place  the female in  the
position for operating for stone, and then introduce one or two fingers  into
the rectum, and gently press up the uterine tumor, by following the con- 
DISEASES  OF  PREGNANCY.
539
cavity of the  sacrum, at first directly upAvards, and then  alternating from
right to left and left to right, so as to raise the Avhole surface of the uterus;
but if the finger or fingers placed in the rectum  cannot reach so high, the
thumb should be put into the vagina so as to elevate the perineum, in order
that the  former may penetrate still  further; and, lastly, to get higher yet,
an assistant might press against the  elbow, or the accoucheur himself could
sustain it Avith his OAvn thigh or body.  M. Amussat  declares that he has
tAvice succeeded in this manner in making a reduction that had previously
been  ineffectually tried by several other practitioners.
  Finally, Avhat is to be done Avhere the reduction is impossible ?  Abandon
the patient to the resources of nature, says Mcrriman; but Avould not  that
devote her to a certain death, in case the inflammatory phenomena did not
determine an abortion ?  And  since a miscarriage is inevitable under the
most fortunate circumstances, Avould  it not be advisable  to  bring it on,
rather than to leave the patient exposed for a  long time to the dangers
which threaten her?  Indeed, most physicians are of this opinion, and I
should not hesitate, therefore, to rupture the membranes by a sound passed
through  the neck of the Avomb.  But, sometimes, the neck is so high up
that it is Avholly inaccessible; and then a puncture of the uterus itself must
be resorted to.  This latter operation  has  been performed both by the va-
gina and by the rectum, but I should think the first preferable.   It is, without
doubt, the last resource,  but ahvays  ought to be chosen rather than the
symphysiotomy recommended by Gardien  and some other accoucheurs.
  After the reduction (Avhen that has  been possible), the patient must re-
main in the horizontal position until towards the sixth month of pregnancy,
and  must carefully avoid all  straining, Avhether  in  urinating or at stool.
These simple  precautions  are all-sufficient, and generally render  the intro-
duction of a pessary useless; Avhich latter, however, Baudelocque considers
indispensable in most cases. Occasionally, the incontinence of urine, brought
on by the pressure Avhich the neck of the bladder has suffered from the neck
or fundus uteri, may still continue some time after the reduction ; and then,
if the ordinary simple means do not cause its disappearance, Ave may resort
to the Avarm mineral waters  of Cauterets, Bareges, or  Balaruc; to frictions
with the  tincture  of cantharides, and blisters on the hypogastrium, together
with tonics and astringents administered internally.

  § 3. Anteversion.
  Anteversion is very rare in the early stages of gestation, and, probably on
this account, has  been passed over by most authors who have studied the
disorders of pregnancy.   The manner  in Avhich the uterus  is developed, the
peculiar form of the anterior and posterior  boundaries of the pelvis, and the
normal direction  of the organ, are so many circumstances which, just in
proportion as they facilitate retroversion, render the occurrence of antever-
sion difficult.   Besides, the influence Avhich a distended rectum  and bladder
have in the  production  and  increase of the posterior displacement, AA-ould
tend to restore the Avomb to its natural  position, should any circumstance
effect a commencement of anteversion.
  KotAvithstanding these favorable conditions, anteversion has been observed 
540
PATHOLOGY OF PREGNANCY.
 by Chopart at two months, by Madame Boivin at three months, and finally
 by Ashwell.  The case of the latter being unknown in France, we shall
 give an analysis of it.  I have myself tAvice detected hat tAvo months  in
 cases of Avomen affected Avith incorrigible vomiting.
   Mrs. M----, thirty-three  years  of age, and habitually very constipated,
 fell,  during the first month of her pregnancy, whilst descending a pair of
 stairs.  Though there was no hemorrhage, she had  a spell of faintness Avhich
 lasted nearly an hour.  For five or six Aveeks there was a feeling of Aveight
 at the pubis, micturition was  frequent  and painful, but  there was  no ob-
 struction to defecation.  I examined her for the first time at the end of the
 second month.  The cervix was in its normal  position, but the strongly-
 inclined fundus formed a round  solid tumor  between  the bladder and the
 anterior  part of the vagina.   Pressure Avith the finger upon the angle of
 inflexion caused pain.  The neck was elongated,  and larger  and harder
 than  usual.   I endeavored, ineffectually, to effect reduction  by pressing
 upon the fundus of the Avomb with the finger, AvhiJst the neck Avas  draAvn
 doAvnward  and  forward  by the index  of the right  hand.   At the sixth
 month, the husband found that the anteflexion  had almost entirely disap-
 peared, and although the lady still suffered some pain in the latter months,
 she was delivered without difficulty.
   Although the author describes this as a case of anteflexion,  it is evident
 that  there was also anteversion, as is proved by the normal  position  of the
 neck, and especially by the spontaneous.disappearance of the displacement
 at the fourth month.   I see, indeed, no reason why an anteflexion should
 disappear suddenly at this stage of pregnancy.
   Anteversion  is, therefore, possible in the early months, though it  occurs
 more frequently in the second half, and especially tOAvards the end  of the
 pregnancy.  At that time, the fundus of the womb, Avhich is naturally in-
 clined fonvards, is supported by the abdominal muscles only ;  now if these
resist slightly, as often happens Avhen Avomen have had several children, the
physiological inclination has a constant tendency to increase.   The axis of
the uterus may thus  become nearly horizontal, or  even  be  depressed still
loAver, until the fundus falls upon the thighs and knees.   The neck, which
is carried very far upAvards and backAvards, sometimes gets above the sacro-
vertebral angle, and is reached by the finger with the greatest difficulty;
 the impossibility of attaining it has occasionally given rise to a belief of the
existence of imperforation.
   Beside the signs furnished by the touch and examination of the abdomen,
some functional disorders may be produced by anteversion at different stages
of pregnancy, whose cause should not  be mistaken when called upon to
treat them.  In the early months, the sensation as  of a heavy weight at the
pubis, frequent and sometimes painful micturition and defecation, are almost
 the only rational signs.  In the latter  months, the Aveight  of the uterine
 tumor, Avhich is carried strongly fonvards, occasions pains and draggings in
 the thighs and groins ;  the extreme distention of the skin  of the abdomen,
 also, produces acute pain, and the pressure to Avhich the bladder is subjected
 is  the cause of vesical tenesmus, Avith dysuria  or strangury.   Finally, in the
 worst cases, Avalking is rendered difficult and often  impossible. 
DISEASES OF  PREGNANCY.
541
   The prognosis is not generally serious; for, Avhen the a. teversion occurs
 m the early months, the development of the uterus may restore it; Avhen it
 occurs in the second half of gestation, it may produce premature  labor,
 though it usually occasions merely the inconveniences just spoken of, and
 never gives rise to accidents in any degree serious, except  during  labor.
 (See Dystocia.)
   Reduction may be attempted in the early months, but has hitherto ahvays
 failed ; too great perseverance would be at the risk of abortion.  The most
 prudent course, therefore, provided  resistance is encountered, is to intrust
 the reduction to the subsequent progress of the pregnancy.  If the discom-
 fort and Aveight are too fatiguing, they may be relieved by the horizontal
 decubitus.
   At a more advanced stage, a body bandage, or a sort of corset or belt for
' the  abdomen, Avell adapted to the size and form of the belly, will  afford
 much relief.  When the abdomen is pendent, the abdominal belt may be
 kept up by suspenders.  -

   §  4. Lateral Obliquities.
   In describing the  physiological phenomena of pregnancy, Ave spoke of
 obliquities of the uterus, and pointed out their probable  causes.  They are
 rarely carried to any great extent, and are never the occasion of serious
 accidents.   Only by tending to produce an unfavorable presentation of the
 child, and by retarding the dilatation of  the  neck, can they have any un-
 pleasant effect upon the  labor.   Therefore, the  present  is not the proper
 time to speak of them further.
                        CHAPTER III.
                      DISEASES OF THE OVUM.

                           ARTICLE I.
                              dropsies.
  § 1. Dropsy of the Amnion.
  The amniotic liquid  may sometimes  augment to a very considerable
quantity;  but, as the normal amount is very variable, it is difficult to  say
above Avhat limits  it should  be considered as a disease; hoAvever, Avhen it
exceeds three or four pounds, the accumulation may be justly attributed to
some morbid condition.
  In the present state of our science, it would be absolutely impossible to
designate the cause of this singular affection, although some facts seem to
militate in favor of its being  produced  by an inflammation of the amnion;
but this opinion requires further confirmation to be received without hesita-
tion, for, notAvithstanding Dr. Mercier claims to have seen the internal sur-
face  of the  amnion covered  several times by  false membranes, and  the
membrane itself highly injected, yet other observers have not detected any-
thing of the kind.  (Journ. Gen. de Med., torn,  xiv.)
  Again, from the  cases cited by Drs. Merriman and Lee, it would  appear 
542
PATHOLOGY  OF  PREGNANCY.
that a dropsy of the amnion is often associated with a morbid condition or
a bad conformation of the foetus, or Avith a state of general infiltration on
the part of the mother;  indeed, some facts would  lead to the supposition
that constitutional syphilis predisposes to this disease.
  In a feAV instances, it has  seemed referable to  sanguineous plethora;  but
as it occurs in  women of every variety of condition, constitution, and age,
this cannot be considered as a fixed rule on this point.   It is much more
frequent in twin pregnancies, and rarely supervenes prior to the fifth month.
   In some cases, the dropsy is preceded by all the signs  of an  active in-
flammation ;  but most commonly a dull  pain in the uterus, a feeling of
Aveight about the pelvis, and a rapid growth of  the organ,  are the only  evi-
dences of its existence. The womb speedily acquires a considerable volume,
and is more distended at the fifth or sixth month than it usually is at term.
Further, the development is proportionate to the quantity of liquid: thus,'
the  latter  often amounts to five or six pints; and  Baudelocque reports a
case in Avhich  thirteen pints escaped from the uterus, and another one of
thirty-two pints.   Certain authors have even knoAvn forty or fifty pints to
exist in the amniotic cavity.   The  fluid  is similar in all respects to the
liquor amnii.
   The  uterus  rarely becomes much enlarged without disturbing the func-
tions of the thoracic  organs in the manner heretofore described, and facts
are not wanting to prove  that it may  even  produce asphyxia.
   In a case reported by  Duclos, the  distention  of the Avomb was so great,
although the gestation had only advanced  to the seventh month, that it en-
larged the abdomen beyond measure, pushed up the diaphragm,  and inter-
fered so much Avith the  respiration and circulation that  the woman's  life
seemed to be seriously compromised.
   The  physicians, called in consultation, decided in  favor of bringing on
the uterine contractions as soon as the neck shoAved  any evidence of dilata-
tion; but,  suffocation being imminent, M. Duclos ruptured the membranes,
at first  permitting a certain quantity  of fluid to  escape, then, by keeping his
fingers  in  the  neck,  he  prevented its  complete evacuation;  and thus, for
four times, after intervals of fifteen minutes each, he alloAved a further flow,
while slight pressure was  made over the abdomen.  In this  manner, fourteen
pounds were collected, without counting Avhat was lost.  The symptoms dis-
appeared immediately, but  as the uterus did  riot  appear capable of  any
effort, and the  neck offering no resistance, it was easily dilated, and a living
infant brought away by the forceps.   The child was feeble and diminutive,
and its limbs were very small.  The  mother recovered.
   M. Evrat, Sen., of Lyons, has published  several cases of almost complete
asphyxia (lividity of features, cessation of pulse and respiration), in which
the Avomen were rapidly  restored by the  puncture  of the membranes  and
discharge of a large amount of Avater.
   A premature  distention  of the uterus  by amniotic dropsy, to the  size
which it usually has  at the  end of gestation, is capable of producing dan-
gerous  symptoms.  It is astonishing, as  Scarpa  remarks, that in cases of
dropsy complicating pregnancy, the  Avomb should occasion  symptoms of
suffocatiou at hich it never determines at the end of the ninth month, though 
DISEASES  OF  THE  OVUM.
543
 Its size be the same.  It is explained by the sudden and rapid development
 in the first case;  whilst in the latter the distention takes  place  almost im-
 perceptibly, the Avails of the abdomen yield gradually, thus  alloAving the
 uterus to project more in front, so as to diminish its elevation slightly, AA'hilst
 it crowds much less upon the diaphragm.
   As before said, ascites often coexists Avith the amniotic dropsy; but as the
 two diseases may occur separately,  it becomes  important to establish their
 differential diagnosis.
   In ascites complicating pregnancy, the urine is small in quantity, whitish,
 and  turbid, the thirst great and  constant, and the lower extremities and
 genital parts  mostly much infiltrated.   It  is difficult and sometimes  even
 impossible  to  distinguish the shape and fundus of the uterus, on account of
 the irregular  form of the belly, and the enormous distention  of the Iwpo-
 chondriac  regions.   Percussion produces an undulation, or sort of fluctua-
 tion, Avhich is much  more perceptible  at  the upper than  at the lower part
 of the abdomen.
   In  dropsy  of the amnion, the size of the  belly approaches much  more
 nearly that of a uterus at term, although the pregnancy may  not have ex-
 isted  more than  five or  six months.   The uterus  is so rounded  as  to be
 almost spherical.  Fluctuation is more obscure, thirst slight or  absent,  urine
 natural,  and  in some cases little or  no infiltration of the lower extremities.
 The umbilical tumor is rarely present, and, AA'hen it exists, has not the trans-
 parency  observed in ascites.
   The great enlargement of the womb often provokes premature contractions
 and abortion.   Sometimes the child is born living, but so little developed
 that it cannot  survive; more frequently, it dies  in the mother's womb, and
 is not expelled until some time after.
   Dropsy of the amnios, Avhich is so  grave as regards the infant, rarely com-
 promises the  mother's life, or even her health.  Some  unfortunate  cases
 have, hoAvever, proved fatal, though  generally she is merely incommoded by
 the excessive volume of the Avomb, and the  consequent interference Avith
 other  organs.   The  expulsion of the liquid is generally spontaneous; the
 foetus, membranes, and placenta passing aAvay Avith the Avaters; whence, the
 cause no  longer existing, the disease  is completely cured.
   According to some authors, the rupture of the membranes and consequent
 expulsion of the fluid is not ahvays folloAved by  the  birth of the child.  In
 this case, the  breach in the membranes takes place at a point  considerably
 above the neck, the uterus is relieved sIoavIv of the superabundant fluid, and
 the pregnancy proceeds Avith no other accident than a more or  less frequent
 discharge of Avater.   I think  that, in most  of  these cases, an accumulation
 of fluid betAveen the membranes and the uterus,  as in the hydrorrhoea to be
 spoken of hereafter, has been mistaken for amniotic dropsy.   I  confess, how-
 ever, that the folloAving case, carefully observed by Ingleby, leaves hardly a
doubt as  to the possibility of the fact: A lady, six months gone in her third
 pregnancy,  lost suddenly a large quantity of Avater during the night.  From
this moment, until the termination of pregnancy, there escaped  every tAvo or
three days  a  pint and a quarter of  fluid.   The Avoman was  delivered of a
large boy.  The after-birth Avas expelled  spontaneously.  I  received  it in 
544
PATHOLOGY OF  PREGNANCY.
my hand, says  the author, so as to avoid laceration of the membranes.  I
examined it with the greatest care, and discovered, besides the opening made
by the head in the centre of  the membranes, a second opening, of circular
form, near the  edge of the placenta.  It was doubtless  through the latter
that the fluid escaped from time to time.
  It is proved,  by many observations, that amniotic dropsy frequently recurs
in the subsequent pregnancies  of the same female.
  A remarkable circumstance, pointed out  by MM. Bunsen and  Kill, and
one instance of which  has come under my own notice, is a dropsical condition
of the foetus, it being sometimes affected with hydrocephalus, and at others
with ascites.
  The same authors  also mention  having observed that in these  cases the
placenta Avas often remarkably large.  Thus, in a case reported by M.  Kill,
in which the extreme distention  of the uterus produced abortion at the  sixth
month, the circumference of the placenta was a third larger, and its thick-
ness double that of ordinary placentas.  It was  pale, and its tissue spongy,
and, Avhen divided, the vessels traversing its substance were found to have
almost the size  of the arteries  and umbilical vein.
  The abdomen of the foetus  contained a large amount of fluid.   The liver
was voluminous, occupying almost the Avhole abdominal cavity.  Its structure
was  normal, without  any indication of SAvelling, but its vessels Avere highly
developed.
  This great size of the liver is supposed by the authors quoted to be con-
nected Avith the extreme development of the placenta, Avhose enlarged vessels
Avould of course supply a great quantity of blood to the umbilical  vein.
(Churchill, page 50.)
  When the malady is once established, it is exceeding difficult to find the
proper remedies, — I will not say to cure, but even to impede its course; — for
instance, diuretics have usually proved of little value.  Some authors, indeed,
seem to  have  observed  good effects from  dry diet;  and  Burns specially
recommends cold  bathing.  But,  in spite of all Ave can do,  the affection
ordinarily goes  on increasing  until the commencement of labor; and in the
greater  number of cases there  is  nothing to be done except to aAvait this
event.  However,  if the  uterine tumor be of excessive size, more  especially
should the dropsy of the  amnion be complicated Avith ascites and a general
infiltration, and the patient's  life  be endangered by the obstructions to the
hsematosis, an  evacuation of  the waters' should be  determined upon  by
rupturing the membranes.
  The puncture is usually effected by the use of a male or female catheter,
or a stylet, Avhich is introduced through  the  neck, and the membranes per-
forated  with its extremity.   When  the cervix is sufficiently dilated, the
rupture may be performed Avith the finger.  When not obliged to act quickly,
contractions may be previously solicited  by introducing and leaving a piece
of prepared sponge in the cavity of the cervix, or by practising some douches
upon the inferior segment of the uterus.  (See Premature Artificial Delivery.)
But should the gravity of the symptoms demand  immediate  intervention,
there would, I think, be some advantage  in  folloAving  the advice  of M.
Guillemot, and to glide the catheter betAveen the ovum and the uterus, so as 
DISEASES OF  THE  OVUM.                  545
to pierce the membrane far above the neck ;  this  process wot id  permit the
discharge of the fluid to be controlled, and  only  the  superabundance, so to
speak, to be AvithdraAvn.  The pregnancy may afterward be left to itself.
  In case of complete  obliteration of the neck, paracentesis by the vagina
and in the vicinity of the uterine orifice must  be performed.  Scarpa and
Camper recommend puncturing  betAveen the umbilicus  and  pubis.   In one
of the observations of Evrat, Sen., the operation was  practised in the place,
so called, of election, for paracentesis.   The patient was delivered eight days
aftenvard of tAvo living children, and recovered  perfectly.  The details given
by the author do not inform us Avhether the  case was one of ascites, or really
of amniotic dropsy, as  he thought.
  The vaginal puncture seems to me likely to subject both mother and child
to the feAvest risks, whenever the neck is inaccessible.

   § 2. Hydrorrhcea.
   The Germans have given this name to those discharges of Avater that occur
in the course of the gestation, but which, in general, are neither preceded
nor folloAA'ed by any uterine contractions; their  nature is such as to interfere
but slightly with the pregnancy, the latter advancing as usual to term, and
at the accouchement the bag of Avaters is regularly formed.
   This  affection is quite common in the latter  months, but very rare at the
beginning of gestation.  I observed it  once betAveen the third and fourth
month,  and it reappeared but once during the  remainder of  the pregnancy,
Avhich terminated happily.  (See Abortion, article Diagnosis.)
   The  frequency of such  discharges, and the  quantity of Avater lost each
time, are exceedingly variable in different cases.   Sometimes  the liquid
comes aAvay in gushes,  at others drop by drop; but the amount may increase
in an incredible  manner, and the loss  may occur but once, or be reneAved
frequently.  Further, the intervals of its appearance are very irregular, and
lasting  a long timeAA'hen it does come on, during AA'hich any mental emotions
or bodily  excitement singularly influence the profuscness of the discharge.
On the other hand, it augments in quantity during the most perfect quietude,
as, for instance, at night during sleep; its cause can rarely be ascertained.
   Most generally, the  female  enjoys her usual health before the discharge
comes on, Avhen she unexpectedly finds herself Avet, the fluid escaping drop
after drop, or  else she hears the peculiar sound caused by the sudden irrup-
tion of a considerable quantity of the Avaters.  In most cases, she suffers no
pain either pending or after this discharge; though  it may happen that a
too rapid depletion of the  uterus, and the  consequent parietal  retraction,
may bring on some slight uterine contractions;  but if the patient then "keeps
perfectlv still, they soon disappear, and everything resumes its natural order.
In color, the discharged Avater is usually a little yellowish, A'ery limpid, and
at times tinged with  blood, leaving stains upon  the linen, and having a well-
marked spermatic odor.
  Should the  hydrorrhoea be attended Avith the uterine pains,  it Avould be
an evidence of an approaching abortion; and some accoucheurs, supposing
the membranes had  been ruptured, have been knoAvn, under such  circum-
stances, to use every effort to accelerate and  to terminate a labor \vhich
      35 
546
PATHOLOGY OF  PREGNANCY.
really had not commenced, and which, without their interference, would not
have occurred before the ordinary period.
  [We  saAv a  case of hydrorrhcea during the sixth month of gestation, in which
uterine contractions had come  on and almost completely effaced the neck of the
womb which was opened to the  size of about a franc-piece.  Rest in bed and opiate
injections  quieted the threatenings of abortion, and the patient was delivered at
term.]
  This error  may be avoided by attending to the fact, that, notwithstanding
so considerable  a Aoav of liquid, the size of the uterus, its consistency and
elasticity, are such as it generally  presents at that period.  These remarks
-will at least be  sufficient to excite  a  doubt  as to the true source of the
waters; and  from the moment that there is a doubt, every effort should be
made to prevent and not to hasten  abortion.
  These fluids,  although having  no relation in their seat  to the liquor
amnii, have,  however, been called  the false waters, so as to distinguish them
from those which escape after the membranes are ruptured in labor.
  Various opinions have  been advanced as to the nature and seat of these
false Avaters;  thus, certain accoucheurs have supposed that they Avere con-
tained betAveen the chorion and the amnion, and that their escape is due to
a laceration of the chorion;  others, that they are  OAving  to the rupture of
an hydatid, lodged either in  the cavity or the neck of the uterus (Bcehmer,
Roederer).  Again, Baudelocque Avas of the opinion that  it  resulted from
the transudation  of the liquor  amnii through the membranes.   Some others
explain it by invoking an cedematous  condition and an infiltration of the
uterine cellular tissue.   It is an  easy matter to refute all  these opinions by
recalling  the fact of the frequency  and abundance of the discharges, Avhich
often come  away in large quantities.   Mauriceau,  Camper, and Capuron
supposed  that these Avaters proceed from the interior of the amnion; for, in
certain cases, they say, the membranes may yield at  a point  quite  distant
from the  neck, and the superabundance of this  fluid will then gradually
drain aAvay, though still an abortion may not occur.
  This explanation is not applicable to the greater  number of cases of
hydrorrhcea,  for observation does  not  shoAV that Avhen water came away
several times during pregnancy the amount lost during labor Avas less than
usual: beside which, careful  examinations of the membranes after delivery
have very rarely detected traces of old rupture.   Some Avell observed cases,
hoAvever,  prove  that Mauriceau's opinion •may be exceptionally true.  (See
page 543.)
  It is much more probable  that the fluid which  thus escapes in the course
of gestation, sometimes a feAV  days only before term, had  accumulated be-
tAveen  the internal uterine  surface  and some portion of the  membranes
(variable in extent) that Avere  detached.   This  is the view adArocated by
Naegele, and it has been lately reproduced by one of his pupils in a thesis
sustained at  Heidelberg, from Avhich I have derived  most of these  details.
That is to say, the fluid secreted by the internal surface of the organ gradu-
ally detaches the membranes, thereby forming a pouch for itself until its
constantly-increasing quantity succeeds in  separating  them as far as the
D<ick, when an irruption of the liquid takes place. 
DISEASES  OF THE  OVUM.
547
   This theory av as confirmed by the autopsy of a pregnant Avoman affected
with hydrorrhcea.  Dr. Duclos, of Toulouse, Avho relates the case, found the
membranes partly detached and from that  point the fluid  escaped.  Else-
where the membranes were raised by  an accumulation of fluid between
them and the uterine wall, being thus  ready, so to speak, to  give rise to a
fresh attack of  hydrorrhoea Avhenever the detachment  should extend to the
cervix.
   Now, if Ave  admit Avith  Professor  Burdach, that  an exhalation  takes
place from the internal surface of the uterus, which, by transuding through
the membranes, reaches the amniotic cavity,  and thereby contributes to the
nutrition of the foetus during the greater part of the  intra-uterine life, it
would be easy to explain this abnormal accumulation of fluids, either by an
excess of secretion or an arrest of transudation.  It may also be explained
by supposing that the secretion continues beyond  the ordinary term, and
the liquid is obliged  to create a cavity or  a  kind of reservoir for itself by
detaching the membranes to a certain extent.
   Generally speaking, this  is not  a serious affection; nevertheless, if fre-
quently repeated,  it might bring on premature contractions.
   The treatment is very simple.  The patient must  maintain the most per-
fect rest, avoiding all moral and  physical  excitement  during the Aoav, and
for seven or eight days after it has  ceased.   Should it be folloAved by slight
contractions, enemata, containing laudanum, Avould arrest them;  and if the
discharge is accompanied by any evidences of general or local plethora, these
symptoms must be promptly met by the appropriate measures.

   [§ 3. Dropsy of the Yili.i of the  Chorion.   Hydatiform Mole.
   The  villi of the  chorion sometimes become distended by fluid which collects
within them, causing them to SAvell and assume the form  of rounded vesicles, com-
parable to gooseberries or grapes, and  having, consequently, some resemblance to
hydatid vesicles.  On account of this analogy, they were,  for a long time, supposed
to be true hydatids.  M. Yelpeau Avas the first to discover  that the hydatiform mole
has its origin in the chorion, and  the microscopic examinations of Prof. Robin ex-
hibited still more clearly the true nature of the disease by showing  that the en-
velope of  the hydatiform A'esicles have all the anatomical characteristics of  the
walls  of the villi of the chorion.   It is now regarded as certain  that the disease
known as hydatiform mole is  nothing but a dropsical condition of the  villi of the
chorion.
  Though the affection is a rare one, we have a good  account of  it in  Dr. Cay la'a
thesis, which we  have found very useful in the preparation of this article.
  If an ovum, presenting the alteration in question, be examined, the villi  are
seen, as usual, detached from the surface  of the chorion.  In some ctises,  the
pedicles will have  undergone no change in  size,  whilst at others they will  be
slightly dilated.   The dilatations, or vesicles, begin to appear where the ramifica-
tion commences, the branches of the villi being found swollen at intervals.  The
dilatations vary in size  from that of a walnut to that of a  filbert, and so down until
they become  almost invisible to  the naked eye.  A whole villus is often almost
completely metamorphosed into a bunch of vesicles almost as large as gooseberries.
Upon the larger of these, smaller ones  are often  inserted, and generally by a very
fine pedicle, a portion of the undilated branch of the chorion.  The pedicle varies
from  -039 to '078 inches in length.  Sometimes it is extremely fine, but may reach a
diameter of -039 inches; in which case  it  allows the fluid to flow through it from 
548
PATHOLOGY OF  PREGNANCY.
one vesicle into the other.   More frequently, it is obliterated  through a greater oi
less extent of its course.  All  the vesicles of the same group  are, therefore, con-
nected by pedicles, forming groups of the  strangest appearance, but, nevertheless,
recalling that of  the villi in the normal condition.
  It is generally easy enough to separate the vesicles from each other, and to trace
the pedicles down to the chorion ;  sometimes, however, they are inextricable.
  The fluid  contained  in the  vesicles  is usually colorless, transparent, liquid  as
water, and containing  albumen in  solution.   Occasionally, the contents are of a
reddish color.
  This  dropsical condition  may affect either the villi of the chorion, properly so
called, or those of the placenta, and in both cases the life  of the foetus is  nearly
always  compromised.  The  dominant fact in the affection is, after all, the arrange-
ment of the umbilical vessels.  Should all  the villi become  dropsical, the death  of
the foetus would  necessarily ensue,  and, occurring at a period very near that  of
conception, it might undergo solution in the amniotic fluid, and thus disappear.
  Should the alteration of the villi be more recent or less complete, we should have
an embryonic mole, in which the body of the foetus would present various  grades
of development.  Sometimes even,  though  rarely, when the alteration  affects  a
small number of villi, the  foetus may be fully developed.  Finally, a  case  of M.
Brachet's proves  that a few hydatiform vesicles occurring on the placenta do not
prevent the binth, at term, of a healthy child of the usual size.   It is certain that
in twin pregnancies an  alteration of one ovum  may affect the other injuriously;
still, some cases,  reported in the Dictionary, in thirty volumes, show that one ovum
may be transformed 'into a  hydatiform mole, whilst the other foetus undergoes
regular development, and is born at  term.
  By what symptoms  may dropsy of the villi  of the chorion be suspected or dis-
covered ?  If the alteration  be  slight, none of the usual signs of pregnancy will  be
wanting, and then a diagnosis  will be almost impossible.  If, on the contrary, the
change  is so great as to completely alter the ovum, the affection may be suspected
and  occasionally discovered.  All  writers  admit that attacks of hemorrhage are
common in such cases, and they almost always coincide with an unusual develop-
ment of the uterus, whose size is no longer  in conformity with the presumed period
of gestation.   These two symptoms  are found conjoined in  a case of M. Depaul's,
already published by M. Cayla. The most important sign,  however, is a too rapid
increase in the size of the  uterus, and by it was  a positive diagnosis  made  in the
folloAving case, which we owe to the kindness of M. Pajot, from whom we received
it.  The account will be read  with  interest: "I saw a case of so-called uterine
hydatids in connection Avith Dr. Gocherand  (of Ivry), and although it was the third
one of the kind which has fallen under my notice, the circumstances attending  it
were very different from my own two first cases, and afforded  the opportunity  of
studying a much  greater alteration of the villi«of the chorion."
  The patient was a young woman who had given  birth to a child about a year
previously, and who now supposed herself to be about three months pregnant. On
making an examination 1 was astonished to find the uterus as large as at the eighth
month of gestation.  A very  marked sense  of fluctuation made me at first suppose
that there might  be  a  collection of  fluid or a rapidly developed cyst of the ovary.
However, I soon  became satisfied  that  there Avas an accumulation of fluid  in the
cavity of the  uterus itself.
  By vaginal examination  I  found that  the  loAver segment of  the uterus was
considerably  developed.  The neck was as soft as at the eighth month of gestation,
and presented the indications of a previous labor.  The finger could be inserted  as
far as to the internal orifice, which was closed hermetically.   By passing the finger
around  the cul-de-sac, the left hand at the same time being applied upon the fundus
of the uterus, the sense of  fluctuation already perceived so  clearly by palpation, 
DISEASES OF THE  OVUM.
549
 was  again  evident.  There  was no  solidity  at  any point of the abdjmen.  The
 patient's general health was bad; she had a dry, hot skin, and pulse at 120.
   It Avas the only one of the three cases in which a diagnosis could be established.
•   I advised the insert .on of a gum-elastic catheter through the internal orifice, and
 the administration of ergot.   The advice was followed the next day, and the patient
 expelled, together with a large quantity of fluid, a multitude of hydatiform vesicles,
 either in a detached state or  in clusters of five or six together.  The entire collec-
 tion would have filled a man's hat.  The vesicles were taken  to Paul  Dubois, who
 Bhowed them to his class,  and made them the subject of a lecture.
   The evacuation was followed by no improvement in the general symptoms; the
 patient continued to lose strength, and died a few days after the operation.  Unfor-
 tunately, an autopsy could not be obtained.    (Pajot.)
   Although the uterus, in these cases, is generally too  large for  the stage of the
 pregnancy, it  is  sometimes  in  the  opposite condition.  (Thesis of  Dr. Louvet-
 Lamarre.)
   The pregnancy usually terminates earlier tt\an in normal cases, expulsion of the
 ovum generally taking  place before the sixth  month, and in the usual  manner;  all
 the symptoms  which precede, attend,  or follow it resembling precisely those  of
 abortion, though the accompanying hemorrhage is commonly  profuse.
   The formation of an  hydatiform mole rarely appears to have any effect upon the
 general health  of the patient, or upon subsequent pregnancies.  Madame Boivin;
 however, mentions some  cases of women who were so unfortunate  as to suffer
 repeatedly from the affection.


                             ARTICLE II.

                LESIONS OF  THE VILLI OF THE PLACENTA.
   Although changes in the structure of the placenta are  quite common, our knowl-
 edge of them is as yet so limited, that in a work like the present we shall be able
• to notice only the most  important of them.
   A clear statement of what may be said of the pathology of the placenta, makes  it
 necessary to revert to some details respecting the chorion and  its villi.   The two
 latter are composed of the same substance, that is to say, of a  membrane formed of
 polyhedral  cells, which  are easily distinguished up to the sixth week.  At a later
 period their nucleolus disappears, the nucleus loses its  transparency, and the cell
 itself becomes  filled with  granules.   In  this Avay the  chorion soon assumes the
 appearance of a continuous membrane, which is more or less granular and sprinkled
 with nuclei.
   In its beginning the chorion has the form of a regular hollow sphere, with smooth
outlines ; soon, however, its surface.becomes covered with multitudinous prolonga-
tions, to Avhich  the  term villi has been applied.   Almost all these prolongations
are traversed by a canal, Avhich'terminates in a cul-de-sac at the free extremity of
the villus, but  opens freely at the internal surface of the chorion.  This internal
surface is, therefore, covered  with minute perforations,  each communicating  with
the eanal of its respective villus.  When the allantoid is formed, it  becomes applied
ogainst the internal surface of the chorion, and quickly sends vascular prolongations
into most of the villi.  Some  of these  villi then continue  to grow, so as to form the
placenta; the rest become atrophied in a way which has  been well described by
Robin (Archives Generates de  Medecine, 1848, et Gazette Medicate, 1854), and which
affords the key  to some of the lesions of the placenta.  Prof. Robin's investigations
may be recapitulated aa follows: —
  1.  During the formation of the villi  the development of some of them is arrested,
e) that thiy contain no central  canal, and consequently can have no participation 
550                 PATHOLOGY   OF  PREGNANCY
in the allantoid circulation.  They appear as solid cyli ders, having imledded in
their  tissue an abundance of grayish granules.
  2. Although most of the villi are provided each with  a canal, some of them  fail
to receive a prolongation of the allantoid ;  these, consequently, remain tubular,  and
are distinguished by the abundance of fatty molecular  granules, with Avhich theii
parietes are sprinkled.
  3. Although nearly all  the villi become vascular at a  certain  stage in  the devel-
opment of the ovum, most of them have become atrophied by the time the placenta
is distinct.  In following  up this process of atrophy, the allantoid vessels traversing
the villus are first observed to  disappear, and the canal is quickly obliterated,
beino- filled  with a tissue resembling the reticulated magma.   The walls of  the
villus itself  become charged Avith fat in the shape of fatty granules and real  oil-
drops, sometimes scattered and sometimes in collections of A'arious forms.
  4. The placental villi occasionally present the same indications of atrophy as  are
constant in  the other villi in the chorion; in other words, the  placental villi may
undergo  atrophy, cease to be vascular, and exhibit an  abundant  fatty deposit in
their walls.
  We shall  soon explain the mode by which  the normal atrophy of the villi of  the
chorion gives rise to important  lesions when it happens to extend to  those villi
which go to form the placenta.

  FIBROUS  OBLITERATION  OF  THE PLACENTAL VILLI WITH OR WITHOUT
                           FATTY  DEGENERATION.
   The lesion in question  has been described as  induration of the placenta, encepha-
loid, scirrhous, cancerous,  tuberculous, and fatty degeneration:  still  oftener has il
been mistaken for a fibrinous deposit, the  remains of a placental  apoplexy.  (See
Placental Apoplexy.)
  The degeneration appears in the form of grayish or whitish masses, which  are
always less red and moist than the  rest of the  placenta, and of a tissue which is
hard,  compact, friable,  and but  slightly stringy.   This appearance has caused them
to be mistaken for concrete pus, masses of crude tubercle or scirrhous formations.
When, hoAvever,  they are examined under  the microscope,  it  is soon-seen that
all the parts of the tissue  thus altered  are composed of obliterated villi of  the
chorion with  their  tissue charged with  fatty  granules.  All the ramifications,
however, are not thus  supplied  Avith  fat, since in the  parts apparently the most
diseased  and distinguished by  their whitish color, the villi contain no trace of  fat
granules, or have them only at long intervals.   In a word, the lesion Avhich Ave  are
describing is characterized by obliteration of the placental villi, precisely similar
to the atrophy which  invades  the villi of the  chorion  after the formation of  the
placenta, and Avhich we have described above.
  This alteration is more  especially met with at the circumference of the placenta,
the cotyledons in that situation being  the ones chiefly affected.   It  may  always be
found in the cotyledons of the periphery, or, at least, in a small portion of some of
them: in this case, however, the affected  ramifications  of the chorion are lost, as it
were, in the midst of those which remain pervious, and in this degree the disease
is of no interest to the clinical  observer.
  In certain placentas, however,  there will be one or several portions of cotyledons,
or even one  or several entire cotyledons,  Avhich  have undergone fibro-fatty degen-
eration ;  and sometimes even the greater  part of the placenta is thus  transformed
into a morbid tissue which is impervious  to blood.
  A placenta examined by MM.  Laboulbene and Hiffelsheim had six of  its cotyle-
dons entirely obliterated, beside Avhich there were discovered  eleven  other small,
yellowish masses, presenting  the same external characters and  structure as  the
diseased cotyledons.  The altered cotyledons are sometimes scattered through the 
DISEASES OF  THE  OVUM.                    551
     placental mass, at other times they touch by their edges, but are ihvays definitely
     separated by deep furrows.   The change is generally more evident upon the uterine
     Burface of tlie cotyledons  than upon  the  side  of the chorion, for there the tissue
     resumes gradually its softness, humidity, and reddish hue.
       " If the placenta be  emptied of blood," says  M. Robin, from  whom Ave borrow
     almost the whole of this article, " the diseased cotyledons will project more  than
     the healthy ones; but if the placenta be  injected, the  former Avill be depressed in
     comparison with  the latter.   This result is due to the fact that  the  ramifications
     which remained  vascular in the emptied placenta, subside in consequence of the
     discharge of their blood ; but  as the obliterated ones do not collapse, their  bulk
     remains greater than that of the others.  When, on the contrary, the healthy and
     vascular cotyledons are distended by injection, they form a larger mass than those
     whose subdivisions are  obliterated, and appear in relief beside them."
       The alterations just described are  independent of hemorrhage  or placental apo-
     plexy.   Whenever the  tAvo affections have been confounded, the observers  were,
     doubtless, deceived by  their coincidence.  It is,  indeed, by  no means rare to  find
     an apoplectic space in the centre of the diseased cotyledons, large enough to contain
     a pea, a  bean, or only a millet-seed, and the fibro-fatty degeneration of the villi
     has often been mistaken for a  bleached clot.  This confusion is now impossible,
     thanks to the microscope, Avhich discovers in the mass of diseased cotyledons not a
     collection of fibrin, but a network of atrophied villi of the  chorion.
       A single  argument remains in favor of the view which  attributes  them to apo-
     plexy, to Avit, that the hemorrhage which takes place causes the obliteration of the
     cotyledons.   To us it seems impossible thus to make the obliteration subordinate
     \o  the apoplexy, and M. Robin's researches tend to prove that the fibro-fatty altera-
     tion may become a cause of hemorrhage as  regards  the  neighboring villi Avhich
     continue  pervious.  Moreover, as a matter of  fact,  placental apoplexy is met with,
     without obliteration of  the  cotyledons, and it is very often  impossible to discover a
     trace of apoplexy in cotyledons which are completely obliterated.  The two lesions
     are, therefore,  mostly independent of each other.
       Obliteration  of  the placental cotyledons is  without  importance as regards the
     mother, but, as will be readily understood, may be  highly injurious  to the foetus.
     It is, indeed, proved that an almost constant relation exists betAveen the  Aveight of
     the foetus and that of the  placenta.   Now in the  case before us, any obliteration of
     the villi cuts off by so much the active portion  of the placenta; if but  a few villi be
     obliterated, the child experiences no bad effect from it,  but  if several  cotyledons be
     altered, its development will be  imperfect, and should half of the organ be invaded,
     its life will  incur the greatest danger.  In a still more advanced stage, its death is
     almost certain.
       All our knowledge of the fibro-fatty degeneration of the  placenta is, so to speak,
     condensed into the anatomo-pathological  statement just giA'en, and Ave are obliged
     to confess, as does Dr. Millet, whose  excellent work may be consulted Avith advan-
     tage, that there is nothing to give us light upon the etiology of this lesion, no sign
v     which enables us to fix  its symptomatology upon  a certain foundation.   Sometimes,
     however, there  have  been evidences of uterine congestion  in cases  in which the
     patients  had complained of weight or pain in the  loins.   These symptoms  then
     resemble those  observed in cases of placental apoplexy, and, we would observe, are
     really so vague or even  insignificant  that it would  seem to  us  almost  impossible to
     diagnose the fibro-fatty degeneration in a case of first pregnancy.   As,  however, the
     affection is liable to recur and sometimes adheres  tenaciously to the  same woman
     in all her pregnancies,  the  accoucheur may take warning and let the least trouble
     occurring either  to the mother or foetus  during  gestation  have  its weight in his
     estimate of  the situation.  M. P. Dubois  says, in reference  to these matters, that,
     if a sense of dull pain  and fulness  is connected  with  a slight diminution of the-
     motions of the  foetus, there is reason  to fear that  it is in serious danger. 
552
PATHOLOGY  OF  PREGNANCY.
   It is possible, then, to suspect or even to foresee the fibro-fatty degeneration of the
placenta;  but how shall it be prevented ?   What course, shall be  pursued if the
woman becomes pregnant again?
   M. Dubois' advice to his pupils, under these circumstances, is thus brieflv stated
by Dr. Millet:  Advise the patient to avoid all kinds of fatigue; insist upon her lying
down, and prescribe a light diet for the purpose of moderating the circulation.   At
the same time practise a revulsive bleeding to the extent of from one to two ounces.
followed the day after by a similar one.   In connection with this apparently
reducing treatment, M. Dubois, without fear of being taxed with inconsistency, adds
the use of iron, inasmuch as it has appeared to him that women are predisposed to
the affection by a certain degree of impoverishment of the blood.  The iron would,
at any rate, seem in several instances to have benefited the patients.

                             ARTICLE III.
                  EFFUSION OF  BLOOD IN THE PLACENTA.
   Utero-placental hemorrhage will be studied in  all  its connections when treating
of abortion or the hemorrhages accompanying delivery (see Abortion, and Dystocia);
we are, however, to speak in this place of certain effusions of blood in the substance
of the placenta Avhich present peculiarities deserving of special attention.  These
effusions differ considerably both in situation and form, the variety being due, for
the most part, to the more or less advanced stage of the development of the placenta.
Thus, if the blood occupy circumscribed cavities formed in the tissue of the organ,
it takes the name of placental  apoplexy giA'en to it by M. Cruveilhier, and will be
described in the next paragraph.  Up to the third month, however, not only may
the blood be effused into the placenta itself, but may even extend beyond its limits
and  spread over the entire external surface  of the chorion.  This last variety will
be the first to engage our attention.
   As utero-placental hemorrhage has been so well treated of by M. Jacquemier, we
can do no better than borroAv several  passages of  his description.  Up to the third
month,  as stated, the blood effused into the placenta has a great tendency to spread
itself over the surface  of the chorion ; in  fact, it  could  hardly be otherwise, for at
the outset  the  placental villi are not  yet connected hy the amorphous tissue which
at a later period forms of  them compact  lobes, and the circumference of the pla-
centa is not yet well defined, there being no distinct  limit between the villi of the
placenta and those of the chorion, which latter are destined soon to disappear.  The'
entire surface of the chorion is, in fact, at this time  covered Avith prolongations which
separate to a certain extent its  external  surface from that of the  decidua reflexa
until  both membranes  are  brought into contact through the atrophy of  the villi.
Should  a rupture now  occur of some of the utero-placental vessels either in process
of development or but recently  perfected, the blood therefrom would  soon reach all
the vascular tufts of the placenta and villi of the  chorion by spreading itself in a
layer between the ovular decidua and the chorion. The aborted ovum  under these
circumstances often has a fleshy appearance,  its surface being  more or less bluish
or blackish, Avhilst its walls  form  an  envelope of  variable solidity and thickness.
If it  be entire, a careful examination will often detect on the  external surface of
the placenta minute rupture's opening into cavities and closed or not  by coagulated
blood.  Frequently, also, there  is  no rupture, although the  placenta may contain
deep-seated, circumscribed cavities or extensive diffused  infiltrations.   If the layers
of the decidua be stripped  from the ovum,  the entire  surface of the chorion, the
portion  occupied by the placenta included, will  be found covered  by coagulated
blood which  is firmly held  by  the A'ascular ramifications of  the placenta and the
villi of  the  chorion  imprisoned in its substance.   Both chorion  and  amnion are
intact, the amniotic fluid having a slightly red color by imbibition.   If the embryo 
DISEASES  OF  THE  OVUM.                   553
 be very young, it may sometimes be found to be entirely dissolved, the  mly trace
 left of its existence being a very small bit of the cord still attached to the placenta
 bv a few fragments of a very soft tissue.  At other  times the  amniotic  fluid may
 merely seem to be a little thicker than usual, resembling in this respect a mucilage
 of guim  Should the structure of the embryo  be firmer, it will be found in its normal
 condition, only more or less Avithered and macerated according to whether the date of
 its death be more or less remote. The blood covering the entire surface of the chorion
 sometimes forms a firm and hard coagulum, which, occasionally,  in some parts has
 lost its color and resembles the buffy coat of blood from venesection ; at other times
 it is soft and presents the appearance of a black, thick, and granular fluid.
  The amount of blood effused varies greatly, and the layer formed by  it may be
 only from '068 to 'I3G inches, or from "78 to *1'17 inches in thickness. In the latter
 case, the ends of the villi will have lost their  relation with the reflected and  inter-
 utero-placental deciduas, thus producing an unnatural widening of  the interstice
 which, in the normal state, is very small.  The layer  of blood is not of equal
 thickness at all points; in some places it collects in larger quantity, and that most
 generally where the placenta would have been formed.  Ova thus affected have,
 sometimes, another appearance ; thus, if during  their expulsion the decidua  has
 been remo\red, as often happens, they look like  a clot of blood, but dissection  and
 washing soon discover in their tissue the vascular  ramifications of the placenta  and
 villi of the  chorion, showing  that  the seat of  the  effusion  is the  same as in the
 preceding case, and that they are not  merely ova Avrapped  in their deciduas  and
 enclosed in  a clot  of blood.
  At a rather later period of gestation, say  the  third or fourth month, the effusion
 spreads much less over the surface of the chorion and shows a tendency to be con-
 fined to the placenta ; still, it will sometimes extend beyond  the edges of the latter
 in the  form of streaks, projecting in various  directions to a greater or less distance.
 The limitation of the effusion is  due  to the approximation and somewhat firm
 adherence between  the chorion and the decidua reflexa, due to the atrophy of the
 villi of the chorion, so that a space no longer  exists betAveen the two membranes
 except for a variable distance  near  the  border  of the placenta.   Even  should we
 suppose that the^e effusions exert a considerable f6rce, it is not generally sufficient
 to rupture the membranous envelopes which  restrain them.  Still it is not so very
 rare for the decidua reflexa to give Avay and allow the blood to pass into  the cavity
 of the  decidua and even reach the internal  surface of the uterus.   As an excep-
 tional  occurrence it is sometimes found to have  ruptured the chorion and  amnion,
 as in  the cases  observed  by  M. Gendrin, who  found blood  effused between  the
 chorion and  amnion, and even in the  cavity of the latter,  where it enveloped the
 embryo completely.  Within the periods of foetal life above mentioned, there  can
 be no doubt that  the  effused blood proceeds from a rupture  of the utero-placental
 vessels, even though it be impossible to detect any lesion upon the external surface
 of the  placenta.   It is impossible to suppose that the blood  comes from the umbil-
 ical vessels, for we have seen that in some cases the embryo is so slightly  developed
 as soon to be dissolved, whilst in others the amount of blood effused generally far
 exceeds the entire bulk of the embryo.   If the umbilical vessels are ever ruptured,
 they could only be so consecutively to rupture of the utero-placental vessels, in
 which  case the fcetal and maternal blood would mingle together.
  An occurrence of this kind happening to the extent just imagined, would, gener-
 ally, be fatal to the foetus, though the ovum Avould not be  expelled until later.  As
 the effused blood is not in contact Avith the walls of the uterus, it does not stimu-
 late the  organ immediately to contraction,  and it very often happens that  when
 abortion  takes place, the blood is found to have already begun to lose its color, as
also to present other  changes indicating that  the  hemorrhage  must have taken
place some time  previously.  Should the  effusion be moderate, it Avould not seem
ur.pos.siHe for gestation to continue.  (Jacquemier.) 
554
PATHOLOGY  OF  PREGNANCY.
                           PLACENTAL APOPLEXY.
  Mr. Jacquemier's book again guides us in describing placental apoplexy.  From
the middle of intra-uterine life the placenta continues to be quite  frequently the
seat of effusions of blood, Avhich  effusions are peculiar from the fact that they no
longer extend beyond its edges between the now firmly united chorion and decidua.
Instead of being diffused and occupying the greater part or even the Avhole of the
placenta, these effusions are more fully circumscribed and confined to the lobes in
which  the ruptured vessels are situated, although they always show a strong ten-
dency to  extend toward the fcetal surface  of the  placenta.  They also present
varieties which may be described under three principal heads.
  In the first variety there is no cavity, properly so  called, produced, but the blood
infiltrates the tissues of one or  more lobes of the placenta, apparently diminishing
its density.   In some places  it accumulates sufficiently to form  little vacuoles
filled Avith a very dark-colored fluid which in some cases has the appearance  of a
very thin jelly.   (Jacquemier.)
  In the  second variety  the  effused blood  forms  a very irregular  cavity, having
prolongations  in various directions,  anTl the  parts adjacent are  infiltrated and
stained  of a  reddish  hue for a very considerable  distance.  The foci are usually
quite  large  and  mostly  communicate with  the external  surface of the placenta
through a rupture of greater  or less size, with detachment of the parts correspond-
ing ; they are irregular  in form  and more  liable  to be found near the edge of the
placenta in  proximity to the  coronary  vein,  which is sometimes  ruptured, and
communicating with the  cavity.  When the effusion takes place near the centre of
the placenta it easily reaches the  external surface of the chorion ; and should  it be
near the point where the principal branches of the cord traverse the latter, a little
blood will sometimes  be  found to have penetrated  to a greater or less extent the
tissues which  surround the umbilical arteries and vein  at tho root of the  cord.
This condition has already been described in several cases, of which one published
by M. Gendrin is very interesting ;  the cord, for the distance of two or three inches
from the cavity in  the placenta was  infiltrated with blood, and yet there was  no
evidence of rupture of either  of the umbilical  arteries  or of the vein.  These
irregular  cavities in the  substance of the  placenta may  be numerous, or there
may be but one ; and in  case there are several, they may have been formed at the
same period or at different times.
  The third variety is the most remarkable of all;  the cavities are here well defined
and regular in  form, even when  the effusion  seems to have occurred but very re-
cently.  Usually there are several of them, and judging from the appearance of the
blood which they contain, they  are produced successively.   It is not uncommon to
find seven or eight of them in the same placenta, and sometimes there  are twenty
or more.  Simpson mentions a four months' placenta in which they were so numer-
ous as  to  give the  impression,  upon  dividing it,  of a collection of innumerable,
small, rounded, and distinct clots, closely compacted together.  (Diciionnaire en  30
volumes.)  It is  rare for  the clots to be larger than a pigeon's egg; some are  aa
small  as millet  or  hemp seeds, whilst others  are  of intermediate size.   They are
also situated at various depths in the  substance of the placenta, some extending to
the internal surface, and  others approaching the uterine surface, upon which some
of them open by a small and irregular orifice.   The surrounding tissue of the organ
is in its normal condition, and the appearance of extravasation of blood extends for
but a feAV lines  beyond  the  boundaries  of the cavities.  These  regularly formed
clots begin to lose their color at the circumference, so that  at a certain  period the
cavity exhibits a white,  thin pellicle, which  detaches  more easily from the clot
than from the placental tissue.   (Jacquemier.)
  We have hitherto said  that the placental  tissue  surrounding the cavities is in a
healthy condition ; but this is not ahvays the case.   It will be remembered, indeed, 
DISEASES  OF  THE  OVUM.
555
 that it is not uncommon to find apoplectic collections  in  the centre  of coty'.edons
 affected with fibrous obliteration of the villi.  (See page  551.)   In such placentas
 occur very small, regularly formed cavities, enclosing  clots of blood of an appear-
 ance compared by M. Jacquemier to black grape-seeds.
   The blood effused  in the tissue of the placenta, when the ovum is  not  expelled,
 separates into two portions, one solid, the other liquid.  The  serum disappears  by
 infiltration, Avhilst  the  solid part forming a clot contracts,  becomes denser and
 someAvhat smaller, and  gradually  loses its color.  The importance of the consecu-
 tive changes in the effused blood  has, however, been  greatly  exaggerated;  thus it
 was supposed that the transformation  might be  so complete as to produce whitish
 and homogeneous masses  resembling concrete pus or tuberculous matter, but it is
 evident that in such cases effects have  been attributed to placental apoplexy which.
 were really caused by fibrous obliteration of the villi.   (See page 550.)
   We have said that when utero-placental  hemorrhage occurs in the first  half of
 pregnancy, it is occasioned by the rupture of some of the maternal vessels, gener-
 ally the veins, and that it  very  rarely  proceeds from the umbilical  vessels.  We
 think that the same  observation applies to placental apoplexy.
   The various kinds of apoplectic formations in the placenta may coincide with the
 lesion  met with  in  uterine hemorrhages, whether internal or external; that is to
 say, with a partial or complete detachment of the placenta and  the  presence of a
 clot of greater or  less size in the artificial cavity thus formed,  together with streaks
 of coagulated blood stretching away to the cervix, and situated between the internal
 surface of the uterus and the uterine decidua.  The ovum is then expelled  prema-
 turely, with the symptoms of an ordinary uterine hemorrhage.  Effusions within
 the placenta, however, rarely occasion such extensive lesions, but are almost ahvays
 limited and compatible with the continuance of gestation.  The effect of placental
 apoplexy, moreover, varies with the  period of gestation at which it occurs, as also
 with the  number and extent of the effusions and the more or less frequent occur-
 rence of the  accidents.   If the points of effusion are  small  and few  in number, a
 considerable part of the placenta retains its natural structure and capacity for the
 fulfilment of its functions ;  in this case not only will the foetus continue to live, but
 its  nutrition will suffer little or not at all.   Under opposite circumstances, if it
 should not die, it  will be born feeble, puny, and emaciated.  Should the apoplectic
 attacks recur at short intervals, they will often produce, in spite of all that can be
 done, gradual diminution of the motions of the child  and of the pulsations of  its
 heart, and the final cessation of both.  In these unfortunate cases, it  is not uncom-
 mon for both the  mother and the  accoucheur to  be obliged to witness, as  it were,
 the sufferings and death of the child.   (DicTwnnaire en 30 volumes.)
  Apoplectic effusions in the placenta  are  rarely betrayed by any symptoms, pro-
 vided the hemorrhage is limited in amount.  In some cases, most of the indications
 of moderate internal hemorrhage are observed, though its occurrence will be rather
 a matter of suspicion than  of certainty, unless the patient has suffered from  the
 affection several times previously;  for it is by no means rare  for the  same woman
 to miscarry several times consecutively, and  always  from  the same cause;  and if
 she should be delivered at term, a number of effusions, both old and recent, aviU be
 found in tlie placenta.   (Jacquemier.)
  Supposing there  is reason to fear the  occurrence  of  placental apoplexy, and
 especially if the Avoman  is predisposed  to the affection, the prophylactic treatment
 had recourse to  in  cases of uterine  hemorrhage during  pregnancy,  will be indi-
 cated  (see  Abortion).  As  measures offering the greatest chance of success,   we
would  mention absolute rest and small  bleedings,  to be  repeated  at longer  or
shorter intervals. 
556
PATHOLOGY  OF  PREGNANCY.
                            CHAPTER IV.

                  DSEASES  AND  DEATH  OF  THE  FCETUS.

   § 1. Diseases of the Foztus.
   Although  the  diseases of the embryo and foetus during  intra-uterine life ar«
 Numerous, they are very little known.   As it does not  enter into the plan of this
 work to treat fully of subjects coming under this head, the history of monstrosities
 and whatever else belongs to teratology  will be laid aside, and we Avill merely pre-
 sent succinctly such diseases as are most interesting to the accoucheur on account
 of their endangering or destroying the life of the child.   As we even think it best
 to defer the  account of such as might obstruct natural  delivery, until Ave come to
 treat of dystocia, our task for the present will be  quite a limited one.
   1. Lnflammation. — Traces of inflammation have been detected in various organs
 of the foetus.  As the most important  Ave would mention  peritonitis, which was
 made the subject of a  special treatise by our colleague  and  friend Dr. Lorain.  It
 was most frequently observed  in lying-in hospitals during the preA'alence of puer-
 peral fever.
   The pleura and lungs are sometimes attacked with  inflammation, though less
 frequently.  But  although rare in  the  human species, it is very common in ani-
 mals affected with epizootic pneumonia,—a fact to which I called attention in my
 paper on puerperal fever.
  2. Fevers. — It would seem that the eruptive fevers may be communicated by the
 mother to the child.  There can be no doubt of the fact as regards A'ariola, and we
 have nothing to add here to what  has been said elsewhere (see pages 44G and 447)
 on the subject; and the same remark applies to intermittent fever.  (See page  445.)
  3. Icterus. — Several  observers  have reported cases of women having  icterus
 giving birth  to children  affected with the same disease, the waters also being of a
 yellow color.  These are, however, exceptional  cases,  as it is far more common for
 children  born of jaundiced  mothers to be free from any abnormal color.  (See
 page 451.)
  4. Syphilis. — We have already said that syphilis may be inherited.   The foetus
 thus affected usually undergoes a very regular development; and not until  some
 weeks or months have  elapsed after its birth, do the accidents appear which, there-
 fore, it does not fall within our province  to describe.  This, however, is not always
 the case, for  it is by no means rare for the syphilitic foetus to be born prematurely
 or even to die before birth.  These children,  like  the  former, Avhen examined im-
 mediately after delivery, generally exhibit  no lesion which can  be  attributed to
 syphilis, though in some, traces of the disease are evident, the most common being
 pemphigus of the palms of the  hands and  soles of  the feet.  When  the bullae are
 perfect, the eruption is easily recognized, but they are almost always ruptured and
 their  place occupied  by rounded erosions  Avith  elevated epidermis.  Still,  they
 have  a characteristic  look.  Pemphigus is more  difficult to recognize  Avhen the
 eruption is beginning:  it then appears  in the form of small, red, and  barely pro-
 jecting spots, marked in the centre with  a Avhitish  point, due, doubtless, to a slight
elevation of  the epidermis.  I haA'e  met with tAvo  cases  of  this kind, which are
 represented in wax models deposited in the hospital of the  Clinique, and the re-
 ports of which were published  by  Dr. Bernardot (Theses de Strasbourg).
  Autopsies of  the children sometimes reveal visceral  lesions due to syphilis, such
as certain  alterations of the thymus gland,  lungs, and liver.   Prof. Dubois Avas
the first to call  attention to syphilitic alteration of the thymus gland.  Externally
the affected organ  seems healthy, but if cut open  and squeezed, a whitish  fluid
 resembling pus  exudes from it.   When the  lung  is the seat of  the  lesions,  these 
               DISEASES  AND  DEATH  OF  THE  FffiTUS.           557

consist of indurated nodules A'arying in number and size, and of about the onsist-
ence of the liver, as stated in a detailed account  of the affection by Prof. Depaul.
Some of these indurated masses project beneath  the pleura, under which circum-
stances they  present  quite a deep-yellow  hue.  At  a later period they undergo
softening  and have at their  centre a cavity containing a fluid of a sero-purulent
appearance.  The  lesions of the liver haA'e been Avell studied by M. Gubler, who
describes them as being sometimes general, sometimes partial, and characterized
by spaces of  indurated yellowish hepatic tissue,  whose normal structure is infil-
trated with fibro-plastic elements and an albuminous fluid  resembling the serum
of the blood.  The indurations are distinguished from the  healthy tissue  of the
organ by their contour, hardness, and resistance to the finest injections.
  5. Dropsies. — Hydrocephalus, hydrorachis,  ascites, and  cysts are affections  to
which the foetus is quite liable;  but as they often  cause difficulty during labor, they
will be treated of under the head of dystocia.  (See Dystocia.)
  6. Spontaneous Fractures. — Cases have been reported of spontaneous  fractures,
almost always multiple upon the same foetus.  Chaussier mentions a child born  at
the Maternity Hospital, in 1803, after a rapid and easy labor, during  which no
force had been applied to it, which had forty-three fractures, involving the cranium
as well as other bones.  Some of  the fractures  were recent, in  some callus was
forming, and  others were thoroughly consolidated.  Another case,  cited by the same
observer, is still  more extraordinary.   The child  in question, which was born after
an extremely short and easy labor,  in a state of debility and of a bluish color, ex-
pired in a short time.  Attention was attracted to it by its  extreme shortness and
an  unusual mobility in the  continuity of  its bones.  One  hundred and thirteen
fractures Avere counted by Chaussier,  involving the different bones of the cranium,
chest, and limbs  (Jacquemier).   The  causes of this singular  lesion are  unknoAvn ;
it is most probably due rather to arrested development of the bony tissue than  to
fracture properly so called.
  7. Complete or Incomplete Amputation of the Limbs. — Cases not less curious than
the preceding are those  in which the children are born with limbs amputated  at
various heights, and having a cicatrix at the centre of the stump.  Chaussier saw
three deprived of the hand and a portion of the forearm.  In one of these cases, a
small bony cylinder found on the fcetal surface of the placenta was recognized as a
portion of the radius.   The  stump, undergoing  cicatrization,  was covered  at its
centre Avith granulations.  Watkinson, in 1824, attended a Avoman in her first labor
who had  experienced nothing  unusual during  her  pregnancy.  The  child was
born prematurely,  and lived  but twenty minutes.  Its left  leg  appeared to have
been amputated just above the malleoli.  The foot, smaller than  the  other, was
found in the vagina, but presented  no appearance  of gangrene or alteration of color
or consistency.  The two divided surfaces (of the  foot and of the limb) were almost
entirely cicatrized, and both presented small projections formed by the ends of the
hones. Montgomery, in a work on this subject,  relates two cases very similar  to
the  preceding, in Avhich  the detached feet were expelled  before the child.  Cicatri-
sation was complete in one, and far adA'anced in the other.  (Jacquemier.)   It would
he easy,  though  I think useless,  to  mention other  examples of this  species  of
deformity.
  Spontaneous amputation is sometimes incomplete; that  is  to say, grooves  of
greater or  less depth, occasionally extending  to the bones, are observed upon the
limbs.
  What is the cause of this singular lesion ?  Some have supposed it due to circular
turns of the cord around the limbs, acting as does  a ligature around the pedicle of a
tnmor; but it is very difficult to suppose that the  cord could  be drawn tight enough
to amputate a limb without arresting  the placental circulation at the same time.      •
Montgomery's explanation is  much more probable; he supposes the amputatiou  t& 
558
PATHOLOGY  OF  PREGNANCY.
be effected  by constricting  materials other than the cord.  In several cases were
found fibrous bands, vrhose origin it  is difficult to determine, which constricted the
limbs as would real cords, and which would have occasioned complete or incomplete
amputation according to the degree of constriction.  It must, however, be said that
these bands are not always to be found, so  that the etiology of spontaneous ampu-
tation is very uncertain.  It cannot be affirmed, says M. Jacquemier,  that they are
always the  mechanical effect of a constricting  agent;  they may possibly be due to
a deep-seated local lesion and to the  constriction  induced in the skin by  an exten-
sive cicatricial action.

  § 2. Death of the  Foetus.
  The causes which destroy the life of the embryo and foetus are numerous, but we
shall  not attempt to recapitulate them here, referring the reader to the chapters
which treat respectively of the diseases of the mother and of the ovum and foetus,
as also to the article on abortion.   It must, however, be confessed that it is often
impossible  to  determine the cause of death or  to discover anything which can
explain it in a satisfactory manner.   Some of these unknown causes have attracted
attention by the persistence Avith which they continue to act in the same Avoman
through several successive pregnancies.  I myself knew a woman in good health,
who, on thirteen consecutive occasions, and Avithout any discoverable reason, lost
her child during the  last month of  gestation.   Since Denman's time, it has been
supposed that in these cases recourse might be had successfully to the induction of
premature labor.  We would also revert  to the  fact  (see. page 271) that in twin
pregnancies one foetus  sometimes dies and assumes a mummy-like condition, whilst
the other undergoes its regular development.   This occurrence can only be  known
after delivery.
  It  is not always easy to assure  ourselves that the foetus  is dead; it will sometimes
be suspected when it ceases to move,  especially after having been unusually active.
At other times, the spontaneous  motions  gradually grow  less frequent and weaker,
and finally  cease.  Too much importance ought not, however, to  be  attributed to
this sign, because the fcetal motions present numerous anomalies, even in  the midst
of the most perfect health.   The surest indications  are  derived from auscultation
of the foetal heart.  " In regarding the subject from this  point of view," says M.
Depaul, "Ave must set aside the threet first months of gestation, during which the
sounds of the heart cannot be heard, and also remember that  in  many cases  it is
impossible to perceive them before the expiration  of the fourth month.  During the
last half of gestation, the conditions  are altogether different, success in the  stetho-
scopic examination being the rule, Avhilst failure should be regarded as a very rare
exception.  Inasmuch, however, as  this exception  may exist,  it is  impossible to
attribute an absolute value to auscultation'of the foetal  heart as a means of deter-
mining whether the child be living or dead.  It would be a great mistake, however,
not to regard it as an  extremely  valuable means, since, in the immense majority of
cases, it leads to probabilities which  amount almost to certainty, and consequently
alloAvs questions of the  highest  practical interest to be solved."   (Depaul, Trade
d'Auscultation.)  Out of 07 women, more than five  months pregnant, in  whom M.
Depaul was unable to hear the pulsations of the heart, but three were delivered of
living children.]

   Further, the phenomena experienced by the mother after the death of the
foetus are  very singular  in these  cases: the  abdomen collapses  instead  of
increasing in  size; the  breasts, which  had become developed, shrink; the
woman suffers from a sensation  of  weight  in the  loins, and  an unusual
pressure in  the loAver part of the abdomen; an inert  body in  the  uterus
vbeys the laws of gravity and falls to Avhichever side the woman turns  in bed. 
DISEASES AND  DEATH OF THE F03TUS.
559
  Other symptoms  are soon  added  to the foregoing.   If the  gestation is
E-oraeA^hat  advanced, eA'erything passes off absolutely  as if  the  expulsion
of the  embryo had  occurred, only excepting the discharge of the lochia:
thus, in the course of forty-eight to sixty hours after its death, the breasts
SAvell up, the phenomena of milk fever are manifested, and the lacteal secre-
tion is fully established, after  Avhich  the breasts again  subside, and  the
usual  order  is resumed.  As a general rule, the prolonged  retention of a
dead infant  does not produce any disastrous result to the mother, and I
suspect that Avriters haAre  greatly  exaggerated on  this point:  they say,
indeed, that the woman becomes depressed, uneasy, and of a fretful temper;
that she experiences lassitude,  alternations of heat and cold, oppression at
the epigastrium, headache, syncope, palpitations of the heart; her  face is
pale, the eyes dull and surrounded by  a livid circle, the breath fetid, pulse
frequent and irregular :  in  a Avord, all  these  general phenomena of  a sIoav
fever have been considered  by them as so many rational signs of the child's
death.  But these symptoms are certainly absent in the  majority of cases ;
for most Avomen, after Ave have succeeded in calming their fears, experience
nothing of the kind, and I have knoAvn many of them to carry a dead child
for several months Avithout even suspecting  it, and  some even to congrat-
ulate themselves upon the amelioration of their general condition, in con-
sequence of the sudden disappearance of the sympathetic disorders of preg-
oancy.  At  an indeterminate period labor  comes on, and the abortion is
effected.
   By examining  the dead  foetus, Ave may learn Avhy its  prolonged sojourn
in the uterine cavity has been Avholly innoxious to the mother.  In fact,
the infant is not putrefied, as  is proved by its having no bad odor ; the solid
parts undergo a  peculiar transformation, and the body is someAvhat analo-
gous in appearance  to one that has been soaked for a long time in Avater.
   When the foetus remains in the uterus thoroughly protected from the air,
it does not putrefy,  but undergoes maceration.  M. Martin (of Lyons) judi-
ciously remarks:  " The kind of alteration which a dead child undergoes in
the Avomb, will  also vary according  to the period of pregnancy at Avhich it
ceased to live.  Thus, in the early stage of its  formation, Avhen its  organi-
zation has but little consistence, and approaches the mucilaginous state, it
dissolves in the Avaters of the amnios, which then become thicker and assume
the characters of a  gummy solution, and no  further trace of the embryo is
found in the amniotic cavity.   But at a period someAvhat later, that is, from
the second to the fifth month, it Avithers away, becomes shrivelled and dried
up, and looks  like a little  mummy of  a  yelloAv color,  or like a  foetus pre-
served for a  long time in alcohol.  Not unfrequently, the  placenta likeAvise
participates in this state of desiccation, the liquor amnii  disappearing and
being replaced by a thick and apparently an earthy humor, Avhich  incrusts
the fetus."  (Memoires de  Med. et de Chir. Prat., page 96.)
   After the fifth month, a child putrefied in  the womb presents so different
an aspect  from one that has undergone the  same  process in the open air,
that it is only necessary to  observe this particular  condition  once or tAvice,
never to mistake it afterwards.
   Imagine the little defunct stretched on a table: the flaccidity  of  its soft 
560
PATHOLOGY  OF  PREGNANCY.
parts is then so very striking, that the  head becomes flattened  under the
influence of its OAvn Aveight, Avhatever position may be given  to it;  the  soft
parts on the thorax exhibit the form of  the ribs; the front of the  chest is
very much flattened, the abdomen sunken  and nearly hollow  about the
navel,  and forming tAvo large rounded projections  on the flanks; even the
extremities exhibit the  same state of  collapse.  The discoloration of the
skin is particularly remarkable, although often confined to the abdomen, at
least yvhen the sojourn of the foetus in  the womb has not been  very long.
The skin of this part has a broAvnish-red shade, Avithout the least  appear-
ance of a greenish hue.   This tint is less marked on  the chest, neck, head,
and limbs; nevertheless,  it  exists there also.  But this is not the broAvnish
hue that often succeeds a green putrefaction;  it is a  much clearer  reddish-
brown.  The cord is no longer twisted, but it forms  a true fleshy cylinder,
of a reddish color, soft, and saturated Avith a broAvn  fluid.    The epidermis
is detached from a considerable part of the surface, and may  be easily sepa-
rated from those places Avhere it  is still  adherent, thus leaving  the humid
dermis exposed, Avhich is  as glutinous  as if it were lubricated by a mucous
fluid ;  and  then the true skin has a bright rose color. . The  epidermis on the
feet and hands is Avhite and thick, and looks as if it had been corrugated by
cataplasms.  The subcutaneous cellular  tissue is infiltrated with  a  reddish
serosity, Avhich is also seen betAveen the muscles, and sometimes in the sub-
stance  of the muscular tissue itself.  The bones of the head are feebly held
together, their periosteum may be readily detached, and they are movable
on each other.   The cellular tissue underneath  the hairy scalp is infiltrated
wit.h a thick serosity,  resembling currant-jelly in  appearance.   Finally,
whenever Ave attempt to move or raise the foetus, it slips through  the hands
just like a fish that lives for some time  out of water, in consequence of the
fluid mucus covering its surface.   (Devergie,  Med Legale.)
  A dead foetus is merely a foreign body in the uterus, Avhich "will soon have
to be discharged.  The time at Avhich the expulsion  will take place varies
greatly; sometimes after  a feAV days only, sometimes  weeks Avill elapse,  and
occasionally a month or more.  The symptoms Avhich arise "will be those of
abortion or labor, according to the age of the foetus at the time of its death.
(See Abortion.)
                          CHAPTER  Y.

                            OF ABORTION.
  The term abortion has been applied to the expulsion of the foetus from the
Avomb, Avhere this occurs at a period of pregnancy Avhen the product of con-
ception is not yet viable: that is to say, an abortion may take place at any
time betAveen  the commencement of pregnancy and 'the  end of the sixth
month.   The ancients applied  the term effluxio to this  accident, if it hap-
pened before the seventh day.1
  1 We place the period of viability  at the seventh month, though well aware that some
cases have been reported where foetuses born at six, or five, or even four months, have
lived; but such instances, besides not having all  the authenticity desirable, are too
rare to invalidate the general Jaw. 
OF  ABORTION.
561
   In a  recent  and very remarkable  article by M.  Guilkuiot, this author
 admits three varieties of abortion, founded on the period of its occurrence:
 thus, ovular abortion is the title he  gives when it  takes place before the
 twentieth day ;  embryonic, if prior to the third month ; and fcetal, from the
 latter date  up to the sixth month of gestation.
   Persons out of the profession, further, designate abortion under the title
 of miscarriage (fausse couche).
   Abortions are much more frequent in the first tAvo or three  months than
 at any other period.  The great vascularity of the  uterine mucous mem-
 brane, become the decidua, and  the ease Avith which effusions of blood may
 take place  into the space which  originally exists  between the chorion and
 the reflected  portion  of  the  decidua  (see  page   552), sufficiently ex-
 plain  the frequency of hemorrhage,  and consequently of abortion in the
 early months.   In  making this  remark, I am not  ignorant that Madame
 Lachapelle has  given a different vieAV, but it Avas because her position at the
 Maternity rarely furnished her  Avith opportunities of  observing abortions
 prior to  the fourth  or fifth month, for females do  not usually go to the hos-
 pitals on account of the miscarriages of the first five or six weeks of gesta-
 tion ; and though other persons have  since adopted her opinion, it is doubt-
 less OAving to the difficulty of diagnosis, and to the errors of females them-
 selves, who, supposing they have  only a  simple retardation of the menses,
 allow an abortion to pass away in the early stages unperceived.
   Morgagni and Desormeaux supposed that abortion of  foetuses belonging
 to the female sex are more numerous than of males, and I do not know
 whether the vulgar opinion opposed to this is true or false ; but certain  it is,
 that at term the boys exceed the girls in the proportion of sixteen to fifteen,
 which Avould seem to prove that female  abortions are the most numerous ;
 and besides, it is possible that the difficulty of distinguishing the sex in the
 earlier periods of intra-uterine life may have had some influence in creating
 the popular error.
   The history of abortion evidently includes the study of the causes produc-
 ing it, the symptoms and consequences Avhich may arise, the signs by Avhich
 it may be detected, and the more  suitable indications for preventing  or
 opposing it.
                           ARTICLE I.
                                 CAUSES.
   Considered in relation to its determining causes, abortion may be  divided
 into the spontaneous and accidental.
   The term  provoked has also been used, Avhere the  abortion  has resulted
 either from  criminal efforts, or from the measures adopted by the scientific
 physician Avith  a laudable object.  We  shall retain  this  division for etio-
 logical purposes.

   § 1. Causes of Spontaneous Aboktion.
  [Tlie causes of  spontaneous abortion may be sought for either: 1.  In the father.
2.  In the  general health and habits of the mother.  3.  In the  state  of the womb
and it& appendages.  4. In diseases of the ovum.  5. In diseases of the foetua
      36 
562
PATHOLOGY  OF  PREGNANCY.
   I. Causes due to the father.  At first thought, says M. Ferdut, considering the
 transitory part taken by the father, it would not seem probable that he could be
 the cause of a miscarriage which should not  take  place until  after two  or three
 months.  Such, however, is the fact, as is proven by the experience of women who
 invariably miscarried during the life of a first husband, but who were several times
 delivered safely at term after a second  marriage.
   The influence of the father in causing abortion may be exerted in two ways—
 by his constitution and  by his diseases.   Ova, fecundated by men who are either
 too old or too young, rarely become, it is said, fully developed, and the same remark
 applies to those whose constitution is exhausted by debauchery or excesses of any
 kind.  From M. Devillier's article in the new Dictionary,  it would seem, however,
 that he thinks the idea of an  influence exerted by  the father in the causation of
 abortion should be received with considerable reserve.  We would remark, says
 this  author, that the procreative  power is entirely distinct  from that of develop-
 ment.  If a man, under the conditions mentioned,  has been able to fecundate a
 robust and healthy woman, the generative influence once having been, communi-
 cated by him, the development of the product  of conception would  thenceforth be
 almost wholly under the influence of the vitality of  the woman ; so that it is prob-
 able that the influence of the father would at least  be very limited.   (Devilliers.)
 It Avirl also be understood  that diseases of the father may,  to a certain extent, be
 transmitted  to  the foetus and produce abortion. Of all these morbid conditions,
 syphilis exerts a more deleterious influence upon the duration of pregnancy than
 any other, though, it should be stated, all authors do  not agree upon the subject.
 We believe,  at any rate, that we would  be correct in  saying that, in some cases, the
 father, and not the mother, ought to be subjected to a prophylactic treatment.]

   2.  General Condition  of ihe  Mother. — Women  of a plethoric habit, and
 having copious menstrual   discharges, are greatly  exposed  to abortion
 during the early months of gestation; in  fact, Ave  have  already alluded
 to those  hemorrhagic molimens  that appear   in  them  at every monthly
 period.  Again, nervous, or  very irritable Avomen, those Avho are strongly
 affected  by  moral impressions, such  as anger,  chagrin, &c.;  females of a
 sedentary  habit, who are ahvays shut up  in  the shops, as Avell as those
 that folloAV  an indolent  life, passing  their time  at balls  or  soirees,  and
 in light reading,  also  abort  very  frequently.   The  surrounding  atmo-
 spheric conditions are not wholly Avithout influence in the production of
 abortion; in fact, Ave may refer to this cause those epidemic miscarriages
 spoken of by most authors.   Mountainous countries, Avhere the air is bleak,
 are considered as being favorable to their production;  for,  according to the
 report of Saucerotte, the women inhabiting the summit of the Vosges are
 very subject to abortion, and they are in the constant  habit of descending
into the adjacent plains to avoid this accident.
   Acute diseases, especially the  eruptive  fevers, and small-pox  most par-
ticularly, occurring in  the  course of pregnancy, abdominal or thoracic
affections,  and  recent cutaneous  diseases,  often  give  rise  to  miscarriage.
Syphilis in  the mother has the most disastrous  influence  upon the progress
of gestation, and even  the mercurial treatment does not ahvays secure from
abortion.   Some writers  think  that  the administration of mercury endan-
gers the life of the foetus.  Their opinion is,  hoAvever, rejected by most
 modern Avriters upon syphilis, almost  all of whom regard the antivenereal
treatment begun at .the outset of pregnancy, as the best means of preventing 
OF  ABORTION.
563
 abortion.   The numerous facts Avhich have come under our own observa-
 tion, have changed our opinion upon this point, and we now think it most
 prudent to begin the treatment as soon as possible.
   It often  happens, indeed, that, notAvithstanding the existence  of constitu-
 tional syphilis, Avhen the mother has been treated properly  and sufficiently
 long, the pregnancy continues to the full period, and the child escapes the
 infection to Avhich  it seemed fated.   (Duval.)
   According to the author just quoted, it  Avould seem that much depends
 upon the length of time Avhich the disease has lasted.  " Numerous observa-
 tions," he says, "shoAV  that syphilis at its commencement does not usually
 endanger  the  product of conception, but  that, at a more advanced  period,
 it involves the greatest peril."   It  should  also be remembered that  Dr.
 Paul's  researches  have  shoAvn  that  lead-poisoning may  likewise  produce
 abortion.
   The  convulsive  diseases may occasion miscarriage  either by provokino-
 uterine contractions, or by directly destroying the child.  (See Eclampsia^)
   3. Diseases of the  Womb and its Ajypendages.—The causes dependent on
 the  uterus  are referable either  to a particular state  of that organ, or to
 a peculiar  habit of  the body,  the  influence of Avhich is  reflected back
 on the Avomb.   The  following are given as  causes of  abortion  dependent
 on this  source:  An excessive  rigidity  of the uterine fibres,  and their
 consequent resistance to  dilatation; an  unusual contractility and  sensi-
 bility of the organ, and  too  great  a  laxity and Aveakness in the uterine
 neck.  I willingly"  admit that, in certain females, the  excessive  sensibility
 of  the  uterine fibre will  scarcely support,  Avithout reaction,  the strange
 modifications  it must undergo  during  gestation; but I do not equally com-
 prehend that species of opposition, Avhich some authors seem  desirous of
 establishing, between the resistance on the part of the uterine Avails and the
 expansive  force of  the  ovum.   What,  indeed, can an  ovule, a feAV lines in
 diameter, effect against the thick Avails of the Avomb ? or, Avhat action  can it
 possibly have on the uterine neck, that  will explain the influence Avhich has
 been accorded  to this pretended laxity of the  cervix,  on the frequency of
 abortions?  The truth is, the ovum  and  the uterus are developed simulta-
 neously, but by forces peculiar to each.   Therefore, although abortions  are
 more frequent in primiparse, AA'here the females have been married too young
 or too old;  and although certain Avomen abort in all  their pregnancies at
 nearly the same period, we must not on that account attribute these accidents
 to too great a resistance of the  body,  or to an extreme  laxity of the neck;
 for these repeated miscarriages, when  not owing to the hemorrhagic tendency
 before alluded to, are far more  naturally explained by the excessive irrita-
 bility of the Avoinb.   The organ has to habituate itself, as it were, to its new
 functions; a proof of which is, that, in many females, the accident is repeated
 a number of times,  but each time at a more advanced period; so that, about
 the fourth or fifth pregnancy, they go  on till full term.   Hence, those uterine
 congestions, Avhich  are so often  produced in  plethoric Avomen by the men-
strual periodicity, and that  excess of sensibility as well as of irritability
observed in nervous  females, are the only tAvo predisposing  causes  that I
coi.^idr as belonging to the uterus proper, and even they are mere exagger- 
564
PATHOLOGY OF PREGNANCY.
 itions, as will be seen, of the physiological condition.  "W cere aborti ins are
 often produced by the  influence of either of these, they are designated as
 periodical.
   But, independently of  these  tAvo  causes, Ave must  evidently  take into
 account all the diseases  of the uterus, Avhether acute or chronic, whose action
 is discernible: thus, the  various tumors which may groAV in the substance of
 its Avails, or may contract adhesions with them and the foreign bodies devel-
 oped in its cavity, also ulcerations, Avhether syphilitic or otherAvise, Avhich
 are  so frequently found  upon the cervix, are so many predisposing causes,
 Avhich may both hinder and oppose its free enlargement; and lastly, let ua
 add the various displacements of the uterus, such as prolapsus, lateral obli-
 quities, or anteversion and retroversion, as acting in the same manner.
   On the part of the appendages, all the chronic diseases to  Avhich they  are
 subject; the adhesions, deformities, displacements, and their divers  degenera-
 tions ; the organic alterations of the  tubes, fibrous, polypous, or other produc-
 tions seated in the uterine tis.sue or neighboring parts;  unnatural  adhesions
 of the broad or the round ligaments, tubes, or ovaries: in a Avord, everything
 that can impede the easy and free  development of the womb, must be re-
 garded as occasional  causes  of abortion.   (Madame Boivin, Recherches sur
 une  cause peu connue d'avortement.)
   Finally, an inflammation of the adjacent organs, particularly the bladder,
 rectum, &c, may, through the irritation thereby communicated to the uterus,
 bring on its contractions.  Moreover, the existence of any voluminous tumor
 in the abdomen must necessarily incommode the development of this organ;
 also the compression of the hypogastrium, that some women produce by the
 use of corsets, may have the same effect.
   According to Peu,  Ave  must add to these various sources of inconvenience,
 contraction of the pelvis  opposing the distention of the Avomb, and sometimes
 its elevation  above the  superior strait;   more especially Avhen the narrow-
 ness of the latter coincides Avith the  regular, or even an increased size of the
 excavation.
   4. Diseases of the Ovum.—Any of the  diseases of the ovum may give rise
 to abortion, and Ave shall not repeat what Ave have said concerning them.  (See
 Diseases of the Ovum).   It will suffice to  mention here that the most impor-
 tant of these diseases are, dropsy of the amnion, hydrorrhcea, the hydatiform
 mole, placental apoplexy, and fibro-fatty degeneration of the  placenta.
   As regards the  insertion of the placenta over the neck, I can  scarcely
 believe that it could produce  an abortion, and hence I imagine that the cases
 cited in support of that  vieAV have  been  misinterpreted; the insertion has
 been considered as the cause  of the  accident in those instances, when it cer-
 tainly Avas  nothing more than a simple  coincidence.   M. D'Outrepont has
 advanced the torsion of the umbilical cord as a cause of determining the
 death of the foetus ;  for the state of compression, says he, resulting therefrom,
 may impede the circulation.   The embryos had  been dead for a long time,
 in all the cases of that kind observed by him.
  Again, it may be asked, if the umbilical  cord is too short, could it drag
off or detach  the placenta, or even  be ruptured itself?   Now, to the facts
 bearing on this point, reported by Mauriceau, Stein, &c, M. Guillemot adds 
OF  ABORTION.
565
ihe folloAving: The foetus Avas about three months old, the umbilical cord
was tightly stretched and even half separated near its origin at the navel;
two folds of it encirlced  the  neck, and some  deep marks Avere left on this
part from their pressure.   The circulation, he  continues, Avas therefore inter-
rupted in the cord by the  tension and compression  it sustained;  and the
strangling of the child's neck also contributed  to its death.   M. Deneux has
furnished a case of a rupture of the umbilical  vein, and effusion of its blood
into the tissue of the cord itself; he found there a clot, equalling a small nut
in volume, Avhich had interrupted the circulation in the umbilical vessels by
its pressure.
  Lastly, the disease of  the membranes, and  of  the  umbilical vesicle, also
prove a frequent cause of abortion, especially in the early stages of embryonic
life; for in  more  than tAvo hundred products of conception, that  had not
passed beyond the third month, M. Velpeau  generally found an alteration
of some part of the ovum.
  5. Diseases  and Death of the Foetus.—Circumstances, which are  often
unknoAvn to us, may arrest the  development  of the  foetus: for instance, it
may be affected in the mother's body, by those acute diseases Avhich at times
beset it after birth ; and such affections,  though  not  always fatal to the
new-born infant, are the most disastrous to the intra-uterine foetus as they
occur the nearer  to the period of fecundation.   (See Diseases of the Pectus.)
We may add, the presence  of several children as a cause dependent on the
child; in  fact, Ave have  elseAvhere seen  that  the excessive distention pro-
duced  by a  twin  pregnancy, frequently brings  on premature  contractions.
HoAvever,  the  uterus  is  rarely developed enough prior to  the sixth month
to provoke such  an accident, for this seldom happens until a more advanced
stage, and then it no longer appertains to abortion properly so called.
  Some diseases of the parents may affect the  child; for example, a vitiated
spermatic  fluid communicates to the  neAV being a principle  which does not
fail sooner or later to  destroy it.   M. Guillemot attributed the numerous
miscarriages of a young  lady Avho consulted him  to this cause; for her hus-
band, although of a suitable age, exhibited all the  characters of  premature
decrepitude.  Having  become a  AvidoAV, she  remarried, was several times
pregnant, and was always delivered happily at full term.
  The mother,  also,  may transmit  her  diseases to the child.   Nothing,
indeed, is more common than to find children  presenting,  a feAV weeks after
birth, evident traces  of  the venereal infection  received from the  mother
during intra-uterine life, and hence we may  conceive  that this  hereditary
taint may prove fatal  to  the foetus Avhilst still  Avithin the Avomb.
  Small-pox is also sometimes communicated from the mother to the fetus,
and causes its death.   It is remarkable that several circumstances seem to
prove, that  the  infection  frequently does not take  place  until after the
mother's recovery.  (See page 447.)
  In some cases,  the body of the mother is but  the  conductor of a conta-
gious principle of  small-pox.  We might here add examples in addition to
those already cited (page 447).
  Some years ago, a Avoman, in the wards of Professor Fouquier, was deliv-
ered ol a dead child affected Avith small-pox, although she had herself been 
566
PATHOLOGY  OF  PREGNANCY.
vaccinated.   Finally,  the illustrious Mauriceau relates  that  his  niothei
Avhen in the last  stage of her pregnancy, had  the  misfortune  to  h se the
eldest of her three sons by small-pox, to Avhom, notwithstanding her condb
tion, she  Avas unceasing  in  her attentions; and  that  at his  birth, Avhich
occurred the day after the death of his eldest brother, he presented four or
five pustules of small-pox.
  In short, all  the diseases to which  the  foetus  is subject may be folloAved
by abortion.   Its death ahvays produces it.

  § 2.  Causes of Accidental, Abortion.
  Besides the  causes just enumerated, that have been designated  by  most
writers as ihe predisposing ones, but Avhich,  perhaps, would be  more appro-
priately called  slow-acting causes, there are yet some others that might be
termed  accidental causes: such as those  which operate from Avithout, and
make their  influence more promptly felt.  The latter are very numerous;*
indeed, on reading the published cases, we find that authors have considered
all  the  moral  and physical  excitements that women are subject  to,  as so
many causes of abortion.  In most of the recorded instances, Ave can readily
satisfy ourselves that the observers have  attached too much importance to
these occasional causes of its production ; for, generally speaking, it Avould
have occurred  without  them, only, perhaps, a  little later; and even  here
the expulsion of the foetus is, in truth, owing to the sIoav and gradual action
>f  the  predisposing cause.   HoAvever, there are some  accidental causes
whose  influence is indisputable.   For instance, falls, excessive fatigue, too
frequent coition, and severe  contusions, have, in some instances, produced
immediately a loss of blood,  folloAved by abortion.
  Falls and contusions may act in tAvo Avays : either by bruising or violently
irritating the mother's organs, or by Avounding the foetus, and determining
its death.  The latter has been denied by some persons :  but to the instances
noAV knoAvn  to science, I will add the folloAving from my own  observation:
A young woman, six months pregnant, struck her abdomen violently against
a table while walking  in  the dark in her  chamber ; during the night, the
motions of'the child were for a time quite tumultuous, then they diminished,
and on the folloAving morning  could  not  be perceived at all.  Two days
aftenvards she was delivered  of a dead child, which presented an ecchymosis
on its back  as large as the palm of my hand.
  Burdach  speaks of a woman who received a bloAv upon the loAver part
of the  abdomen, when in the sixth month of her pregnancy,  and  Avho Avaa
delivered of a  child, the  bones of one of Avhose legs and of a  forearm had
been fractured, and united at an acute angle.   The jarring attendant upon
travelling by rail, or too great use of a sewing-machine, are also capable of
giving rise to abortion.
   I shall not  enumerate here the various circumstances that have been
considered  as  occasional  causes;   but,  by  way  of shoAving hoAv  their
importance  has been overrated, I will merely remark that, although certain
women, who are constitutionally predisposed to miscarriages,  may abort in
consequence of a  trifling fright, or the odor of a badly snuffed candle, yet
 ihere are others, on the contrary, who will suffer the most acute moral im- 
OF  ABORTION.
567
 pressions, and the most violent physical shocks, without any accident Avhat-
 ever  resulting therefrom;  and nothing would be more easy than to bring
 fonvard  numbers of cases  in support of this proposition ; the folloAving,
 however,  may be sufficient: I had an  opportunity of observing,  at the
 Hotel Dieu, Avhen acting as an " interne " in the obstetrical Avards, a young
 girl in the fifth month of pregnancy, who, being rendered desperate by the
 desertion of her lover, cast herself into the Seine, from the Pont Neuf, yet,
 notwithstanding so violent a shock, the gestation pursued its regular course.
 Again, M. Gondrin speaks of a young  lady Avho was thrown from a chaise
 over the horse's head by the animal  falling in his  career.  This lady avas
 then five months pregnant, but the accident did not prevent her from reach-
 ing her full  term. I met with a case precisely similar in the wife of a notary
 living near Paris.
   I Avas consulted, in Sept., 1845, by a  young lady,  avIio was evidently six
 or seven months advanced.  Her physician had suspected an inflammatory
 engorgement of the womb, and during the  third or the fourth month this
 gentleman had applied fifteen leeches on the neck of the uterus itself; and,
 strange to say, not only Avas this  application  unattended by any accident,
 but the patient  seemed relieved of  the distress  and pain in the hypogas-
 trium.  And, lastly, is it necessary to  refer here to all the  manipulations,
 and all the violent remedies, that  some distracted women make use of in
 vain to procure an abortion ?

 § 3. Causes on Account of avhich Abortion is artificially produced.
   The third order of cases still remaining for our examination are the means
 of producing  abortion. These must be distinguished  according to the pro-
 posed object: that is, Avhether, in producing an abortion, the indication be to
 relieve theAvoman as Avell as the infant, if the latter is  well developed, from
 the dangers  that threaten them (and Ave shall treat of the means to be em-
 ployed in such cases when Ave speak  of  the indications presented by the
 mother's vices of conformation), or  Avhether, contrary to all  the laws of
 morality, the design  is to destroy the foetus in the body of its mother, for
 the sole purpose of concealing the traces of an illegitimate pregnancy.  But
 we have nothing Avhatever  to say concerning the measures resorted to by
 criminal hands in such cases, for,  unfortunately, they are too well known.

                          ARTICLE  II.
                       SYMPTOMS OF  ABORTION.
  The signs of abortion vary with  the  period  of its occurrence, and also
 with its determining cause.   Thus, Avhen  it happens  in the early days of
 gestation,  it  is attended by but very feAV remarkable phenomena;  and, in
 general, the  pain is  so trifling that the patient  scarcely suffers  more than
 from a difficult menstruation.   The first uterine contractions are sufficient
 to  produce the complete separation of the ovum,  the adhesions  of Avhich are
still very feeble ;  and it escapes either in  mass  or  in  shreds, usually sur-
rounded by fluid or half-coagulated  blood, and,  being  mistaken for a clot,
 it often passes aAvay unnoticed, most Avomen then supposing that they have 
568
PATHOLOGY  OF  PREGNANCY.
only had a slight postponement of their menses, folloAA-ed by a more difficult
and abundant flow than usual.
  At a more advanced stage, the symptoms are  much better marked, but
still vary with the cause of the abortion.  For instance, when this accident
has been  produced  under the influence of bad health in the mother, or of
chronic diseases, or those causes that operate sloAvly, by altering the genital
organs, or the ovum  and its  membranes, the following symptoms are ordi-
narily observed, namely:  shiverings succeeded by heat,  anorexia, nausea,
thirst, spontaneous lassitude, palpitations, cold extremities, pallor, sadness,
depression of spirits, tumefaction and  lividity  of the eyelids, Avant of bril-
liancy in the eyes, a  sense of  sinking at the epigastrium,  of cold about the
pubis, of weight near the anus and vulva, pain in the loins, vesical tenesmus,
frequent ineffectual desires to urinate, and a Aveakness and flaccidity of the
breasts, from which  a serous fluid sometimes exudes.  These  phenomena
may be considered as the precursors of an abortion ; for, Avhen they have
lasted for some time, the pains in  the  loins  become more and more acute,
extend  round to the hypogastrium, and are  reneAved at short intervals,
finally assuming all  the characteristics of the  regular uterine contractions.
During these pains, if  the uterus  is sufficiently high  up to  be easily  dis-
tinguished  above the pubis,  it will be felt to harden sensibly, whilst at the
same time a sanious discharge takes place from the vagina, aftenvards
becoming sanguinolent, and  eventually  replaced by  liquid or  grumous
blood.  If the Avoman  be  then examined per vaginam, the neck will  be
found partly dilated, the dilatation advancing progressively Avith  the  fre-
quency of the pains; the  membranes begin to protrude, then engage, and
ultimately rupture;  the waters escape, and the foetus and placenta are suc-
cessively expelled.   Usually  in those cases in which the cause has operated
sloAvly, whether dependent on  diseases  of the  mother or affections of the
ovum, the foetus dies before the labor, or at least during the first pains.
  When the abortion is a consequence of the occasional violent causes, it
usually has quite  another  course.  Thus, in  some  instances, the expulsion
of the ovum closely  folloAvs the accident;  a Avoman slips in  descending a
staircase, and falls violently on her seat; Avhen she rises, her clothes  are
flooded Avith blood, for an ovum of six Aveeks has been driven out, together
with a large quantity of fluid blood.  This, hoAA'ever,  is more apt to occur
in the beginning of pregnancy; for, at a more  advanced period, some inter-
val ahvays elapses between the accident and the consequent abortion.  The
phenomena then observed vary, according to Avhether the cause has affected
the mother's organs, or  has directly influenced the foetus itself.
  In the former case, the mother experiences, at the time of the accident, a
sharp pain, either about  the loins, or else  in some part of the abdomen;
after the lapse of a feAV  days, during Avhich the pain has diminished, or even
entirely ceased, it is violently renewed, and followed almost immediately
by uterine pains and contractions, a slight dilatation of the neck, some dis-
charges of serosity from the vagina, at first reddish, then sanguinolent,  and
lastly pure blood.
  Finally, if the travail conti tue, the foetus is expelled as usual, and often
living. 
jF  ABORTION.
569
   The expulsion is almost always effected very sIoavIv, and the pi ogress of
 the labor is far from being as regular as at term.  The resistance occasioned
 by the length and hardness of the cervix at this period sufficiently explain
 the extreme sloAvness of its dilatation ;  and even Avhen the latter is sufficient,
 the contractile poAvers of  the  uterus  are yet  so feeble that the ovum may
 remain engaged  in the orifice for several days, and  even project into the
 upper part of the vagina, before being expelled completely.
   When the cause  has acted directly  upon the foetus, either mechanically,
 as by a violent bloAv or  concussion, or physiologically, by destroying to a
 greater or less extent  its vascular connections Avith  the uterus, the subse-
 quent course of affairs is different; for  here the phenomena Avhich announce
 the death of the product of conception are the first to be manifested.  After
 the feAV hours necessary to dissipate the agitation  and fears  caused by the
 commotion she has experienced, the AA'oman feels no pain nor inconvenience ;
 everything is  calm, and  seems to resume  its natural  order; but, after the
 lapse of a few days, sometimes only eight or ten, the movements of the
 foetus, Avhich had up to this time maintained their usual force and frequency,
 become Aveaker,  are separated  by longer intervals,  and finally  become
 imperceptible.  From this moment, the uncomfortable sensations and diges-
 tive disorders, which had annoyed the  patient from the outset of pregnancy,
 disappear as though by magic; the SAvelling of the breasts  and  prickling
 sensations which had  affected them, also diminish or  cease  entirely.  A
 miscarriage is then inevitable, for the ovum is a foreign body in the uterine
 cavity, and soon irritates the Avails of  the organ by its presence; the latter
 contracts, and the expulsion  is generally effected about eight  to nine  days
 after  the accident.  In this  case, the  process  advances in a more regular
 manner, because  the  Avomb  has had  time to prepare itself  for the act.
 HoAvever, this term is  not uniform, it being not at all uncommon  for the
 dead  foetus to remain much  longer in  the Avomb :  tAvo or three Aveeks, or  a
 month, for example.  I saAv a Avoman at the Clinique, in Avhom the child's
 death Avas clearly ascertained, though  she did not abort until  six Aveeks
 aftenvards.  Cases are also recorded of the embryo remaining  in the Avomb
 until  the ninth month.
   The development of the contractions  is solicited by the  derangement
 Avhich this condition of death gradually produces in the placental circu-
 lation; indeed, the  quantity of blood arriving  in the placenta  often dimin-
 ishes by degrees, and ultimately becomes almost nul; but this is not ahvays
 the case, since, in  some instances, the circulation continues, and  the placenta
 enlarges,—attains even to double the volume of that at term,  and after its
 expulsion  exhibits the same degree of integrity.   Lastly, in other cases, says
 M. Guillemot,  the placenta retains its vitality and  groAvs; but, at the same
 time, assumes  unusual  forms, and a singular structure, exhibiting a cavity
 in Avhich remains of the fcetus are hardly  to be found.
   Where a long time thus ensues betAveen the period of the child's death
and that of its expulsion, there is, in general, less danger from  hemorrhage
than if the premature labor had  taken place immediately.  In these abor-
tions,  less blood is usually lost than in  the labors Avhich come on naturally,
after tin most favorable gestations; which is  probably OAving to the fact 
570
PATHOLOGY  OF  PREGNANCY.
that the  child's death  diminishes  the  activity of the uterine circulation,
especially that of the  utero-placental vessels, Avhich  must  then become
obliterated  in a great  measure, and  consequently can  furnish  but little
blood at the time Avhen the placenta is separated.
   We have seen (page 558) that the general phenomena experienced by
the mother  after the death of the foetus are very singular in these cases, but
abortion does not ahvays folloAv immediately, a variable interval, sometimes
a long one, intervening  before labor begins.  The child born under these
circumstances  has  a  peculiar, macerated  appearance, but no evidence of
putrefaction.
   But it happens otherwise Avhen, the foetus being  dead, the membranes are
ruptured, and  the  expulsion is delayed; for then a rapid  putrefaction sets
in, as a consequence of the contact of the child Avith the  external air.  A
high fever,  characterized by the symptoms of a veritable infection, develops
itself; a dark  fetid liquid oozes  from the  genital parts, mixed Avith shreds,
in a state of putrefaction; and if the uterine  contractions do  not speedily
relieA^e the organism from this source of infection,  the  patient  may rapidly
succumb  under its deleterious influence.  Finally, Avhen the abortion is
brought on  by the  existence of tAvo children, the  tAvins are nearly ahvays
expelled simultaneously; although Ave have occasionally knoAvn the women
to abort of  one child in a multiple  pregnancy, Avhilst  the other continued
to groAV.
   Hemorrhage  is one of the most  common  symptoms.   It  may precede,
accompany, or folloAv the  expulsion of the foetus, and  is of sucb frequent
occurrence  that most authors make it the principal  disordei   In  some
cases it is certainly the  cause of the abortion, though  often merely a con-
sequence.  Sometimes, indeed, the  miscarriage is accompanied  Avith but
slight hemorrhage.   The latter circumstance is, howeA^er,  rare,  especially in
the false labors that take place before the  end of the fourth month; because
a more or less abundant discharge of blood nearly ahvays shows itself during
the first expulsive pains, and persists until the uterus is completely emptied;
but, as Ave all  knoAv, nothing of this kind  is observed in labor at term.  M.
Jacquemier has happily explained  the difference betAveen the two in the
folloAving manner:  He states that, toAvards the end  of gestation, the placenta
spreads out  from the centre towards the circumference, in  order to conform
itself  to  the uterine enlargement at its greater extent;  and this is accom-
plished in such a Avay that its different lobes, by separating from one another,
have a considerable space left betAveen them.1*  From this it follows, that,
Avithin certain  limits, the uterine contractions  have no tendency to detach
it; for the placenta accommodates itself wonderfully to the retraction of the
organ until  it reaches  its OAvn proper  limits; and even then its great flexibility
permits a further reduction, so as to folloAv the uterus as it  becomes less,
before the detachment commences,  and this latter phenomenon only takes
place "\lien  the entire foetus is nearly expelled.   But, prior  to  the fourth

  1 To convince one's  self of the  truth of this fact, it is only necessary to see the pla-
centa still  adherent to a uterus which  has been developed but is not yet retracted, or
even the uterine surface this  mass occupied; for the latter is nearly one-third larger
than the surface of the placenta which covered it.   (Jacquemier.) 
OF  ABORTION.
571
month, the after-birth  is far from offering  the  same conditi ins; since the
thickness of the utero-placental decidua  and the large amount of plastic
matter interposed  betAveen the lobes at that  time, confer upon  it a much
greater density; and therefore it can only yield within very narroAV limits,
either in the way of extension or retraction  tOAvards its centre.  Hence, the
facility of its  separation during the early  contractions,  the  rupture of a
certain number  of vessels, and the  incessant hemorrhage throughout the
whole duration of the labor.

                         ARTICLE  III.
                              DIAGNOSIS.
  Judging from the numerous signs just given, the diagnosis of an abortion
ought to be very easy;  but, unfortunately, these signs are not very clearly
marked until  the  accident is inevitable, and consequently,  Avhen  it is a
matter of  indifference to the  patient whether, the physician  makes out a
clear diagnosis or not.
  It is, therefore, in the beginning  of such symptoms, especially, that  we
should endeavor to recognize  their true nature, because  then only can our
art succeed in arresting their progress; but this is exceedingly difficult.
  The diagnosis of abortion  involves  the solution of several questions.   Ia
the Avoman pregnant ?  And, supposing the pregnancy to  be determined,
are the symptoms those of  a simple uterine  congestion, or of a commencing
abortion?   Lastly, is the abortion inevitable?
  1. Is the Woman Pregnant f — This first question is quite readily  resolved
after the fourth month of gestation, though before that period it is almost
ahvays unansAverable.   xVll practitioners of obstetrical experience are aAvare
of the difficulties Avhich often involve it.   Thus, a Avoman  in  good health
has her courses suddenly suppressed  for several months Avithout any appre-
ciable cause, the breasts swell, and  the body increases in size:  in a Avord,
she experiences several of the phenomena properly regarded as  rational
signs of pregnancy ; then, all at once, at the return  of the  third or fourth
menstrual period, some symptoms of congestion of the uterus appear, last
for several days, and  are  soon folloAved  by a slight Aoav of  blood.  Hoav,
then,  shall Ave determine avIiether the pains  felt by the patient, and  the dis-
charge of blood from the vulva, are OAving  to  a return of  the interrupted
menses, or to an approaching abortion ?   The  pains  attendant on difficult
menstruation,  especially after a suspension of  seA'eral  months, resemble
greatly, both in situation and intermittence, those of abortion.   According
to Madame Lachapelle, in abortion  the uterine orifice is open, the hemor-
rhage precedes the pains, and the  latter persist notAvithstanding the abun-
dance of the discharge ; whilst in difficult menstruation the orifice is closed,
the pains are felt before the hemorrhage appears, and they diminish or even
cease  entirely  Avhen the discharge is well established.  The contrary, how
eA-er, not unfrequently occurs.
  Doubtless a strict investigation  of the circumstances which accompanied
and folloAved  the  suppression of the  menses, and an examination of  the
uterus, might  lead to an opinion  as  to the probable state of  the case;  but 
572
PATHOLOGY  OF  PREGNANCY.
 what  experienced physician does not  know how  deceptive  are  all thes«
 rational signs, Avhen Ave take into consideration the tendency to exaggerations
 of the females, Avho so readily believe AA'hat they wish or Avhat they fear, a>
 also Iioav nearly the congestion, which  precedes and accompanies the sus-
 pended menstruation, places the uterus  in  the same physical  conditions as
 in a commencing pregnancy?
   Does the blood escape from  the  genital parts as  a clot ?   It  has been
 hoped that the shape of the latter might furnish a reliable sign.
   It has  been  stated  that  the clot driven from the unimpregnated Avomb
 exhibits a triangular form, corresponding  to that  of the cavity Avhere  the
 blood  coagulated, which never happens when a product  of  conception is
 present; but this may fail, as the clot  is mostly changed  in  its shape by
 tra\rersing the neck;  and, on the other hand, in abortion, the blood may
 collect and coagulate in the vagina, and  the coagulum  exhibit  the indi-
 cated character.
   But, if the coagulum be still in the cervix uteri, and supposing the finger
 is able to reach  this point, how can Ave distinguish whether the foreign body
 felt there is a clot or ovum ?  For this purpose, Holl has laid doAvn the fol-
 lowing signs:  If the finger introduced into the orifice perceives the mass to
 become tense during the contraction, to augment in  volume and  advance
 tOAvards the vulva, it is an ovum  engaged in the os uteri; and if it Avere a
 clot, it might  be recognized by its fibrinous structure; besides, during the
 pain, its exterior surface Avould not be more tense, nor more smooth, and it
 would  not appear forced doAvn, but rather compressed; finally, as the ovum
 resembles a  soft  bladder,  its  inferior extremity is  rather rounded  than
 pointed, while the coagulated mass is  more resistant and solid, is less com-
 pressible, and has, in general, the form of a cone, the enlarged  extremity of
 which  is above and the apex beloAV.
   Finally,  if we should then attempt to move the  uterus in its totality by
 pressing on this mass, it might be easily effected if there Avere a clot con-
 cerned, Avhilst the parietes of the ovum Avould yield, and Avould  not  transmit
 the motion to the organ Avhich  envelops it, and Avith  Avhich it is  then but
 feebly  adherent.
   The  question is therefore by no means  simple, yet  it is important to knoAV
 Avhether pregnancy really exists;  for  as  the  appearance of the menses is
 then of very rare occurrence, especially Avhen they are absent  in the early
 months, a Aoav of blood  should  be treated  as a serious accident, Avhich, on
 the contrary, would be promoted, if attributable to  a return of the courses.
NotAvithstanding these uncertainties, there may be a union of circumstances
such as to allow of at least  a probable diagnosis.   Thus, if a  AS'oman, Avho
has been habitually regular, finds her catamenia to stop suddenly and unac-
countably ; if this suppression is folloAved by other rational signs of preg-
nancy ; if the pains continue notAvithstanding the  discharge of blood; if
they appear as an effect of any violence  Avhatsoever, or if they present any
thing unusual as respects either intensity or duration, it may be concluded
that abortion is imminent.   The diagnosis becomes more certain if the blood
floAvs more  profusely than  in ordinary menstruation,  if it  is accompanied
with sharper  pains in the  hype^astrium  than is  usual, if  coagula are 
OF  ABORTION.
573
  expelled, and if the orifice is sufficiently dilated to admit the extremity of
  the finger.
    '2. Pregnancy existing, may the symptoms  be attributed to simple  con-
  gestion of the uterus, or should they be regarded as  the first tokens  of a
  threatened abortion ?  Though it is very difficult to decide this question
  within the first three or four months, and at the beginning of the accident,
  its >olution  is happily  of little importance as  regards the treatment, the
  measures indicated by  simple  congestion being equally  applicable to the
  preArention of miscarriage.
    When symptoms, Avhich in all appearance Avere  due  to simple congestion,
  have yielded to proper treatment, the physician  is often required to ansAver
  a question AA'hose rigorous solution is ahvays impossible: namely, the abdom-
  inal and lumbar pains being allayed, and all the other alarming symptoms
  removed, is  the patient therefore out of danger  of miscarriage?  In the
  majority of cases Ave can tell nothing about it, for  it is impossible to knoAV
  Avhether the  congestion has been arrested in time  to prevent a  rupture of
  blood-vessels, and an effusion between the placenta and  uterus, or Avhether
  the separation of the  placenta  is extensive  enough  to have destroyed the
  fietus immediately ; e\ren supposing the child  to be still  living, Ave cannot
  ascertain the degree of separation of the placenta, nor  foresee the effect
  which a partial destruction of its maternal attachments may have upon the
  fetus.  Very frequently, indeed, the latter, by  being  cut off from a con-
  siderable part of its means of respiration, is placed in the condition of an
  adult Avhose  lungs are in  great measure destroyed, and  whose  respiration
  and nutrition being insufficient, gradually Avastes  aAvay, so the child often
  does not perish until after the lapse of eight days, tAA'O weeks, and frequently
 even not until the next menstrual period; this, too, Avithout the appearance
  of any new  symptoms to  explain its unlooked-for death.  The  physician
 cannot  therefore be  too  reserved in  his diagnosis, as regards the  possible
 consequences  of such accidents.
   3. Finally, supposing the abortion  begun, can  we hope  to  arrest  the
 symptoms?   The intensity of the pains, their constant direction from  the
 umbilicus towards the coccyx, the previous duration of the discharge, and
 the amount of blood  already lost, softening  and dilatation of almost  the
 entire neck, and even of the internal orifice, and projection of the mem-
 branes during the contraction, doubtless  indicate a very unfavorable prog-
 nosis, though they should not destroy all  hope.  All these symptoms con-
 jointly  have in fact been knoAvn to yield to appropriate  treatment, every-
 thing to resume  the natural state, and the pregnancy to go on  as usual.
 Some  authors even state that the rupture of the membranes and  discharge
 of the amniotic fluid does not render abortion ineA'itable.  This last asser-
 tion, however, seems to me to be at least very contestable, for it is infinitely
 probable, not to  say certain, that in the cases  alluded to there  has been a
 mistake in reference to the true origin of the waters lost by the patient.  It
appears  to  me that  a rupture of the ovum  must  inevitably give rise to
abortion; and Desormeaux  has  certainly confounded cases of hydrorrhcea
with the true  discharge of the amniotic fluid.
  A young lady, Avho had already been so unfortunate as to miscarry in her 
574                 PATHOLOGY OF  PREGNANCY.
 rirst pregnancy, to be delivered of a dead child in the second, and final!),
 to have lost a little girl of six months, had advanced three months and a
 half in a fourth pregnancy.  After returning from mass, in a church very
 near her dwelling, there was a sudden  discharge of fluid from  the genital
 organs, to an amount estimated by the patient at about a tumblerful.  Oti
 first seeing her, I thought abortion inevitable.  Then, upon a careful exami-
 nation of the uterus, it  seemed to me, that, notAvithstanding the  loss which
 had occurred, the organ presented its usual size, a certain elasticity, a pecu-
 liar suppleness  shoAving that some fluid must still remain AA'ithin  the amni-
 otic cavity;  there Avas nothing  peculiar in the state of the cervix; no flow
 of blood;  neither was  there pain before, during, or after the discharge of
 water.   In acquainting the patient Avith the fears  Avhich I entertained,  1
 also assured her that all hope Avas not lost, and that the circumstances just
 mentioned presented collectively features which do not usually appertain to
 ruptures of  the  ovum  itself.  Absolute quiet, a small bleeding from  the
 arm, opiate enemata, and hand-baths,  to be repeated morning and evening,
 were directed.  No neAV symptoms supervened, and the development of the
 uterus continued.  For  the first tAvo days, there was  still a  very  small dis-
 charge of water.  At four months and a half, and also Avithout appreciable
 cause, there Avas a sudden escape of five or six spoonfuls of a fluid  similar
 to the preceding.  After this, nothing of the kind occurred until the end of
 her pregnancy, AA'hich terminated very happily.  (See Hydrorrhcea.)
   Abortion is really inevitable only Avhen the foetus has ceased to live, or
 when the separation of the placenta and the rupture of the  utero-placental
 vessels are so extensive that  the remaining utero-placental attachments are
 unequal to the support of the foetal respiration.
   In order to estimate  the  probable degree  of  disturbance of  the utero-
 placental relations which has taken place, much more regard must be had
 to the amount of the discharge than to its duration.   A simple exudation,
 or a moderate flow of blood, may continue for several days or Aveeks, since
 it may originate in the rupture  of very feAV vessels ; I have knoAvn it to last
 for six Aveeks and tAvo months, Avithout  compromising the pregnancy; but
 that the patient should  lose  a  considerable amount  of fluid or coagulated
 blood in a short time, the placenta must be separated to a considerable extent,
 and abortion almost necessarily ensues.
  There is still another peculiarity not mentioned by authors, which appears
 to me of importance, inasmuch  as it cuts off almost  all hope of arresting
 the progress of the  symptoms: I allude to a particular  form of the neck.
 When the patient has been for a short time only pregnant, we knoAV that it
 is ahvays easy to distinguish  the neck  of the  uterus from its body; in the
great majority of cases, Ave may even feel  the  angle Avhich separates them.
 Noav, Avhen the contractions have lasted  for a certain time, they have grad-
ually dilated the internal orifice; the  cavity of the neck  has become con-
founded Avith that of the body, and when the finger in the A'agina is  passed
over the entire loAver segment of the uterus, the neck can  no longer be dis-
tinguished  from  it; a well-defined limit betAveen  them is no more to be
detected, and all that belongs to the neck of the womb has  the shape of a
pear, the larger part being continuous Avith the body of the  organ, and the 
OF  ABORTION.
575
loAver extremity corresponding with the external orifice.   Whenever I have
met Avith this  condition of things, abortion has taken place.  " The vagina
itself," Dr. ( offin remarks, " is so far  afi'ected, that its upper extremity
becomes rounded, the rugas are effaced, and the finger meets everyAvhere a
smooth and regular surface like that of a polished vase."
  It is impossible to ascertain certainly in the earlv months, Avhether the
foetus be living or dead.  I must, hoAvever, mention a peculiarity Avhich  in
my estimation is of great value in reference to this question : namely, the
sudden cessation  of the vomitings, salivation, or any  other sympathetic
functional disorder of pregnancy.  When, after an accident, vomiting and
salivation cease, there is cause to fear that the child is dead, the persistence
of these discomforts being on the contrary a favorable sign.  Happily, though
the uncertainty upon this point makes an exact prognosis  impossible, it  in
no Avise affects the treatment.   Whenever, indeed, a collective examination
of the general  and local  symptoms leads to  the supposition that the child
is living, and that Ave may hope to arrest  the  progress of the accident, Ave
ihould act as though Ave Avere certain.
  We see, therefore, that in the first third of  gestation the diagnosis, at the
best, can be only probable.
  At a more  advanced stage of gestation, the diagnosis is much more cer-
tain.  First, because Ave can then generally ascertain the  development  of
the uterus Avithout difficulty ;  then, again, pains  are more energetic : the
blood floAArs in  greater abundance, and the dilatation of the os uteri is more
easily detected; but it  becomes still more certain Avhen the death of the
fetus can be verified  in a positive manner.   (See Signs of the Death of the
Foztus, page 558.)
                          ARTICLE IV.
                    DELIVERY OF THE AFTER-BIRTH.
  The spontaneous  expulsion  or the extraction of  the placenta  presents
very different  phenomena according to the period  Avhen the abortion takes
place; and, in this respect, it is highly important to distinguish the accident
in the first tAvo months from that of the third and fourth, as also from that
of the fifth and sixth; for  the ovum is usually expelled entire in the first
and  second months, but in the tAvo latter  the  expulsion of the placenta is
accomplished  nearly in the same Avay as at term.   But in the third and
fourth months it  is  altogether different,  because  the  placenta, Avhich  is
already A'oluminous, has contracted at this period  numerous and very inti-
mate  adhesions Avith  the Avomb, Avhich  has not as yet acquired all the con-
tractility of tissue that it possesses at  term ; consequently the premature
contractions, although sufficiently energetic to rupture  the ovum, are not
adequate to the destruction of the utero-placental adhesions.  Hence, under
the  influence of such contractions, the  amniotic sac, being pressed on  all
sides, yields near the neck, the Avaters escape, the little foetus is expelled,
and the very delicate umbilical cord breaks easily;  at the same time a cer-
tain quantity of liquid or coagulated blood is poured out, and very often the
small foetus is lost in the midst of the coagula that accompany its discharge
Then  the uterus,  being partially  evacuated,  retracts, the  neck closes up 
676
PATHOLOGY OF PREGNANCY.
and the symptoms disappear; nevertheless, the placenta and membranes are
still undelivered,  and may remain in the womb for  eight, ten, or tAvefve
days, or even longer.  Dr. Advena, of Labischin, reports an instance Avhere
the after-birth was not expelled till three months subsequent to the abortion,
this latter having occurred at the fifth  month of pregnancy.  (Journal de
Chirurgie, Aug. 1843.)
  The complete closure of the neck evidently makes the introduction of the
finger impossible, so that every  attempt  made for this purpose Avould prove
fruitless.   Ergot may, indeed, be administered with the object of exciting
contractions, though I have never seen it haA'e any good effects Avhen given
under these circumstances.  To wait, at the same time  watching carefully,
is all  that can be done.
  The symptoms which may then result from  retention of the placenta are
very variable, and should be carefully studied.
 ■ 1. Very frequently, nothing at all  unusual is observed for a few days fol-
lowing the miscarriage.  The general health is good ; the patient, believing
herself entirely cured, gradually resumes her ordinary occupations, Avhen ah
at once, and Avithout  any knoAvn cause, some  intermittent pains are felt in
the hypogastrium, and a little blood  escapes from the vulva.  The  Avoman
often  neglects these primary symptoms, but they persist and augment in
intensity, thereby constraining her attention to them;  for the placenta has
become a foreign body in the womb, and,  irritating the uterine Avails by its
presence,  excites their contractions; these  break up  the  utero-placental
adhesions, and  the after-birth is almost free  in the uterine cavity.  This
separation is always accompanied by hemorrhage, which  is at times very
abundant, because the os uteri dilates with so much difficulty, to permit the
foreign body to escape, that the latter, by remaining in the womb, encourages
a hemorrhage by irritating the organ and preventing the complete contrac-
tion of its walls ; insomuch that, if  art does not  seasonably interpose, life
itself may be endangered by the great amount of  the  discharge.  What is
still Avorse, if the physician did not happen to be present at the time of the
miscarriage, if he had  not  carefully examined all the clots himself, the
attendants Avill not fail to tell him  that  the after-birth  and  the child Avere
expelled  together, and,  should he pay  any regard to  their statements, he
may possibly overlook the cause of the accident altogether.  I have  been
summoned several times to such cases,  and  have  invariably been told by
the persons questioned that the placenta Avas delivered.  Consequently, the
accoucheur should rely exclusively on his OAA'n personal  examination in such
cases.  He must  absolutely touch the female, Avhen he  will usually find the
os uteri to be partially dilated, and a portion of the placenta hanging in its
orifice.  It then is only necessary to seize  this portion Avith  the two  fingers,
for  its extraction  is, in  general, quite easy.   In case of necessity, Levret's
abortion-forceps, Duges'  placenta-crotchet, or Pajot's  curette, might be used
for  this purpose.1
  1 This is a blunt hook, formed of  a loop of  iron or silver wire, of a line or  more in
diameter.   The  loop is narrow in proportion to the thickness which it is desired the
hook should have, never, however, exceeding an inch and a half in width.   It is curved
near its extremity, so as to  form a hook of the  size required.   The remainder of the 
OF  ABORTION.                         577
   Sometimes the  adhesions of the  placenta are so numerous that it is im-
 possible to destroy them, and  extract the latter, even with Levret's forceps.
 It is then possible, by strong pressure upon the hypogastrium, to depress the
 womb, so that the forefinger of the other hand can be passed into its cavity,
 and glided betAveen the placenta and the uterine walls.   Lastly, if this does
 not succeed, the tampon must be resorted to, and the ergot administered at
 once ; for the conjoint use of these measures rarely fails to arrest the hemor-
 rhage, and bring on a sufficient degree of contraction to expel the secundines.
   Such are the measures which  should be resorted to, Avhenever the hemor-
 rhage becomes  dangerous either by its duration or abundance.  When, how-
 eA'er, it is arrested, especially Avhen the placenta is partially engaged beneath
 the orifice, and seems to prevent, by its presence there, further discharge, Ave
 should Avait, and be very careful how Ave attempt to extract it immediately.
 The engagement of the placenta in the cavity of the neck maintains in the
 latter a degree of  dilatation likely to facilitate  its complete expulsion, and
 besides exciting, as a foreign body, the sensibility of that part, also excites,
 or at least keeps up, the contractions of the fundus of the Avomb.   Tractions
 upon the engaged portions might tear the placental  mass at the point of
 constriction by the retracted  internal orifice.   Now, immediately after this
 partial extraction, the neck would resume  its former condition, the internal
 orifice Avould  close  more  or less completely,  and  render  impossible the
 removal of the portion of  placenta  remaining in the cavity of the body of
 the uterus.
   2. But matters  do not ahvays pass off so happily, and a retention of the
 placenta may give rise to the most serious  accidents.   In fact, it sometimes
 remains in the uterine cavity after haA'ing been separated wholly, or in part,
 and soon undergoes decomposition, just as  though it Avere exposed to the air;
 the lochia become fetid; the uterine walls, being in  contact Avith the sub-
 stances  in course  of putrefaction, absorb a portion thereof, and, as a conse-
 quence, fever is developed, together with all the symptoms of a putrid infec-
 tion.  In  these distressing cases, Ave should evidently relieve the Avomb from
 those foul materials that infect the Avhole economy ; but, unfortunately, the
 neck of the uterus is completely closed, and an introduction of the finger
 thereby rendered   impossible.  Often, indeed, it is exceedingly difficult to
 make the extremity of a canula enter for the purpose of throwing detergent
 injections into the uterine cavity, and Ave  are then compelled to aAvait the
 complete  expulsion of the excessively fetid sanious matters resulting  from
 the decomposition  of the placenta.   In s.uch cases, M. Velpeau speaks favor-
 ably of the use of ergot.  This, indeed, is a remedy that might be used, but
 from which, nevertheless, Ave should not  expect too much.
   A lady, thirty-five years of age, whom I suspected to be pregnant, although
 she Avould not believe it, felt a discharge from the parts after a suspension
 of the  menses for tAvo months and  a half, Avhich she at first mistook for  a
 return of her courses,  but which, after riding out  in a carriage, Avas suddenly

loop, which serves as a handle, receives the curvature necessary to facilitate the in-
troduction and use of the instrument.  It is directed into the  womb by a few fingers,
when it receives the  soft mass in its concavity, and is then slowly drawn out.  (Diet
Med et Chir., en li) volumes.)
      37 
578
PATHOLOGY  OF  PREGNANCY.
converted into a profuse fiooding.   Having been summoned immediately. I
found the os uteri  slightly dilated, and I forthwith employed  various mea-
sures  adapted to the  arrest of the  discharge, and among others the ergot.
The hemorrhage gradually diminished, and at ten o'clock  p. m. (six hours
subsequent to the invasion of the symptoms) it had entirely ceased.   During
the first five  days the  patient did very well, but on the sixth I thought I
detected a slight odor in the lochia, and at three o'clock in  the afternoon a
violent chill came on, Avhich lasted an hour.  From this moment all the
phenomena of absorption were manifested.  I immediately  administered
forty grains of the ergot, but Avithout effect, for nothing came aAvay; and
notAvithstanding the enlightened efforts of Messrs. Chomel and  Moreau, who
were several times called in consultation, this unfortunate lady died on the
tenth day following the  appearance of the first symptoms.   At the post-
mortem examination we found -the uterine tissue softened, and its cavity filled
by the putrefied  and  still  adherent  placenta, which we could not separate
without tearing.
  3. It may further  happen  that  the placenta, maintaining its  vascular
adhesion with the internal  surface of the organ, continues to  be developed
after the child's death,  the cord and foetus become atrophied, and then com-
pletely destroyed ; or, indeed, the ovum may rupture, and the  little product
escape,  leaving the membranes behind.    These envelopes  may  undergo
various modifications, but the most common is the morbid product known as
a fleshy mole.   It  has been generally conceded,  since the researches of M.
Velpeau  on  the subject, that moles which are  expelled from the uterine
cavity are merely the remains of an altered product of conception.
  4. Lastly,  there is yet another mode of termination, admitted by Naegele,
Osiander, &c.  I allude to the absorption of the placenta  retained in the
cavity of the womb;  for although such  an absorption has been  observed
even after delivery at term, yet most of the reported  cases refer especially
to miscarriages.  (See Delivery of the After-birth.)

                            ARTICLE V.
                               PROGNOSIS.
  The prognosis of abortion  is necessarily variable, according to the time
of its  occurrence  and  the cause which has produced  it.  As regards the
foetus, it is ahvays  mortal, since the expulsion takes place  before  the  pro-
duct of conception is fitted for an extra-uterine life, though  I am Avell aware
that cases are reported of  children,  born prior to  the  period of  viability
fixed by law, Avhich have lived ; but these examples, even were they authen-
tic, are too rare to invalidate the general proposition just laid  doAvn.
  As regards the mother, the prognosis  is said  to be more grave than that
of labor at term ;  but this proposition, Avhich has been  advocated  since the
days of Hippocrates,  requires explanation, and should not be received Avith-
out some restriction; for the  prognosis, considered in relation  to immediate
consequences, is certainly less serious in a  case of abortion tha n in a natural
labor; but the remote effects are undoubtedly more disastrous  in the former
case.   Thus, the acute diseases which attack lying-in Avomen  are more ftp- 
OF  ABORTION.
579
 quent after labor, whilst  the chronic disorders of the genital organs Avhich
 appear in  advanced  age are  more common  Avith  females who have often
 aborted than Avith those Avho have always been delivered at term.1   Again,
 it is highly important to  notice the unfavorable  influence that one abortion
 seems to have over subsequent pregnancies; for Avhenever a woman has had
 a miscarriage, she is more predisposed than others to a similar accident, and
 hence great precautions should always be taken  to prevent it.
   The period at Avhich an  abortion occurs also influences  the prognosis,
 although Ave cannot exactly say, Avith Desormeaux, that it is more  serious
 for the patient in  the advanced stages  of gestation.   Doubtless, as  before
 stated, it  scarcely constitutes  an  indisposition in the  first  or even the
 second month;  but in the  third  or fourth, the expulsion of the foetus de-
 mands a certain dilatation of the os uteri,  and tolerably energetic contrac-
 tions ; for the neck and body  of the uterus have not as yet undergone the
 modifications necessary to such an effort, and the delivery of the after-birth
 often presents difficulties  less frequently met with at a more advanced stage
 of gestation ;  Avhence I conclude, that an abortion is then more grave and
 painful to the patient, as  also more dangerous, than in the fifth or the sixth
 month.
   Lastly, the prognosis varies with the  cause of the accident.  Thus, the
 most serious of all is an abortion  brought  on  either by medicines adminis-
 tered internally or by manipulations; while  a  miscarriage determined by
 slow and  gradual influences is usually attended with less danger than one
 caused by external violence or some powerful moral commotion.  In this
 latter case, the hemorrhage  which precedes,  accompanies, or  follows the
 abortion, is nearly ahvays much more  serious.   Lastly,  Avhen it occurs in
 the course of an  acute inflammation of an important organ, or during the
 existence of an acute disease of the skin, it  is exceedingly  dangerous.

                           ARTICLE  VI.
                       TREATMENT OF  ABORTION.
   The treatment of abortion consists in preventing it, in favoring the expul-
 sion  of the ovum when this is inevitable, and in remedying the various acci-
 dents that  may complicate it.
   1.  Preventive Measures.— When the  miscarriage is dependent on the
 Avoman's bad constitution, or on a lesion of the genital organs, Ave must en-
 deavor to combat and destroy this pernicious predisposition, more especially
 in the intervals betAveen the gestations.  I shall say nothing at this time of
 the means of modifying  the general vices of the  constitution, since, they
 necessarily vary Avith the nature of  the affection.  It is particularly impor-
 tant, hoAvever, to bear in mind  the disastrous influence of syphilis, Avhether
 the father or the mother be infected Avith it, over the life of the foetus; and
 we should persuade them to submit to a mercurial course.
  1 Would it be unreasonable  to suppose that, inasmuch as  women who  have hud fre-
quent  miscarriages  are  particularly liable to chronic diseases, the tendency may be •
due to tlie fact that they have long  borne the  germ which  occasioned their previous
abortions!   Which was the causes and which the effect?  (Blot.) 
580
PATHOLOGY  OF  PREGNANCY.
  When it happens that several abortions  have resulted in consequence of
some  displacement of the  uterus, the latter  should be  remedied by the
appropriate measures: for instance, in the commencement of pregnancy, the
wpman should avoid  all fatigue and every violent  effort;  and  it is  eA'en
advisable for her to. remain in the recumbent position until the uterus rises
above the superior strait.
  We  aAvard the proper value to the influence attributed by Desormeaux
to the supposed rigidity and excess of sensibility  or  contractility in the
uterine fibre, as well as to the excessive weakness or relaxation in the fibres
of the neck.  But, whilst interpreting the action of those causes in a differ-
ent manner, we  believe, Avith him, that  bathing, general bleedings opiate
injections, and a  regulated  course of living, are the means  best suited to
moderate this great irritability of the organ ; and that a tonic and strength-
ening  regimen, aided b,y the ferruginous  preparations, cold baths, and the
chalybeate  mineral waters, will be the most  usefully employed in those
cases where the general debility of the patient may have seemed to exercise
some influence over her former abortions.
  Plethoric Avomen, who usually have profuse menstrual  discharges, and
who may have previously suffered from abortion at the  periods of menstrua-
tion, all  of Avhich had been preceded by the symptoms of general or  local
plethora, and all followed by more  or  less copious discharges,  should  be
subjected before fecundation to a restricted regimen ; and during gestation,
they should avoid all moral  and  physical excitements, and should remain
in bed eight, ten, or even twelve days at every monthly term  ; besides, they
ought  to be bled several times during the earlier periods of pregnancy, more
especially just before the time for the menses to appear.1
  These, more than other pregnant Avomen, should renounce the use of cor-
sets, AA'hich, independently of the  restraint they make  on the development
of the breasts, oppose the free return of blood, by interfering more or less
with the abdominal and thoracic circulation, and thereby favor congestion
of the  inferior organs.
  Feeble, cachectic females, who are impaired by former diseases, and those
whose tissues are soft, and their  circulation  languid, or who, from being
habitually irregular, are affected with chronic leucorrhcea, are often attacked
by hemorrhages during pregnancy AA'hich ultimately lead to an abortion.
  In such patients the face is pale, the pulse  soft, small, and irritable, the
tongue white, digestion painful, the intestines torpid, and the extremities cold.
The least exercise fatigues them, sometimes  even exhausts their strength.
The fatigue is often accompanied by a sensation of weight, of painful drag-
gings  in the groins and lumbar regions, and, should they remain standing
for any length of time, the uterus  seems to require  some support, as it ap
pears just on the point of escaping by the vagina or rectum.   Even in the
  1 The physician often meets Avith much opposition from persons out of the profession
when he proposes a preventive bleeding in the early stages of gestation. Particularly,
should  any accident happen shortly afterwards, they  would not fail to reproach him
with it.   This, however, is  no just reason for not acting according to his  convictions,
or for yielding  in cases where he believes it really useful; now experience has fullj
proved that,  in such instances  as those we have,described, it is one of the best pre
ventive measures. 
OF  ABORTION.                         581
earliest si ages, they feel something like a weight in the lesser pelvis, always
pressing on the most dependent part.
  Noav, the best mode of preventing such a condition, is to prescribe a tonic
regimen,  together Avith the ferruginous and bitter preparations.  Canella, iD
poAvder, has been recommended;  and Sauter  highly  extols the  use of pow-
dered savine; he asserts, that he has succeeded in correcting this pernicious
predisposition  in pregnant women, who  had previously had several  mis-
carriages, by administering fifteen grains of the poAvder three times a day,
continuing it for three or four months ; by this remedy he has arrested flood-
ing and  prevented abortion, and many patients  can attribute the fact of
having children born at full term to the employment  of this precious drug.
  White, of Manchester, has particularly reconrmended cold bathing, espe-
cially sea-bathing, to  be often repeated, both before and during pregnancy.
  The accoucheur must therefore search in the history of former miscarriages
for the indications to  guide him in the use of preventive measures; and it
is likeAvise very important that he should make himself acquainted Avith all
the accompanying circumstances.
  Pregnant women  are  very often  constipated, and this constipation  fre-
quently becomes  the  cause of periodic abortions, by the  irritation it pro-
duces ; hence, it should be prevented  by the use of some  simple injections,
with the addition of one or two tablespoonfuls of linseed-oik regularly, every
other day, for tAvo Aveeks before the period when the  abortion occurred  last
time,  and they ought to be continued  for tAvo Aveeks after it.
  But Avhatever may have been the predisposing cause whose influence  was
exerted in the previous pregnancies, there is one very important precaution,
the neglect of which might  render all others  useless.  In  all cases where
abortion has occurred several times, it is indispensable that the organ should
remain undisturbed,  and the  husband be recommended to allow from six to
eight  months,  or even a year to elapse, Avithout  the wife being exposed to
become pregnant.
  When  this accident has already occurred a number of times in former
pregnancies, it is ahvays indispensable for the Avoman to abstain altogether
from intercourse Avith her husband, for  all sources  of irritation must  evi-
dently be AvithdraAvn from the Avomb.  Again,  if the foetus was  expelled
dead in the preceding gestations,  and this death had been caused by some
lesion of  the ovum, it is almost impossible to recognize, and consequently to
prevent, a similar alteration.
  The case is rather different Avhen the previous abortions  have been  attri-
buted  to  utero-placental or  intra-placental effusions, for these are almost
always the result of a congestion of the uterus, of sufficient intensity to pro-
duce  a rupture  of vessels.  In another pregnancy, it might be possible to
avoid  such accidents.   We would, however, call attention to the fact, that
these  local congestions may occur  in chlorotic as Avell  as in   plethoric
women, and consequently, that, although revulsives applied to the upper part
of the body, or to the superior extremities, are useful in all, bleedings from
the  arm  at the  menstrual periods are very advantageous Avith the latter,
whilst the former are benefited by the preventive use of ferruginous  pre-
parations, administered from  the commencement of gestation. 
582
PATHOLOGY  OF  PREGNANCY.
  Under some unfortunate circumstances,  nature seems to deride all the
attempts of art, and  abortion  reoccurs.   Still, we must not  despair Avhen
the woman becomes again pregnant, for experience fully proves that, not-
withstanding numerous former abortions, a fresh pregnancy has sometimes
succeeded in reaching  full term.  Dr. Young (Rigby, 91)  relates, in his
lectures, the history of an unfortunate lady, Avho, after having had thirteen
successive abortions, became pregnant for the fourteenth time, and Avas hap-
pily delivered of a living infant at term.
  But, notwithstanding all these precautions, it sometimes  happens that an
abortion is threatened.  The patients are affected with shiverings from the
most  trifling causes,  pains in  the  hypogastrium, loins, &c.; uterine con-
tractions appear, the sexual parts become moist, and occasionally even the
os uteri dilates; but even here Ave must not lose all hopes of arresting the
accident, notwithstanding those symptoms.
  If the patient is  robust, the pulse full and  frequent, more especially if
the development of the symptoms  had been  preceded by  indications of
plethora, bleeding in the arm should  be at once resorted to, the Avoman be
laid as horizontally as possible, and opiates immediately administered.  The
laudanum of Sydenham may be given in the dose of twenty, forty, or even
sixty  drops, diffused in a small  quantity of some mucilaginous liquid  as an
injection, and repeated at  intervals  of an hour, until the contractions dis-
appear.  This remedy, of which we have before spoken, is one of the most
efficacious  in  cases of this kind, and sometimes it alone has enabled us  to
arrest a labor whose termination seemed to be inevitable, and thus has per-
mitted the gestation to pursue its regular course.
  I cannot refrain from  citing the  folloAving  instance in illustration.   A
woman, advanced  to  three months and a half, was taken with pains in the
abdomen  and loins, after a violent  altercation with  her husband; on the
folloAving day the pains augmented, and a little bloody fluid escaped from
the genital  organs; the pains still  continuing, and the discharge having
somewhat  increased,  on the third day  the patient  came  on foot to the
Clinique.   I found  on her arrival that the uterine contraction Avas very dis-
tinct, the pains sharp, and renewed every eight or ten minutes; pure blood
was discharging from  the vulva, and  the orifice was sufficiently dilated to
permit the finger to pass readily as far up  as the naked membranes.  I ad-
ministered sixty drops  of laudanum, divided into three doses, which AA'ere
given at intervals of three quarters of an hour,  and by the end of this time
the pains disappeared, everything resumed its natural order, and the gesta-
tion went on till full term.
  I might multiply such citations almost  ad infinitum, but the above is suf-
ficient to shoAV that, hoAvever inevitable the abortion may at first appear, Ave
should  never abandon all hopes of preventing  it.  I  may add,  that the
administration of opium  in  the doses just indicated, or even carried to a
hundred drops in the tAventy-four hours, has never been folloAved  by serious
consequences.  Sometimes, perhaps, a little somnolency or heaviness about
the head, or a general torpor may result, but Avhich a feAV glasses of lemonade
will soon dissipate.   For, after all, Avhen even death of the foetus must have
been  either the cause  or the  effect  of the  primary symptoms, Avhat do  we 
OF  ABORTION.
583
 risk in calming  or arresting the uterine contractions ?  because, as Ave have
 already seen, the dead child may remain long within the  intact membranes
 without  any unfavorable  consequences  resulting  to  the mother.   And
 besides, as it is almost impossible to ascertain its death Avith any degree of
 certainty prior to the fifth month of gestation, we must act in such doubtful
 cases just as if it Avere living;  although there can be no question that, if the
 foetus Avere really dead, it would be better to permit the contractions to go
 on, and its expulsion to be effected.  But, even supposing these  are wholly
 suspended, the expulsion is somewhat retarded, and  that is all; for after the
 lapse of a certain time the foetus, acting like a foreign body in the uterine
 cavity, will irritate  its walls, and a new labor sooner or later take place in
 consequence.
   To these  remedies (the venesection and opiate treatment) we must add
 strict confinement to bed, absolute rest of mind and body, the use of demul-
 cent beverages, cold lemonade, veal-broth, chicken-Avater, and  the applica-
 tion of cold compresses, frequently reneAved, over the abdomen;  which com-
 presses are to be saturated Avith some fluid Avhose temperature is progressively
 loAvered.   " Local  bleedings," says M.  Gendrin, " are too much neglected,
 especially in the treatment of the utero-placental  hemorrhages;  indeed, we
 have so  often had  occasion  to  congratulate ourselves for having advised
 them in those cases, that we now prescribe them with great confidence Avhen-
 ever the general condition does not directly indicate a depletory venesection.
 We direct them: 1. When there  are any sharp pains in the neighborhood
 of the uterus or groins, and we apply  them  to the latter, the anus, or even
 the vulva; 2. In cases of a considerable turgescence of the hemorrhoidal
 tumors  (if any  such  exist) ;  and  3.  In the phlegmasia of the  adjacent
 organs, such as the  large intestine,  &c."
   In these two latter cases we fully coincide in the opinion of M. Gendrin;
 but, in the first, Ave should much prefer having recourse to a general bleeding
 in the arm, or,  as  he himself advises, further on, to the application of
 leeches at a distance from the uterus : for instance, near the breasts, armpits,
 &c, etc.   Finally, to the means already enumerated, Ave must  further add
 the use of irritant revulsives,  placed upon the upper part of the trunk and
 the thoracic  extremities, and  must also recommend  in a more special
 manner the application of dry cups, the decidedly beneficial effects of Avhich
 Ave have often Avitnessed in cases Avhere uterine plethora seemed to be the
 cause of the  symptoms, but Avhere the general condition required some pre-
 caution in the use of blood-letting.
   2. It  has been already stated that  a  copious  hemorrhage, intensity of
 the pain and of all the other  phenomena, and more particularly a rupture
 of the membranes, render abortion  thenceforth inevitable; and hence, the
 only course  in such cases  is  to facilitate the expulsion of the  product of
 conception.  But still, if the hemorrhage is not of such a character during
 the first  three  months of gestation as to  compromise the Avoman's life, the
 physician  should remain a simple spectator of the efforts of nature,  and
confine himself to  superintending the  progress; for the expulsion of the
ovum ought  to  be  left entirely to the  uterine forces.   Sometimes it comes
ftAvay Avhole, Avhich is a very favorable circumstance.  Moreover, according 
584
PATHOLOGY  OF  PREGNANCY.
to the recommendation of Baudelocque, he  should be very careful not to
rupture  the  membraae3,  for  that  would only  retard  the  delivery of the
placenta, and  render it  still  more  dangerous.  In fact,  Avhen the foetus
escapes alone, this latter might be attended with the difficulties pointed out
in one of the preceding articles.
   We should here remember  how slowly the  expulsion of the ovum is
effected  in certain cases, even when  the orifice is sufficiently  dilated to
oppose no obstruction  to its  exit.   This  great slowness is sufficiently ex-
plained by the slight contractile power of the  uterus.   When no accident
complicates the abortion, the physician has nothing to do but  Avatch the
progress of the labor, and expect the complete delivery to be effected by
the uterine efforts.'  At a more advanced period, that is, towards the fifth
Dr the sixth'month, the  course of the physician is very nearly the same as
it would  be at term.  The size of the  foetus, Avhich has now become quite
large, requires a greater dilatation of tire os uteri; and this, in consequence of
the greater softening of the cervix, is accomplished with somewhat greater
rapidity.   Generally, it  is necessary that the child should present  one or
the other extremity of its long diameter to the os uteri; however, it some-
times happens that some portion of its trunk presents there, and its delivery
is  neither much more difficult nor much slower than usual.   It is in such
cases  especially that the mechanism  of spontaneous evolution may be fre-
quently observed.   The delivery of the  after-birth does not, as  a  general
rule, exhibit  those difficulties  which it presented in the earlier months; in
truth, it closely resembles  the same process in the labor at term.
  3. Hemorrhage is not only one of the most common symptoms, but it may fol-
low the expulsion of the foetus, and become the most serious feature  of the case.
  Whenever, notwithstanding the use  of  general measures,  such  as the
horizontal position, cold drinks, the application  of refrigerants to the hypo-
gastrium or  thighs, and the administration  of opiates,  the  discharge of
blood continues so great  as to endanger the  mother's life, an abortion thence-
forth  becomes  inevitable, and the primary object of the accoucheur should
be to  bring on the  contractions and the evacuation of the organ.
  He should also administer general stimulants to sustain the yvoman's
strength, and, at the same time, those medicines having an immediate action
on the womb itself, such as the tincture of canella, &c, but above all the
ergot.  However, when  the miscarriage comes on at an early stage of the
gestation, these measures are often ineffectual, for it is then exceedingly diffi-
cult  to excite  the contractions of a viscus whose muscular organization is
still  so  imperfect; or  at  least, if they are  aroused, they  are  frequently
inadequate to  dilate  the  neck sufficiently.   The tampon  is then the only
resource; this,  yvhen well applied, acts  in  tAvo  ways: 1st, by opposing the
escape of the blood externally, thus forcing it to coagulate, and conse-
quently to obliterate the  bleeding vessels; 2d,  by  irritating the Avomb by
mere contact, thereby determining its retraction, and  the expulsion of the
product  of conception.   This circumstance, indeed, is  one of the  best-
founded  objections to the use of the tampon in the early months of gesta-
tion.   But, in truth, is it  not rather an advantage than otherwise? because
the  cessation of  the flooding is ahvays  a  necessary consequence of the 
OF  EXTRA-UTERINE  PREGNANCY.
585
uterine contractions ; and is  the  mother's  life bought too dear, when it is
Baved by the expulsion of a foetus which, in most cases, is dead even before
the application  of  the tampon ?   Besides, this measure is not ahvays
necessarily followed  by abortion.   Again,  iaere is  no reason to fear the
conversion of an open into a concealed hemorrhage by the employment of
the tampon, before the sixth  month; for, notwithstanding the observation
of Chevallier, the accumulation of a large quantity of blood in the Avomb
would seem to be impossible at this early period, without  supposing an ab-
normal relaxation of its walls.   Where, hoAvever, the pregnancy is advanced
to the fifth month, the accoucheur should  carefully Avatch the body of the
uterus after the tampon is applied, and assure himself, every  moment, that
its volume is not increasing.
   We shall  describe hereafter (see Operations)  the mode of applying the
tampon, but it should be remembered that its use is  almost always folloAved
by abortion, and that it  should be had  recourse to only Avhen the  latter
Beems to be  inevitable.
   When the ovum remains intact, and the labor lasts too  long, the contin-
uation of the hemorrhage being at the same  time such as to cause serious
anxiety, some practitioners prefer rupturing the membranes to applying the
tampon.  This  measure, to which I shall again allude in speaking of hem-
orrhage during the last three months, does not  seem to me applicable before
the sixth month, except in a few occasional instances, and I should, in
general, decidedly prefer  the tampon to it.
   In fact, a  rupture of the membranes  is  necessarily folloAved  by miscar-
riage ; but the tampon, when  early applied, leaves some hope that the ges-
tation may continue till term ;  again,  the tampon always arrests the bleed-
ing, whereas, after rupturing the membranes, it may happen that the uterus,
Avhose muscular fibres  have not acquired the contractile poAver which they
Avould have at a later period,  might not retract, nor the hemorrhage  cease,
so that it might still be necessary to have recourse to the tampon.
   Finally, let us add that, in  the first three months, the rupture is followed
almost immediately by a  discharge of the waters and the  escape  of the
foetus;  but the expulsion of the placenta and membranes is  thereby rendered
much more difficult.
   After the  complete expulsion of the ovum,  the patient must  observe the
Bame precautious as are required after ordinary labor.
                        CHAPTER  VI.
                  OF EXTRA-UTERINE PREGNANCY.
  The fecundation, as elseAvhere stated, most frequently takes place in the
ovary, and the impregnated ovule is then received by the fimbriated extrem-
ity of the tube, Avhich applies itself on this organ, doubtless  by a kind of
spasmodic contraction.  Having bee 1 once deposited in the tubal canal, the
ovule traverses its Avhoh length, and falls into the uterine cavity, Avhere its 
586                PATHOLOGY  OF  PREGNANCY.
development continues until term.  Such is the course observed in normal
or uterine pregnancy; but it may happen that  the ovule is  arrested,  or
diverted, in  the route it thus travels, and ingrafting itself, so to speak, upon
the point of stoppage, is there developed;  in the  latter case, the pregnancy
is called an  abnormal, or an extra-uterine one.
  This species of gestation has been subdivided into several varieties, which
have received different names, according to the part of the  passage Avhere
the ovule  becomes  fixed.  Dezeimeris admitted the following divisions,
namely:
                  1. Ovarian pregnancy.
                  2. Sub-peritoneo-pelvic pregnancy.
                  3. Tubo-ovarian pregnancy.
                  4. Tubo-abdominal pregnancy.
                  5. Tubal pregnancy.
                  6. Tubo-uterine interstitial  pregnancy.
                  7. Utero-interstitial pregnancy.
                  8. Utero-tubal pregnancy.
                  9. Utero-tubo-abdominal pregnancy.
                 10. Abdominal pregnancy.
   Such Avas the  classification Avhich, in an anatomo-pathological view, was
adopted in the six first editions of this work.  We now think it would  be
better to make a more simple arrangement, and shall, accordingly, describe
but five varieties of extra-uterine pregnancy:
                  1. Abdominal pregnancy.
                  2. Tubo-abdominal pregnancy.
                  3. Tubal pregnancy.
                  4. Interstitial tubo-uterine  pregnancy.
                  5. Utero-tubal pregnancy.

   1.  Abdominal Pregnancy. —To render fecundation possible, it is necessary
 that there should be direct contact betAveen the sperm  and the ovule, and,
 consequently, that the Graafian vesicle  should  burst  into  the abdominal
 cavity of Avhich it, for  the moment, forms  a portion.   But, should the fecun-
 dated ovule, instead of engaging in the tube, remain in the just ruptured
 ovisac and be retained at  the surface of the ovary, or fall into the peritoneal
 cavity, its development gives rise to an  extra-uterine  pregnancy Avhich Ave
 shall  designate under the general name of abdominal pregnancy.  Three
 varieties of this class will be recognized:  in the  first, the fecundated ovule
 is  still contained in the just ruptured ovisac, and  is developed upon  the
 spot: the pregnancy is then styled internal ovarian.  In the second variety,
 the fecundated ovule,  having escaped from the Graafian vesicle, adheres to
 the surface of the ovary, Avhere  it undergoes development: this  is called
 external ovarian  pregnancy.  Finally, should the ovule, after leaving  the
 ovary, attach itself to some part of the peritonei; m, it receives the name of
 peritoneal pregnancy.
    In internal ovarian pregnancy, the ovum is  developed within the ovary
 itself.  This variety has  given  rise to  numerous  scientific discussions, inas-
 much as it Avas for a long time  admitted  that the ovule  could be fecundated 
OF  EXTRA-UTERINE PREGNASCV.
587
 without previous rupture of the Graafian vesicle.   Amongst the observa-
 tions pleaded in favor of this  hypothesis, one related by Bcehmer ought to
 be mentioned.   He describes Avith much care both the membrane proper
 of the ovary itself and its peritoneal envelope.  M. Velpeau, hoAvever, very
 justly observes that it is often extremely difficult to determine precisely the
 point of departure of the tumor;  therefore aac admit Avith him  that, in this
 species of pregnancy, the ovisac is ahvays ruptured.  If the minute wound
 resulting from it be not evident  Avhen the dissection is made, it  is because it
 has been obliterated by the process of cicatrization and the production of a
 newly-formed membrane.
   External  ovarian pregnancy cannot be doubted.   It is,  relatively speak-
 ing, quite common, and the fecundated ovule retains its intimate connections
 with the ovary upon which it is  applied whilst undergoing  development in
 the abdominal cavity.
   Peritoneal pregnancy was for a long time contested, but is now supported
 by so great  an array of facts, observed both in women and  animals, that it
 is impossible to deny its occurrence.  It has, doubtless,  often  been con-
 founded Avith the ovarian and other forms, but in several  published cases
 there can be no question that the oVum had no connection with the internal
 generative  organs.   M. Dezeimeris makes  tAvo  varieties  of this form  of
 pregnancy, viz.: primitive and secondary.  In the  former, the product  of
 conception has never been located elseAvhere than in the peritoneal cavity,
 into which it fell on quitting the ovarian vesicle; in the latter, on the con-
 trary,  the first  development  of  the  ovule  took place  in  the ovary,  the
 tube, or the Avails of the uterus,  but at a  later period extreme distention  or
 pathological alteration of the Avails of the tumor caused their rupture, and
 the ovum being  partly or Avholly expelled from the containing cyst, became
 lodged in the cavity of the abdomen, where it Avas at last found.  The sec-
 ondary abdominal pregnancy of M. Dezeimeris is, therefore, merely a tubal
 or interstitial pregnancy, ending  in rupture of the primitive  cyst.  Whether,
 therefore, this rupture occurs at a very early period or at the regular term
 of gestation, it  deserves to  be regarded merely as an  epiphenomenon, and
 can, in no  case, constitute  a distinct variety.   We apply, therefore,  the
 name peritoneal pregnancy to that form in Avhich, from  the  very outset, the
 ovule has become adherent to some part entirely distinct from  the interna]
 generative organs.   The points at Avhich  it  may thus attach itself are ex-
 tremely numerous, so that the placenta has  sometimes been found inserted
 upon the peritoneum, covering the right or left iliac fossa, sometimes to  the
 mesentery, or to a part of the small and large  intestine,  and  sometimes,
 finally, to the anterior wall of the abdomen.
  Most of the cases described by Dezeimeris  as sub-peritoneo-pelvic preg-
nancies belong, Ave think, to the peritoneal variety.  The author applies the
former name to cases in which the ovule was unable, after leaving the ovary,
to engage in the external opening of the tube, but slipped  betAveen the tAvo
layers of the broad  ligaments  and was developed there.  According to his
vieAv, the ovum here is outside of the peritoneum, and remains principally
in the pelvic cavity.  Cases of the kind, he  thinks, are not rare, and,  on
account of the situation of the ovum, are to be reckoned amongst the least 
588
PATHOLOGY OF PREGNANCY.
dangerous.  The position is, indeed, remarkably favorable to the sponta-
neous expulsion of the debris of the foetus, or makes them  easily accessible
in case it should be thought necessary to abstract them.   Whilst accepting
this prognosis, we think that Dezeimeris is in error as regards the  slipping
of the ovule between the two layers of the broad ligament; it seems to me
impossible that  it should folloAv this  route.  The observers  Avere, in  these
cases, deceived by the fact that upon opening the abdomen the peritoneum
of the lesser pelvis seemed to be raised by a subjacent tumor.  The appear-
ance,  hoAvever,  misled them, for  the  tumor is not,  really, covered by the
peritoneum, but by a newly-formed false membrane, Avhich  soon  acquires
the shining and polished appearance of a serous  membrane, and which
blends, Avithout  a well-marked line of demarcation, Avith the surrounding
peritoneum.  If this pseudo-membrane be incised, a careful dissection Avill
reveal the true  peritoneum below the foetal  cyst.  The  tumor, therefore, is
not extra-peritoneal, but intra-peritoneal.  In short, the same phenomenon
occurs here which  for a long  time sustained  the  idea  that retro-uterine
hematocele was seated outside of the peritoneum.
  2.  Tubo-abdominal Pregnancy. — It  is evident that, if the tube be obliter-
ated  near the enlarged extremity, the ovule which  has scarcely entered its
canal will be arrested ; and if the development occurs at this point, the tubal
walls  Avill necessarily be dilated, and one portion of the surface of the ovum
be free in the abdominal cavity; to this variety the name of tubo-abdominal
is applied.  The placenta  is attached in the interior of the  tube, and the
foetus developed in the abdominal cavity, and both are surrounded by a cyst,
the Avails of which are partly made up by the parietes of the tube.
  We include in the tubo-abdominal pregnancies  those cases which  have
been  described  under the name of tubo-ovarian.  In this the cyst, which
surrounds the foetus, is formed partly by the ovary, and partly by the open-
ing of the dilated tube, \Vhose  extremities have  contracted some adhesions
with the  ovarian tunic.
  The following case of Dr.  Jackson's is justly quoted by M. Dezeimeris as
serving for a type.  A woman, aged thirty-two years, was seized, in conse-
quence of a violent blow on  the epigastrium, with some inflammatory symp-
toms, to which she speedily succumbed ; at the autopsy, a large quantity of
blood was found diffused in the abdomen, and a foetus of about ten Aveeks
Avas found enveloped in an enormous  clot; the fundus uteri  rested against
the pubis, and its cervix near the middle of  the sacrum.  This change from
its natural position had been produced by a tumor situated on the  left side
of the Avomb, which tumor  Avas formed  by the ovary, the Fallopian  tube,
and the broad ligament, that had become considerably thickened and modi-
fied in their structure ; the fringed extremity of the tube adhered intimately
to the ovarian envelope, and a  cyst was formed  by  these tAvo organs, Avhose
distention by the body contained therein had produced the rupture.
   In  another case, related by  Bussieres, Avhich seems to me equally conclu-
sive, the  tube on  the  right side  was  extremely dilated at the extremity;
and this  dilatation, Avhich Avas an inch in its largest diameter, extended for
rather more than an inch and a half  in length, gradually  diminishing as  it
approached the womb.  The portion of the tube thus dilated Avas curvea 
OF  EXTRA-UTERINE  PREGNANCY.
589
 m itself, and embraced nearly the whole ovary, to the men brane of Avhich
 it AAas so adherent that it  could  not be separated A\ithout rupturing the
 attachments.  An unctuous, limpid fluid escaped  as soon as it Avas opened,
 and then the ovum appeared, which was about  the  size of a hazlenut, and
 was surrounded by the liquid; three-fourths of it had already escaped from
 the hole made in the ovary, so that it no  longer seemed to rest there; yet,
 on attempting its removal, it was found attached by a hard pedicle covered
 with blood-vessels.
   3.  Tubal Pregnancy. — This is the  most frequent of all the varieties of
 extra-uterine pregnancy;  which fact is readily accounted for by the length
 and narrowness of the canal, and by the adhesions and morbid obliterations
 presented by its walls.   Under such circumstances, the ovule is arrested and
 developed at some point between its abdominal extremity and the spot Avhere
 it enters the uterine  parietes;  and by its  continual growth distends enor-
 mously the fibres  of the  tube which  constitute the envelope of the  foetal
 cyst.  To the numerous cases of this kind  reported by Velpeau and Dezei-
 meris, I might add another, already published by me in the Bulletin de la
 Societe Anatomique, but so many examples are everywhere met Avith that it
 seems useless to reiterate their details.   Dr. Lesouef's thesis may be advan-
 tageously consulted on this point.
   4. Interstitial Tubo-uterine Pregnancy. — In this case the ovum is arrested
 in that part of the tube which traverses  the thickness of the uterine walls;
 and although this  is its  principal characteristic, tAvo varieties  have been
 made of it, of which Ave shall say a few words.
   In the first variety the Avails of the tube, yielding to the distention occa-
 sioned by the development of the ovum, press back  the surrounding tissue
 proper of the uterus, but always form the most internal layer of the cyst in
 Avhich the product of conception is enclosed.
   In the second variety the  ovule reaches that paft  of the tube which tra-
 verses  the uterine Avails;  but having  arrived there,  it opens a Avay through
 the tubal parietes, penetrates into the  midst of the fibres of the Avomb, and
 thenceforth  has  no further  relation with the tube;  hence, the surrounding
 cyst is formed by the  muscular fibres  of the womb  alone.
  After having been once located  among the uterine fibres, the ovum may
 either take an imvard or an outAvard direction, and consequently may become
 seated near the mucous layer, or else to the peritoneal coat.  In  a prepara-
 tion  belonging to M. Pinel Grandchamp, the volume of the uterus Avas about
 the same as at six Aveeks  or tAvo months  of pregnancy; at its left angle, a
 small tumor, slightly ruptured  behind, constituted the cyst containing the
 product of  conception.  The tube, which passed behind  it, communicated
 Avith it by an almost microscopic orifice, and presented nowhere any increase
 of calibre.  The cyst was about large enough to  contain an almond.
  5.  Utero-tubal Pregnancy. — NotAvithstanding the  free  communication
existing betAveen  the  tube and uterine cavity, there is no absurdity in the
supposition that  the ovule may become  deposited  in a little depression of
the mucous membrane, and there stop and  ingraft itself, just at the internal
orifice of the canal.  In this case, phenomena similar to  those of the tube-
abdominal  gestations will  arise: that is, the ovule, which may  have con- 
590
PATHOLOGY  OF  PREGNANCY.
tracted  some intimate  adhesions with  this  extremity, may, by rts deAelop.
ment, encroach upon the uterine cavity itself; and I do not hesitate, there-
fore, to consider this variety of gestation  as  possible.
   It is probable that certain singular  cases described  by Dezeimeris under
the  name of utero-tubo-abdominal  pregnancies belong properly to tubo-
uterine pregnancies.   In this variety, examples of Avhich have been furnished
by Patuna, Hunter, and Hoffmeister, the foetus is  found  in the abdominal
cavity ;  the cord leaving the umbilicus enters the  Fallopian tube, traverses
its whole length, and  is inserted in the  placenta, Avhich itself is attached to
the internal surface of the uterus.  HoAvever extraordinary these facts may
appear, I think that no one can doubt them  after reading the subjoined case,
taken from the memoir of M. Dezeimeris.1

  1 Helen Zopp, aged 35 years, had been married for twelve years, and had given birth
to eight children, two being twins.
  As  she was  preparing for church on  Sunday,  July 10th, 1763,  she was suddenly
attacked, after a violent fit of anger, with a profuse flooding  and the  pains of child-
birth (being then at term);  however, she did not pass the waters, but what proved to
be pure blood; and she felt the motions of her child up to the last moment.  The mid-
wife, summoned on the occasion, declared at once that the accouchement was at hand;
but after the lapse of several hours, as the loss of blood continued without any positive
signs of an approaching  delivery, a physician and a surgeon were simultaneously sent
for, the former of whom soon arrived, and recognizing at once the imminence of the
danger, he ordered the administration of the sacraments, at  the same time prescribing
divers remedies for the discharge.   The venesection of the cephalic vein was followed
by a  profound syncope, without causing the  least abatement of the metrorrhagia; and
the sacraments had scarcely been administered, when the patient died, at 11 a.m. on
the same day.
  Patuna and his father  (the public surgeon  to the city) arrived just as she was expir-
ing.   After assuring  himself of her death, he  immediately made a Caesarean section
upon the right side, where the abdomen offered the most resistance, and, as soon as the
ventral walls were divided, an enormous  foetus, resembling a child nine months old,
presented itself;  the position was such that  its back corresponded with the abdominal
parietes of the mother;  the  head was somewhat inclined,  was directed towards the
vertebrae, and rested immediately under the  diaphragm; the knees flexed towards the
head, the right hand upon the thighs, and the left  near the  navel: the umbilical cord
was of considerable length;  it ascended to the right, wound around the  neck, and
then  entered the  Fallopian tube on the right  side.   A case of extra-uterine pregnancy
being new to Patuna, although acquainted with most of the published examples, his
researches were made in the most careful manner.
  Having enlarged the opening made in the abdomen, so as to examine its cavity to bet-
ter advantage, he sought for the fcetal envelopes with all possible attention, but in vain;
for he neither found the amniotic liquid, nor fluids of any  other kind in this cavity.
By tracing the umbilical cord with his hand, he found that it penetrated into the right
tube  at the distance of a finger's breadth from the uterus;  the uterine portion of the
tube  was  more voluminous than  that part which ran to the ovary, whence he judged
that the cord passed through the former into the womb.
  This organ was larger than the fist, and had the natural pyriform shape, but not the
keast vestige of any rupture; not the smallest cicatrix could be seen, and it hardly rose
above the pelvis.
  These observations being concluded, Patuna  incised the  tube from the entrance of
the cord towards the uterus: this presented nothing peculiar, excepting the adherence
to the cord where the latter perforated it.  The uterus was then opened, and exhibited
no trace in the interior of any previous laceration whatever; the walls were an inch
»nd a half in thickness,  and their substance was  nearly  bloodless; the placenta wa« 
OF EXTRA-UTERINE  PREGNANCY.
591
  Wo explain them by supposing the existence of a tubo-uterine pregnancy
endinir in rupture of the tube Avith passage of the foetus into the peritoneum,
whilst the placenta remains in the uterus.  The cord traverses  the  tube in
its passage from the foetus to its placenta.
  We have not been able, from the restricted limits of this chapter, to bring
forward a larger number of cases, but sufficient has been said to furnish  an
idea of  the importance that ought to be  attached to the different varieties
of extra-uterine pregnancy admitted by us.
  The reader may consult with benefit the article of Professor Velpeau, in
the fourteenth volume of the Dietionnaire de Medecine, the learned memoir
published by M. Dezeimeris, in the fourth year of the Journal des Connais-
sances Medico-Chirurgicales,  and the able articles of Messrs. Breschet, Me-
niere, and Guillemot.
  The physiological and pathological  history of these different pregnancies
is yet to be given, and we  shall therefore commence Avith their pathological
anatomy.

  § 1. Pathological Changes.
  The anatomo-pathological  examination of extra-uterine  gestations evi-
dently comprises  the peculiarities offered both by the product of conception
and the parts of the mother.
  A.  Product of Conception. — In these pregnancies the ovule has its proper
membranes, the chorion and the amnion.  I may state that I Avas utterly
astonished to hear  several honorable  members contend, in a recent discus-
sion before the Academy of Medicine, that the envelope of the ovule, in ab-
dominal gestations, Avas only composed of the amnios, and that no  chorion
existed;  for  although,  in  certain very old  pregnancies, the  most exterior
fcetal membrane is confounded Avith the Avails of the cyst, it is not fair to
conclude from thence that it did not  exist at the  commencement.
  Indeed, it is only necessary to recall our remarks on the mode of develop-
ment of the ovum, to comprehend that the absence of the chorion supposes
that of the allantois, and without the latter  no circulatory relations can  be
established between the embryo and its mother.
  The structure of  the walls of the cyst varies according to the species  of
extra-uterine pregnancy.   In the tubal variety, they are formed  by the
Avails  of the tube  itself, and in the internal ovarian, by the  integuments  of
the  ovary.

found within adhering to a narrow space  at the fundus, a little to  the  right;  it ex-
tended more towards  the left, but was there  detached.   It was about two fingers'
breadth in  thickness,  and four inches in  diameter, and it commenced very near the
uterine opening of the right tube, and adhered more strongly there than at any other
place.  The extremities of some vessels were evident both on its convex surface and
at the fundus uteri upon which it was ingrafted; its concave face, from the middle of
which  the cord arose,  was covered by two membranes: one, the interior, being thicker
and vascular, while  the exterior was very thin and translucent; but these joined when
they approached the border of the placenta, forming there a more solid substance, and
having some very delicate vessels ramifying through it.   The internal uterine orifice
would hardly admit  the little finger.
  Everything else remained in a natural state, excepting the change in the situation
of the intestines.  (Barthelemy Patuna.) 
592
PATHOLOGY  OF  PREGNANCY.
   In the so-called sub-peritoneo-pelvic gestation, or whenever  the ovule,
that was originally located in  the ovary, tube, or even the uterus, is trans-
ferred, after the rupture of the cyst which  inclosed it, to some part of the
abdominal cavity, there is besides a pseudo-membranous  cyst, representing
the uterine decidua, produced  by the inflammation which the presence of
the ovule determines  around it.  But this enveloping membrane, the cyst,
does not  exist in primitive peritoneal pregnancies.   M. Dezeimeris thus
explains the latter circumstance: When  a fecundated ovule  gets into the
abdominal cavity immediately  after quitting the  ovary, we can readily be-
lieve that a corpuscle so minute, soft, and fragile could only produce a very
slight irritation at the point of arrestation, and that the extent of this excita-
tion Avill not pass beyond the limits of contact Avith the little foreign body;
in a Avord, it  cannot produce an acute inflammation, or extensive adhesions,
nor an  exudation of plastic lymph sufficient to form an enveloping cyst.
Now, if it has not primarily caused all these derangements, the neighboring
organs will not be injured by its ulterior development, because they  become
gradually habituated thereto;  and the ovule, having obtained  a right of
possession, lives, grows, and presents to the smooth, polished  surfaces Avhich
touch it, a surface equally smooth, polished, and moistened at their expense:
and not having occasion for any other protecting envelope, no cyst is formed.
But Avhen a voluminous product of conception suddenly bursts, and  its con-
tents, placed  at first like it in the tube or'ovary, are transported to the peri-
toneal cavity, the ovule becomes there a foreign  body, Avounding and irri-
tating the abdominal  organs which are unaccustomed to its vicinity, and
determining an acute inflammation around it, which results in the exudation
of plastic lymph; this, by coagulating, forms a cyst, and completely  isolates
the foreign body.  If, under these circumstances, the displacement of the
foetus is such that it completely escapes from the amniotic cavity, and sud-
denly locates itself Avith its surrounding licpuid in the midst of the intestinal
mass, an inflammation occurs,  and the cyst we have  just described forms
around  it; the neAV cyst then completely environs the foetus.   But in some
cases the displacement is  not so complete — the  largest part of the trunk
may still  remain in the amniotic  cavity after the rupture, a portion only
being displaced, and  the  latter alone first  determines  an  inflammation
around  it, and then the exudation,  Avhich is transformed  into a false mem-
brane ; this, by uniting Avith the lacerated margins, forms  only a part of the
foetal cyst, the remainder being constituted  by the old fcetal envelope, the
walls of the Fallopian  tube, for instance, in the case of a tubal pregnancy.
The same relations  may be established Avith  the membranes  of the ovule
when the chorion and amnion are ruptured at an advanced period in a case
of primitive  abdominal pregnancy.  For instance, in a case cited by M.
Dubois, the cyst that inclosed  the foetus was formed of a membrane Avhich
was not altogether uniform in its structure and  appearance:  thus,  for the
greater  part of its extent, the internal surface was of a light-broAvn color,
owing  perhaps to the imbibition  of the  adjacent liquids, and simulating,
both to the  touch and sight, the aspect of the  mucous  membrane of the
small intestines, or, still better,  the accidental membranes that occasionally
line fistulous canals;  while at other points, those for instance Avhich Avere 
OF  EXTRA-UTERINE  PREGNANCY.
593
near the circumference of the placenta, and on the largest part of this  sur-
face, the cyst was  more smooth  and polished;  presenting, in fact, the ordi-
nary appearance of the amnion.
  The cyst was simple, and about a fourth of a line in thickness at the part
where it exhibited the broAvn and villous character above alluded to; but
on  the  contrary, Avhere the surface Avas smooth  and  polished, it evidently
consisted of two membranes (the chorion and the amnion.)
  In all cases, numerous and  large vessels  form in  the walls of the  cyst
whose rupture it is evident must give  rise to hemorrhage, which very often
proves fatal to the mother.
  When an extra-uterine pregnancy is somewhat prolonged, these envelopes
are sometimes destroyed, being perforated with  fistulous canals, communi-
cating directly with the intestinal canal, vagina,  bladder, uterus, or an ex-
ternal  abscess.   At times, the destruction of the  cyst is partial, at  others
complete; so much so, indeed, as to leave in certain cases no vestiges of its
former  existence;  on the  other hand,  the  envelopes sometimes undergo
osseous  or cretaceous transformations, which may convert them  into solid
shells.   As a general rule, the foetus exhibits nothing peculiar in its devel-
opment : for example, in several cases studied anatomically a long time after
the term of pregnancy, the osseous  system appeared to have a better devel-
opment than in the ordinary child of nine months.  The  existence of several
teeth has frequently been noticed, or else traces of the eruption of these little
bones, which would seem to afford an indication that the fcetu's continued to
live and grow beyond the ordinary term of gestation.
  The most common of the numerous  alterations which  it may undergo, is
the putrescent dissolution of its soft parts, from  macerating in a compound
of amniotic liquor, blood, and pus ;  the separation of the various pieces of its
skeleton, and their discharge through the divers routes just mentioned.  At
other times, it seems  to have  undergone a kind  of mummification, a com-
plete drying-up.   Again, in other  cases, all  the  tissues  appear to be trans-
formed  into an osseous  or cretaceous substance,  or  into one  resembling
adipocire,—and here, it  is doubtless unnecessary to  add, it is  no  longer
possible to discover any trace of the fcetal membranes.
  B. Tissues of the Mother. — Some very large vascular canals are seen to
develop themselves in those parts Avhere  the  ovum is  attached, hoAvever
devoid of blood-vessels they might have been previously ;  and sey^eral great
veins are found to  ramify under the peritoneum  tOAvards the circumference
of the placental attachment; and Avhere the ovary or the  tube happens to be
the  seat of pregnancy, it presents a soft  tissue, apparently fungous in char-
acter, and impregnated Avith blood.
  The Avomb does  not continue  so indifferent  to the advancement of the ■
extra-uterine pregnancy as  might be supposed;  for its volume increases in a
remarkable  degree, the  tissues become softer, and the mucous membrane
hypertrophied  and more  vascular, so as to form from the outset  a true
decidua.  M. Velpeau, hoAvever,  disputes this  last assertion;  but I have
endeavored  to refute his opinion  in the Bulletin de la Societe Anatomique
(Sept. 1*36), to which the reader is referred.
  This  hypertrophy of the uterine mucous membrane is of short  duration.
      38 
594
PATHOLOGY  OF  PREGNANCY.
For, as the ovum does not  enter the uterus, it has nu  iffice to perform,
and, therefore, like every other  useless  organ, becomes atrophied, loses  its
vascularity, and  in a feAV months has returned  to its usual condition.  A
gelatinous  substance, a kind  of thick, ropy mucus, is also frequently found
in the neck of the uterus; but Avhen the pregnancy has  advanced beyond
term, theAVomb gradually regains its natural condition.   Finally, in certain
cases, the calibre of the Fallopian tube has been found obliterated at some
part of its  length.

   § 2.  Symptoms and Diagnosis  of Extra-Uterine  Pregnancy.
   During the early months it is exceedingly difficult to recognize the exist-
ence of an extra-uterine pregnancy ;  for the modifications which then occur
in the size, form, and consistence of the body and neck of  the uterus, Avill
certainly lead to error, and give rise to the belief of a true gestation.   With
regard to the menstruation  and the lacteal secretion, no constant rule is
observed.   Sometimes the menses continue to appear  ; at others, they do not.
In some  instances this function is not re-established, even after the  period
when the accouchement should have taken place; and similar variations are
met Avith in the  secretion of  milk.   Again, menstruation has been  known
never to appear during an extra-uterine pregnancy Avhich lasted  more than
thirty years, Avhile the lacteal flow continued throughout  the whole of that
time.
   There  are, likewise, some abdominal  pains, at a period not very distant
from the date of conception, more or less analogous to the uterine pains, and
at times a constant, fixed, circumscribed one in the pelvis, groin, or umbilical
region.   (The woman Avhose preparation  I  presented to the Anatomical
Society, had on this account been treated for a partial peritonitis.) Not un-
frequently  there  is an inability to  lie  upon one side.  When  the tumor,
Avhilst  still  small, falls into the lesser pelvis, it pushes the uterus fbnvard,
the  neck  being directed in front and quite high behind the pubis.   This
displacement of the neck of the Avomb, together Avith the presence of a large
tumor  occupying the excavation posteriorly, and the dysuria occasioned by
the pressure made upon  the neck of the bladder,  has  been mistaken for
retroversion.  Several examples of this error are mentioned  by Burns.
   At a later period the tumor rises above the  superior strait.  The motions
of the  child are felt  at the  usual time, but they appear to be more super-
ficial, and are generally felt on one side only.
   The  labor-pains come on at the natural term,  or at the seventh month, or
even sooner, generally lasting for three or four days, but occasionally much
longer; and, should the  pregnancy be unusually prolonged, they are  apt to
return  at varied intervals, and again pass off.
   Schmidt  reports a case Avhere the  gestation  lasted three years, Avithin
which  period the labor-pains  Avere reneAved eight times, and on each occasion
continued for several weeks.
   In another gestation, of ten years' duration, the pains returned annually
at the  period corresponding to the term of pregnancy.
   These  pains are not produced by contraction  of the Avails of the cyst, as
many have stated;  because, excepting the cases of tubal  and  interstitial 
OF  EXTRA-UTERINE  PREGNANCY.
595
pregnancy, they never  contain  any muscular fibres,  and hence Ave must
search for the cause in the uterus itself; for the great development exhibited
by this organ, and the mucous and albuminous matters inclosed in its cavity,
the expulsion of Avhich requires  some  contractions, sufficiently account for
the pains  experienced by the patients.  But  it is  exceedingly difficult to
explain in a satisfactory manner their  frequent coincidence with the  usual
term of gestation.
  The physical signs Avhich require our notice are, the changes in the uter-
ine body and neck,  just indicated, the more or less irregular development
of the belly, and the possibility, in some cases, of distinguishing tAvo tumors,
one being the uterus,  Avhile the other is formed by the abnormal cyst.
  In the sub-peritoneo-pelvic variety, the product of conception, by occupy-
ing the pelvic exca\ration, displaces and compresses the organs there situated,
the vagina and  rectum, for  instance,  and pushes them to one side.   The
vagina and rectum are found to  be obstructed by a  tumor situated betAveen
them, and frequently the  different parts of the foetus  may be  detected by
the vaginal touch.
  The foetus  seems  to be  much  nearer the surface  in  the  abdominal preg-
nancy than in either of the other \rarieties, hence its  motions are more  easily
perceived, and are  more  distressing to  the mother, and the forms of the
different parts more  clearly distinguishable.    Besides, the rounded and
regularly circumscribed tumor formed by the uterus in a normal gestation
is not present.
  In the tubal and ovarian varieties, says Baudelocque, the foetal movements
should be less vague, and its limbs more  retracted.  The body of the uterus
is associated  Avith the tumor formed  by the fcetal cyst, and  can neither be
separated nor readily distinguished from it.
  I have thus brought fonvard the various signs by Avhich authors endeavor
to detect the  different species of extra-uterine gestation, although they have,
in my estimation, but little practical importance; nor  do I see  that auscul-
tation itself could render us much service in determining the  diagnosis.
  I ought to  observe that  the possibility  of a fresh fecundatiou is a feature
common to all the varieties of extra-uterine pregnancy.
  Perhaps it  may be serviceable  to note that the vacuity of the uterus might
be detected by the touch.  Very  frequently  its habitual  position will be
changed by the pressure of the tumor, more especially Avhen the latter occu-
pies the excavation, and urges it against  some part of the pelvic Avails.
  Finally, Avhen by  the usual signs Ave have become assured of the existence
of pregnancy, and Ave suspect that it is extra-uterine, the  diagnosis Avill be
reduced to a  certainty if Ave can  determine the capital  point,  which is, that
the uterus is  empty.   Now Ave havajust seen that  this knoAvledge can be
arrived  at by means of palpation and the touch. Professor  Stoltz  was the
first to use the uterine sound  for the same purpose; but it will be readily
understood Avhy great prudence should be exercised  in  deciding  to employ
it.  In  case  of a normal pregnancy,  the sound Avould, in fact, be almost
sure to produce abortion, and then the mistake would be irreparable.   The
use of the uterine sound is more rational  and truly useful Avhen  the question
to be decided is,  Avhether there be an extra-uterine  pregnancy or a fibrous
tumor of the  uterus. 
596
PATHOLOGY OF  PREGNANCY.
  § 3. Progress and Termination.
  It is but rarely that an extra-uterine pregnancy is prolonged beyond the
fourth or fifth month; for generally the Avails of the cyst give Avay, in con-
sequence of their distention, before it  has had time to become very large.
Sometimes, however, the foetal  envelopes resist the pressure to which they
are subjected, and if the  foetus itself do not perish through  Avant of nourish-
ment, or by some accidental disease, its development may  progress until
term,  and it may even live for some time after the expiration of the ninth
month.  Such is reported by Dr. Grossi to have  been the case Avith a lady.
who, in all probability, carried an extra-uterine foetus, Avhose motions Avere
perceived clearly by himself and several  consulting  physicians, through a
space  of fourteen months.  Usually,  the  child.perishes  either before or
shortly after the term of pregnancy ; and Ave  shall noAV proceed to point out
the possible consequences of its retention.
  A. Rupture of the Cyst.— When left to itself, an extra-uterine pregnancy
will generally terminate in a rupture of the cyst; but the  time and conse-
quences thereof are very variable.   Were Ave to  class  these  pregnancies
according to the frequency of the rupture, and the early period of its occur-
rence, they would  stand as follows:  the tubo-interstitial, tubal, and ab-
dominal.
  It is very rare for the  period of the rupture to  extend beyond the middle
term of pregnancy, except in the last variety.   Dr. Lesouef very properly
dAvells on  the tendency of tubal pregnancies to rupture  at a very early
stage  of gestation.  According to the  same author, and  to M. Bernutz, his
master, if the rupture of the  tube  occurs at one of the points Avhere it is
covered by the peritoneum, the  consequent  effusion takes place into the
peritoneal  cavity;  this,  however, is  not  necessarily so, because  the tube
might give Avay at its adherent  edge,  and alloAV the ovule to slip betAveea
the two layers of the broad ligaments. In this case, the result Avould be a
true consecutive sub-peri ton eo-pelvic pregnancy.
  The rupture, which is  usually spontaneous, always gives rise to exceed-
ingly  grave phenomena, Avhich  may  be  described  as the primitive and
secondary  consequences.  Thus,  the  patient at  once suffers from violent
pains for several hours;  then, after a pain Avhich is much stronger than all
the others, a perfect calm comes on.   The  abdomen  sinks, or becomes flat-
tened, and the former tumor disappears;  a gentle  and equal heat spreads
over  the  abdominal  cavity, and if the pregnancy  is Avell advanced, the
patient feels as though  a voluminous body had been suddenly displaced;
the skin loses its natural hue, faintings come on, the pulse is small and con-
tracted, a cold sweat covers the whole body, and death  frequently folloAvs,
because the rupture of the cyst is often the immediate cause of a hemorrhage
that speedily proves  fatal.  Should any circumstance Avhatever arrest, the
hemorrhage, the first symptoms that follow the displacement of the product
of conception, and  the transference of the waters, blood, or  even the foetus
itself, to parts not accustomed to such contact, are those of a vei y violent
peritonitis.  The patient generally dies, though  sometimes she is able to
resist  the violence of the first inflammatory symptoms, in which case the
course of the dil ease differs from that  time, according to Avhether the debris 
OF  EXTRA-UTERINE PREGNANCY.              597
of the  pregnancy are to be inclosed in a cyst of new formation for  the re-
mainder of the patient's life, or Avhether they are to be eliminated in various
ways.  In the first case, the  foetus may undergo all the transformations
described under the head of the pathological anatomy; and  in the second,
the symptoms vary with the manner in which the elimination is effected.
  B.  Prolonged Retention  of  the   Cyst.— As we have already stated, the
peculiarities of extra-uterine  pregnancy, Avhen the  integrity of the cyst
allows  the development of the foetus to proceed until term, and even some-
what beyond it, Ave shall  not reconsider it.  We Avould, hoAvever, add, that
in some cases the disorders of  the general health, produced by the develop-
ment of these abnormal pregnancies, have been so great as  to prove fatal,
without there being  any >discoverable  lesion to account  therefor.   Thus,
says  M. Jacquemier,  the autopsy reveals neither rupture of  the cyst, nor a
trace of hemorrhage,  peritonitis, nor process of elimination going on in the
cyst: the unfortunate sufferers appearing to have succumbed under a kind
of exhaustion of vital poAver.
   The development of the cyst ceases with the  life of the foetus, the circula-
tion  in its Avails becomes feebler, the vessels Avhich maintain the connections
necessary to the support of the fcetal life, gradually become  atrophied, and
even in great  part  obliterated; so that the  foetus  and its envelopes are
thenceforth a foreign  body Avithin the. organism of the mother.  Occasion-
ally, the latter becomes accustomed to their presence ; for some Avomen carry
a fcetal cyst for  many years Avithout their health  appearing to be much
injured thereby: Ave have mentioned what transformations the foetus and its
envelopes  are liable  to undergo in such cases.   Sometimes,  hoAvever, the
weight of the tumor, and the pressure which it  exerts upon the neighboring
parts, disturb the general functions so seriously as to make the female de-
mand earnestly to be  relieved  of the cause of her suffering by an operation.
   Whether  the tumor be the  cause of acute pain to the woman or not, it is
likely, after the lapse of  an indeterminate period, to become  the seat of an
inflammation, Avhich  extends  rapidly to- the neighboring parts.  Inconse-
quence of this inflammation, which may progress Avith greater or less rapidity,
adhesions  are contracted  betAveen the Avails of  the cyst and the parts adja-
cent ; ulceration begins at  the points of adhesion, perforation folloAvs Avith
the formation of  communications  betAveen  the cavity of the cyst and that
of one  of the neighboring organs, or with the exterior, in case  the abdominal
walls be invaded by the ulceration.
   The foetal debris find their  Avay to the exterior, at  times by the bladder,
rectum, vagina, and  even the stomach,  at others by means  of an  abscess
opening into the perineum, or through  the anterior abdominal parietes.
Furthermore, since these  latter communications are common  to all kinds of
extra-uterine pregnancies, Ave can understand that the situation of the foetus
in the sub-peritoneo-pelvic variety, Avhich, as before stated, is the most deeply
engaged in the excavation, will render its expulsion by the vagina or rectum
more frequent than in the others.
   Most generally some one of  the above-mentioned organs serves as an ex-
cretory canal, but in certain cases several of them are simultaneously attacked
bj the adhesive inflammation;  of  course, ulceration and  perforation soon 
598
PATHOLOGY  OF  PREGNANCY.
folloAv ;  and the wreck of the foetus escapes at once by the anus, the vagina,
and through a fistulous opening in the abdominal Avails.
  This  expulsion  greatly endangers the  mother's  life — for very often the
inflammation and suppuration of  the cyst,  by spreading  to  neighboring
parts, exhausts the patient, and sooner or later she succumbs.   In the more
fortunate cases, the sac is  gradually emptied, cleansed, and contracted, the
suppuration ceases, and the Avound cicatrizes, or  at least becomes a simple
fistulous ulcer.
  The long-continued suppuration, and consequent exhaustion of the  patient's
strength, will always render a complete expulsion of the foreign bodies highly
desirable, for nothing else will put an end to  the suppuration and alloAV the
fistulas to close.   Unfortunately, the hair, teeth, and pieces of bony substance
adhere very strongly to the walls  of the cyst, in  Avhich they seem to be im-
bedded, and are detached Avith difficulty ; yet it  is very necessary to be  care-
ful not to use too much force for  their extraction,,  lest the walls of the cyst
should be torn, and an opening made betAveen it and the cavity of the  peri-
toneum, rendering liable the occurrence of  a  quickly  fatal peritonitis.  The
interference of the surgeon should be restricted  to the dilatation of all the
openings and fistulous passages by means of compressed sponge, to cleansing
injections within the  cyst, and to the withdrawal, by means of  forceps, of
the completely detached portions of bony matter which present themselves at
the openings.   In no  case, I repeat, should  any effort  be made to detach the
strongly adherent portions.

  § 4.  Causes.
  Nothing can oe more obscure than  the causes  of extra-uterine pregnancy,
although numerous facts Avould seem to prove that  the action of terror, coin-
ciding with the time of fecundation, may produce such an effect as to prevent
the impregnated ovule from being ulteriorly transported into  the uterus;
but notAvithstanding the high authority of those Avho  have adopted  this doc-
trine, it does not appear to be admissible, since the ovule does not  abandon
the ovary at the moment of conception, but several days after or even several
days before this event.
  M. Dezeimeris brings forward one case that seems to prove that a bloAV on
the hypogastrium a short time after a fruitful coition may be the  cause of
this anomaly, though I should rather refer it to a particular disposition of
the mother's organs.   When, indeed, we consider the narroAvness of the tubal
canal, we can readily conceive that any deviations, even slight ones, of the
Fallopian  tube, any paralysis  or  spasm, an  excess or defect of length, an
engorgement, the swelling and ulceration of the mucous membrane, or hard-
ening of its pavilion, or any retraction at  the internal orifice; in one word,
all the anomalies and alterations described  by authors may take place there,
and give rise to it.  I myself have  had an  opportunity of observing two
cases (reported in the Bulletin de la Societe Anatomique) in Avhich  the tube
was obliterated  betAveen the point where the ovule Avas  developed and the
internal orifice of this canal.1
  1  The  obliteration of the tube in the case referred to  is so remarkable an occurrence,
that I endeavored to learn, by referring to various authors, whether similar cases had 
OF  EXTRA-UTERINE  PREGNANCY.
599
   Finally, if we take into consideration the singular anomaly described by
 M. G. Kichard (see page 86), we may suppose that the fecundated  ovule

 been reported.  Most of them have  not  observed the state of permeability or imper-
 meability of the tube;  others, on the contrary, have given their attention to this point.
 Thus,  Smellie (vol.  ii. p. 77) quotes an observation of Dr. Fern, in which  an  oblitera-
 tion, or rather an excessive retraction of the tube was described.  In the memoir of
 M. Breschet, on interstitial pregnancy, I found several  instances where the  oblitera-
 tion of the uterine orifice was  also noted.   M. Mayer communicated a case to M.
 Breschet, where the foetus was developed in that part of the tube which traversed the
 substance of the uterine walls; M.  Mayer further remarks, that the right tube was
 dilated at its fringed extremity, contracted in the uterine portion, and was completely
 obliterated at about three lines from the uterus; the left one, in  which  the ovule was
 developed, was permeable as/ar as the morbid mass, but from this point to the uterus
 the canal ceased.  He adds: It is  very probable that an induration of the uterine
 substance formerly existed at the insertion of the left tube, which caused the occlusion
 of its  orifice, and furnished an obstacle to the passage of the ovule.
   M. Schmidt reports that in an example of interstitial  pregnancy, of six weeks, the
 internal orifice of the  right  tube  was completely closed.  (The  ovule was developed
 on the right side of the womb.)
   M. Meniere (Archives, June, 1826) furnishes a case of interstitial pregnancy located
 in the left cornua, and he says the left tube was impermeable at its internal part.
   M. Gaide, in a similar instance  (Journal Ilebdomadaire, t. i.),  ascertained  that  the
 right tube had no uterine orifice.
   Another case is reported in the Archives.of a mortal hemorrhage produced  by tubal
 pregnancy.   The author adds: " The left tube (the ruptured one) formed a consistent
 membranous sac, and its free extremity embraced the whole ovary; below the dilata-
 tion and in the uterine portion, the canal was completely obliterated in such a manner
 that it was wholly impossible to reach the uterus through it."
   I might cite a  greater number of  examples, but I think these  will suffice to prove
 that an obliteration of  the tube is  sometimes met with in extra-uterine pregnancies;
 for whenever we find the canal effaced between the ovule and uterus in a  tubal gesta-
 tion, it seems natural to suppose that, if  the  product of conception  has  been  arrested
 in the  course it has to travel in order to reach the uterus,  some mechanical obstacle
 has opposed its passage, and that the effacement is the cause of such hinderance in the
 progress of the  ovule; consequently, the cause of this variety of gestation, at least,
 seems  to me clearly indicated.  But how  long has the  effacement existed?   Was it
 prior or  subsequent to the conception'.'  In  reply, it may be said  that, according to
 the ideas generally admitted by physiologists, an obliteration of the tubes is an infal-
 lible ground of sterility, and when met with  in a pregnant woman it would be absurd
 t'> suppose that such an obstacle was in existence before impregnation.   In this case,
 the seminal fluid could not reach the ovule, for its only way is closed  up  and the
 fecundation cannot occur.
   Let us examine,  however,  whether this  is the only admissible opinion: it is well
 known that the obliteration of a canal, lined  internally by a mucous membrane, can
 only result either from the coagulation of a secreted liquid, the chronic engorgement
 of its walls, or from their adherence to each other; and in either of these cases it is
 necessary to suppose the existence of a previous inflammation;  but in neither of the
 instances mentioned have 1 noticed that the females exhibited any peculiar phenomena
 during the early periods, those immediately following the  fruitful coition.   Again,
 even supposing the inflammation is .latent, and  too  feeble to produce  any  sensible
 effects, we must admit that its progress has then been very slow, and that it could not
 determine an obliteration of the walls (whatever be the mode of its action) until after
 the lapse of a considerable time; now the ovule, at the earliest, arrives in the womb
about the tenth day, and therefore the inflammation and the subsequent effacement
must take place within that short pericid;  but, even admitting this hypothesis  to be
 true, some cause for this phlegmasia  in the  tube must be assigned, and the partisan? 
600                  PATHOLOGY  OF  PREGNANCY.
might, in its progress along the  tube  toyvards the uterus, escape through
one of those accidental openings, and so fall into the abdominal cavity.

of that opinion have not hesitated to assert that it is either produced by the irritation,
and the sanguineous congestion, experienced by all the genital apparatus at this period,
or by a spasmodic  condition of the tubal walls, or, further,  by the presence of the
ovule itself.
  I shall reply to this perfectly hypothetical explanation, by simply presenting a single
fact.   It is this.  In some of the cases related in the memoir of M. Breschet, and ui
several others from different writers, not only was the tube that served  as  the seat of
gestation obliterated, but also the one on the opposite side; and consequently, in these
instances  at least, we cannot admit that a spasm of the walls, or any irritation from
the ovule's passage, was the  cause of effacement, and therefore we have to believe that
it existed previously.
  From all which it follows, as a natural consequence, that, contrary to the opinion
generally received,  it is not  necessary for  the sperm to pass successively through the
uterus and the Fallopian tube, so as to approach and fecundate the ovule; and, further,
this conclusion permits  the adoption of certain  facts which have been rejected as im-
probable; for we can explain by it  how,  in  some females, there may happen to be a
complete occlusion of the os tincae at the  period  of labor; how, in others, the  fecun-
dation has taken place without a proper introduction of the membrum virile, the phys-
ical proofs of virginity even remaining at  the time of labor.
  But  how, then, can conception  be explained ?   Without adopting the theory  of the
aura seminalis, Chaussier, Mad. Boivin, and M. Duges thought it was only necessary for
the spermatic fluid  to be deposited  at  the entrance of the vagina, so that,  by absorp-
tion, it might be taken  into the circulation,  and then be brought back through the
blood-vessels to the ovary, where the fecundation occurred.   This hypothesis would,
indeed, explain all the anomalies; but  it is not  founded on a  single anatomical fact,
nor yet upon any direct experiment, and further,  it is at variance with the researches
of modern ovologists; so of course I shall not dwell further upon it.
  Perhaps comparative  anatomy might  throw some light  on  the question  before us:
thus, in certain mammalia, such  as the hog, cow, &c, the Fallopian tube is not the
only canal that affords a passage to  the sperm;  for M. Gartner, of  Copenhagen, has
announced the existence of a particular duct in  these animals, which extends from the
external parts through  the  substance  of  the broad ligaments.  In 1826 lie  came to
Paris, and, conjointly with M. de Blainville, made some new researches on  this point,
the results of which the French naturalist has communicated  to  the public in the Bul-
letin de la Sociite Philomatique, t. 9, p.  109, 1826.   The latter says, that if the vagina of
a young sow  be carefully examined, a particular canal will be discovered, having its
external orifices on each side of the meatus urinarius, and running through the mus-
cular fibres of the vagina; it becomes contracted near the  neck  of the uterus, but does
not the less continue in  the uterine tissue.  This  canal at  first follows the body  of the
womb, then abandons it, and runs in the substance of the broad ligament  parallel to
the corresponding cornua and close to the origin of the  Fallopian tube, where it is
lost by seeming to spread out, or  to subdivide into two or three filaments,  which can
scarcely be distinguished from the vessels, and  more especially from  the proper tissue
of the  broad ligament.
  M. de Blainville says  he has searched in vain for similar canals in women, but he
has not met with anything of the kind.  Analogy, however, renders their existence
probable in the human species; and this probability becomes  still stronger from the
account of a case  communicated by M. Baudelocque to  the Academie  de Medecine
(Arch,  de Med. 1826), as a unique anomaly in  the  science; although it is  a very sin-
gular fact that  Dulaurens, according to the report of Mauriceau (Traite des  Maladies
des Femmcs Grosses, p. 12, t. 1), had several times observed that the tube, after arriving
ax the angle of  the uterus, separated into  two distinct canals, the larger and  shorter
of which was inserted in the fundus uteri,  while the other, being narrower and longer,
terminated at the neck,  near its internal orifice. 
OF EXTRA-UTERINE  PREGNANCY.
go:
  ;;• 5.  Treatment.

  It is evident that no operation could  be attempted  in the earlier months
of pregnancy, even if we should be fortunate enough  to ascertain with cer-
tainty that the ovule was not developed in the uterus.
  It is my opinion, however, that frequent  copious bleedings should be  re-
sorted to in such cases, for the double purpose of causing the  death of the
foetus, and of preventing (possibly) a congestion, or rather too great a deter-
mination of blood toAvards the point  at Avhich the ovum is being developed.
  Indeed, it seems clear to me, that  not only does the constantly increasing
weakness of the Avails of  the cyst, but also  the local congestions so common
during pregnancy, contribute to render rupture of the  cyst more frequent.
  Venesection, practised  within the  limits authorized by the general health
of the patient, will be the more indicated here, as its  unfavorable influence
on the child's life is not to be dreaded, since its death is the most fortunate
event that  could occur.   Might this latter result  be obtained  by passing
electric shocks through the cyst?  Still, if no obstacle can be opposed to the
constant development of  the foetus, every operation  must be  proscribed  at
this period for extracting the foetus from its mother's body, because an opera-
tion Avould  be  as  dangerous as the  anticipated  accident.   Even when the

  Dc Graaf (Opera Omnia, p. 212) thought he had found canals  in  women,  similar to
those described by M. Gartner as existing in certain mammalia.
  Lastly, Mad. Boivin  declares she has met with cases analogous to  the bifurcated
canal of M. Baudelocque.   Hence, in these examples  at least, there  is good ground
for supposing that a  conception may occur,  even when  the internal orifice of the tube
is wholly obliterated.
  Now  if,  as  Mauriceau and Dulaurens  say (whose researches the modern authors
seem to have entirely overlooked), such anomalies were found at a period when dissec-
tions were  much more rare  than  at the present time, we may conclude that, if the
writers of our own day have not realized that disposition, it is because their efforts
are not directed to the  same end.
  I shall close these remarks by bringing forward a case, reported by M. Reynauld, in
the second volume of the Journal Hebdomadaire, An. 1829, as follows : A young woman,
aged 21 years, died at La Charite" in consequence of a vertebral caries.  At the autopsy,
the uterus was found as large as the pregnant organ at six weeks, and its enlarged
cavity was occupied by a false membrane having just the same shape, but in which no
  -ening was discovered.  The adhesions  to the walls were easily broken up,  and three
or four ounces of a yellowish liquid were  found inclosed within.  No  trace of the
internal orifice  of the  tubes existed, and they  Avere equally obliterated at the free
extremity.  The long diameter of the ovaries exceeded an inch in length,  and their
surfaces exhibited evident traces of numerous cicatrices.  Both of  them contained in
their interior a rounded body of a brownish-red  color (a true corpus  luteum),  and
small fibrous pouches  were detected in  several places, with wrinkled and retracted
walls.  Numerous little ovoidal bodies, about the size of  hemp-seed,  resembling the
ovules, existed along the course of the tubes and in the thickness of the broad  liga-
ment.
  It was very remarkable in this case that, notwithstanding a complete obliteration
of the  tubes, the organs  of  generation we're found in  a condition  similar  to what is
observed at the commencement of the geiuiative action.  However, I shall  deduct no
direct, conclusion therefrom; but I would ask your attention to  the  confirmation it
affords of the ideas promulgated in this report (Report of M. Cazeaux, extracted from
the Bulletin de la Societe' Anatomique.) 
602
PATHOLOGY  OF  PREGNANCY.
spontaneous rupture of the cyst, during  the  early stages, occasions a just
fear of mortal hemorrhage, we can only employ those general means Avhich
are the best calculated  to  prevent profuse  discharges, such  as rest, refrig.
erants, etc.   Again, supposing  that a  well-marked case  of extra-uterine
pregnancy has advanced almost  to term, or that the labor has actually
commenced, Ave may still justly dread  the laceration of the cyst as a conse-
quence of the expulsive efforts;  and the  question then arises whether gas-
trotomy, which has been successfully practised in similar cases, ought to be
resorted to.   If the child's safety be alone considered, this question is easily
resolved.  But is not the life of the mother almost necessarily compromised
by such an operation ?
  How shall we persuade the patient, Avhen the proper period for operating
has arrived, if she herself  does  not suspect the danger she  encounters by
refusing ?  Or hoAv, indeed, can we ourselves decide, Avhen the possible con-
sequences are foreseen, the Avhole difficulties of a delivery  appreciated, and
the necessity staring us in the face of leaving  open in  the abdomen a vast
cyst, the inflammationand suppuration of which are so difficult to dry up,
and are of themselves sufficient to endanger the sufferer's life ?
  In such cases, who can doubt, says M. Dezeimeris, that if  there was any
measure  at all that could suspend the commencing labor, the ties of human-
ity alone would render its employment a duty ?   And I fully embrace the
same opinion.
  Now among the  means  calculated to  restrain the ordinary uterine con-
tractions, I knoAV of nothing more serviceable than opium, when  exhibited
in large doses per anum, and  I  certainly should not hesitate to employ it
under these circumstances ; ■ but if the labor continues, notAvithstanding its
use, gastrotomy may then be authorized.
  The cyst is generally opened  through  the abdominal parietes, the place
of selection being the same as in the common Csesarean operation, though,
in case  the head be felt through  the vagina during  the  expulsive efforts,
less danger Avould certainly accompany an incision through the Avails of the
latter.  The child may be extracted by turning, or by the forceps, if neces-
sary.   In tAvo cases, one of Avhich is attributed to Lauverjat, both mother
and child Avere saved by an  operation of the kind.  In three other cases,
collected by Burns,  the child was extracted alive, but the mother perished.
  Finally, it is evident that if a prolonged labor has produced a rupture of
the cyst, it is very doubtful whether gastrotomy could be successful.
   The first efforts should  be  directed toAvards moderating the hemorrhage,
and Avhen the first dangers have been  removed, every means of preventing
and opposing consecutive inflammation should be energetically employed.
   But the primitive phenomena once calmed, Avhether there be a  rupture or
not, our art may evidently interpose to prevent  the consecutive  accidents
that have been enumerated, and Avhich compromise to  so great  an extent
the health and even the life of the patient.  When the inflammatory symp-
toms have  ceased,  it  is  proper to wait; and  especially after the cyst  is
ruptured, hasty action becomes unnecessary.
   In fact, a considerable period is requisite  in such cases for the develop-
ment of "a new cyst around the displaced parts, and a certain length of time 
OF  EXTRA-UTERINE PREGNANCY.              603
 is necessary for the adhesions to form betAveen them and the adjacent parts,
 and it would  be exceedingly rash to interfere with this  salutary action  by
 any inopportune operation on our part.   In old  abnormal pregnancies, the
 resources of art vary Avith the particular case.  Sometimes, indeed, an elimi-
 natory effort has already commenced by an inflammation of the integuments
 placed just in front of the  tumor, whereby an abscess  is formed;  and the
 only question then is, whether to open it, or by suitable incisions to enlarge
 the spontaneous solutions of continuity ;  in either case Ave encounter a vast
 abscess,  which must be emptied and cleansed by the usual methods.
   When some portions of the foetus get into the bladder, and we are assured
 of that fact by  the use of the catheter, the operation for stone may be prac-
 tised either through the vagina or by the hypogastrium.  Again, a Avoman
 may present herself with  an extra-uterine foetus of one or several  years'
 standing.  Can the resources of art afford  her any relief?  We reply, that
 if the gestation  is a source of severe suffering, and it renders  her incapable
 of discharging her duties; and if, besides, the tumor may be reached through
 the vagina without difficulty, the  vaginal incision  should  doubtless be per-
 formed.   But if  she  is otherwise in good health, Avould it be prudent to
 interfere for the mere purpose of anticipating the accidents  to Avhich  she
 will probably be aftenvards exposed?  Or is there any ground for hoping
 to  extract the  foetus  en masse, by a prudent and  methodical operation?
 This last  question is far more difficult  to solve.  In a case  of this kind,
 where the  head of the foetus, from being Avedged at the superior strait, could
 readily be felt through the  posterior superior part of the vaginal parietes,
 I kneAV Professor P. Dubois (notAvithstanding sharp opposition from several
 of his brethren  in consultation) to resolve  upon  incising freely the vaginal
 wall, as well as  the cystic envelopes, intending to  apply  the forceps  on  the
 head, and  thus, extract the foetus  bodily; but  the Avails of  the cyst and
 vagina having  been  cut  through, an  intimate  adhesion was discovered
 betAveen  the former and the foetal  head, Avhich caused the operation to  be
 abandoned.  It was not Avithout benefit, hoAvever, for in the course of a feAV
 days it Avas folloAved  by the discharge of a putrid mass, comprising all  the
 soft parts of the foetus ; the  detached bones of the skeleton Avere gradually
 extracted by the aid of long pincers, and frequently repeated injections ; the
 cystic Avails contracted sloAvly; and Avhen, at length, nothing remained, and
 the parietes Avere cleansed, the opening gradually closed up, and by the end
 of tAvo months the patient Avas completely cured.   At the time of operating
 she had been pregnant tAventy-tAvo months.
  This plan, I think, ought to be folloAved  up in similar cases, more espe-
 cially if  the female's health is visibly affected.
  Incision  by the  rectum has been  practised in some few instances Avhere
 the vulva Avas obliterated.
  Finally,  gastrotomy alone Avould be practicable when the foetus, from its
high situation in the abdomen, is inaccessible by  the vagina or rectum; but
this operation must be regarded as the last  resource, and only to be resorted
to where  the patient's life is seriously endangered. s 
PAET  V.
 OF DYSTOCIA, OE PEETEENATUEAL AND PAINFUL LABOES,

   ALTHOUGH labor is a natural function, and the resources of the organ-
      ism are usually sufficient for its accomplishment, yet there are a num-
 ber of circumstances which  may interfere Avith the work  of nature, and
 render the process difficult, dangerous, or even Avholly impossible.  It is to
 the exposition  of those difficulties and dangers, and more  particularly to
 the indication of the appropriate measures  for preventing or for remedying
 them, that the fifth part of this work is devoted.  In it will  be pointed out
 the difficulties and accidents which may complicate labor and demand  the
 intervention of art.
  The causes that render a labor either difficult, impossible, or dangerous,
 and which therefore require  the more or  less  active interposition of the
 accoucheur, are  numerous, varied, and far from ahvays having the same
 mode of action; some, indeed, operate  only by  enfeebling or reducing  the
 forces necessary for the expulsion of the child, while others constitute an
 obstacle to its delivery by occasioning  a disproportion betAveen  the dimen-
 sions, of the pelvic canal and those of the body that must traverse it, thus
 rendering the most  poAverful  contractions  of the womb entirely nugatory.
 On the other hand, Avhen all  the conditions are  apparently most favorable
 to a natural labor, Ave may find a number of accidents suddenly manifesting
 ;hemselves, of a character dangerous to the lives of both mother and child.
  Consequently, as regards the causes that  may  thus  interfere Avith the
 regular  process  of  nature,  Ave may distinguish three different groups of
 difficult labors, namely:  1. Those rendered difficult, impossible, or  danger-
 ous, by a  deficient or excessive  action of the expulsive forces.  2. Those
 rendered difficult, impossible, or dangerous, by obstacles to the expulsion
 of the foetus.  3. Those  complicated by accidents liable to endanger  the
life or health of the mother and child.
  The term accident is more especially  applied to any morbid phenomenon
occurring  during labor, liable to be rapidly fatal to either mother or child.
These accidents, in the  above  restricted sense, are, fortunately, but few.
They are  on the part of the mother:   1.  Eclampsia.   2. Eupture of  the
uterus.  3. Hemorrhage in its various forms.   On the part of the foetus,
the  only accident to be apprehended  is prolapsus of the cord  or  its com
 pression.
                                                             604 
EXTREME  SLOWNESS OF  LABOR              605
                           CHAPTER  I.

 OF LABORS RENDERED  DIFFICULT, IMPOSSIBLE,  OR  DANGEROUS, BY
    DEFICIENCY OR EXCESS  OF ACTION IN THE  EXPULSIVE FORCES.

   In practice, we meet with numerous cases  in which the position is favor-
 able, the  organs of the mother and child Avell  formed, and in Avhich  none
 of those grave  complications, hereafter spoken  of, that have given rise to
 the title preternatural labor, are  met with;. but  in Avhich, notwithstanding,
 the different stages of the labor are not accomplished Avith the customary
 ease or regularity.   Noav,  everything  seems so admirably arranged in the
 works of nature, that the least deviation is sufficient to interfere with  their
 accomplishment; and whether this  deviation be dependent on an unusual
 sloAvness or an excessive rapidity in  the course of the phenomena of parturi-
 tion, it may prove detrimental, in either case, to the mother  or her child,
 and require the  intervention of art  just as imperiously as would  a hemor-
 rhage or a contraction of the pelvis.  We therefore believe it Avill prove ser-
 viceable to treat, Avith a little more  detail than has hitherto been done, of
 the causes and proper measures for  preventing the disastrous  consequences
 of extreme sloAvness or a too rapid progress of the labor.


                           ARTICLE I.
                OF  EXTREME SLOWNESS OF  THE LABOR.
  Whilst  stating (page 297) the usual duration of labor, Ave Avere careful to
 remark that it  Avas  often  prolonged beyond  the fixed period, and  that a
 duration of eighteen or tAventy hours, in primipara? especially, could not be
 regarded as an alarming circumstance; but that, in  all cases, Avhere more
 than tAventy-four hours have elapsed from  the time  of its  commencement,
 serious accidents might result therefrom, either to the mother or the child,
 which should ahvays be prevented  by removing immediately the cause of
 this excessive sloAvness.
  In  natural labor, the phenomena occur with  such a marked degree of
 regularity that, as regards  the duration, the period of dilatation of the cer-
 vix is to that of the expulsion as two or three  to one; though it is proper to
 state that  the delay may be manifested during either the first or the second
 stage, and then, of course, this proportion no longer exists.  This distinction,
 Avhich might serve to establish a classification  of the  causes that retard the
 labor, if, indeed, they do not make their influences felt in all stages,  merits
 a particular attention with regard to the prognosis;  for, although  the  first
 stage  may be prolonged without danger, the second, on the contrary, cannot
 pass  beyond certain  limits Avithout  greatly endangering the health  of the
patient, and oftentimes the  life of her child.  It is found that the latter is lost
at least one time in four, Avhen the head remains in the excavation  longer
than seven jor eight hours after the complete dilatation of  the os uteri,  and
the rupture of the bag of waters, whilst it nearly always survives when the 
606
DYSTOCIA.
first period is prolonged even to forty, fifty, or sixty hours and more.1  Be
sides, in the latter case, there are scarcely any symptoms worth mentioning
presented  by the mother, for the great fatigue  caused particularly by the
loss of sleep, and in nervous women, a considerable irritation, depression of
spirits, and alarm,  are about the  only inconveniences that  result from it;
since the contraction, although feeble, returns at regular intervals, and the
labor makes  some  progress, notAvithstanding it is  sIoav.   But Avhen the
period of expulsion is extended beyond ten or tAvelve holirs, the pain, as  a
general rule, is found to become irregular, both in its returns and intensity;
and, although it be sometimes more severe and frequent, it is in reality less
efficacious, to such  an  extent, indeed,  that  the foetus really  seems to be
retrograding  instead of advancing; in a Avord, there  are uterine pains, but
no expulsive  contraction.
  The local  disorder is  accompanied, or at least is  soon folloAved, by a vio-
lent trembling; the patient has an inclination to vomit, and  even throws up
bilious matters;  she is uneasy, excited, and changes her position every
moment; the skin  is hot and dry; the pulse runs up to a hundred or  a
hundred and fifty per minute; the tongue is dry, and both it and the teeth
are covered Avith a dark coating.  The vagina and cervix are hot, and sensi-
tive to the touch, and a yelloAvish  liquid escapes from them, Avhich occa-
sionally has a fetid odor; the pressure of the child's  head on  the neck of
the bladder prevents the emission of urine;  and the  parts that line the
superior  strait and the pelvic excavation, being compressed for a long time
by the head, may become  inflamed or even  gangrenous; which complica-
tions may subsequently  prove a source of the most serious accidents.
  If the woman still remains  undelivered,  these symptoms   augment in
intensity in a frightful manner; the vomitings become more frequent, and
the abdomen more distended;  the excitability  of the  patient  knoAVS no
bounds ;  the  pulse is more and more feeble and frequent, and  she falls into
a half stupid or a semi-delirious condition,  Avhich  is soon  terminated by
death.   It is  scarcely necessary to remark that, in the latter case, the life
of the child is also  most seriously compromised.
  We have felt bound to point out these differences in the danger of the
symptoms, in order to prove the necessity of the distinction  Ave have made;
and Ave may now proceed to study the divers  causes Avhich, at times, retard
the course of labor, and also to  indicate the means calculated to remedy
them, Avithout the necessity of repeating in each, that the dangers to which
they expose the mother and child are much more grave in the  second  than
the first  stage of the labor; and that, although in the latter Ave may trust
longer to the resources of the organism, in the former, the  intervention of
art is demanded at  an earlier period.
  The causes that  may retard the delivery depend  either on the patient's

  1 The following summary, which I take  from Churchill, is  calculated  to confirm the
above: in one  hundred and thirty-t.hree  cases, Avhere the  first stage  was prolonged
from twenty-four to sixty hours, only eight children were lost; in  eight that lasted
from sixty to  a hundred hours, but one died; and in three cases ranging from  a
hundred to a hundred and  seventy-seven  hours, not a single death  occurred.—
Churchill,  192. 
                EXTREME  SLOWNESS OF THE  LABOR.            607

 general condition, or on a special modification of the genital organs;  and,
 in both cases, their influence may be exerted at the commencement, or only
 at a subsequent period of the labor ; consequently,  Ave have to consider the
 three folloAving conditions: 1, where the pains or contractions are slow or
 feeble in  the commencement; 2, Avhere, after having set in with consider-
 able energy, they aftenvards relax, diminish, or even cease altogether; and
 3, where  they exhibit great irregularity in their duration, intensity, and
 returns ;  an irregularity that almost wholly destroys their expulsive action.
 The English writers  have applied the term  tedious labor to all these vari-
 eties, and this appellation merits our  adoption, for it is perfectly adapted
 to the cases Ave are about to describe.

   § 1.  Of  Slowness or Feebleness of the Contractions.
   A slowness  or feebleness of the  contractions may  occur at the A'ery com-
 mencement of the  labor, and persist throughout  its Avhole duration;  the
 pains are  quite feeble, the dilatation of the os uteri is effected very sloAvly,
 and at a rather later  period they seem unable to effect the expulsion of the
 head.   This sloAvness of labor may be  dependent  either on the  Avoman's
 general condition, or on  a  local  disposition of the Avomb.   In  the former
 case, it  occurs in women endoAved Avith a delicate or  debilitated constitution,
 or in those accidentally enfeebled by chronic diseases.
   It should, hoAvever, be borne in mind that, as Avas stated, page 150,  gen-
 eral debility of the muscular system has but  little  influence upon the con-
 tractile power of the uterus, the latter being often very strong, as in  con-
 sumptive  patients for example.  The labor sometimes progresses even more
 rapidly than usual  in such individuals, for ay hen the uterine fibre preserves
 its contractile powers, the slight resistance at the floor  of the pelvis seems
 to expedite  the delivery.
   Generally speaking, there is  nothing to be done but to  encourage  the
 woman  to have" patience, and to make use of  some slight stimulus, such as
 broth, claret, or a feAV spoonfuls of sherry-Avine; in a Avord, to  sustain  her
 strength as much as possible, resorting to the ergot, or preferably to the
 forceps, as soon as the cervix is sufficiently dilated, if the uterine contraction
 is too feeble to effect the engagement and subsequent expulsion of the head.
  But Avhere the sloAvness of the labor is to be Avholly attributed to a local
 condition  of the Avomb, the determining causes ought to be carefully sought
 after, as they are variable, and require the employment of different means;
 and hence we learn the importance of a correct diagnosis.
  A. An excessive  distention of the uterine Avails, Avhether dependent on
 dropsy of  the  amnios or on the presence of several children in the womb,
 should be  placed in the first rank of these causes.  In fact, this overdisten-
 tion  renders the  uterine walls much thinner than usual, benumbs them in
 some  measure, and  diminishes their  force  of contraction.   Independently
 of a considerable enlargement of  the belly, and the unusual elevation of
 the  head  tOAvards the end of  gestation or beginning  of labor, which is
 worthy  of attention,  there is  something  then altogether peculiar in  the
character of the pains.  The contractions, though feeble  and only returning
at distant  and  irregular intervals, reduce the patient to a state of anxiety 
608
DYSTOCIA.
 and continual suffering;  and, if we may judge from  her expression, seem
 to  implicate the  fundus  alone, without extending  loAver doAvn, for  the
 amniotic pouch, if still unruptured, scarcely bulges out during their  con-
 tinuance.  Under such circumstances, Ave should carefully avoid  resorting
 to stimulants, which Avould have no other effect than to  augment her suffer-
 ings, without rendering the contractions any more energetic.  The rupture
 of the membranes is here the  only remedy,  because,  by facilitating  the
 discharge of the waters, we relieve the excessive distention of the organ, as
 Avell as the continual distress thereby occasioned, and then the genuine pains
 become more frequent and more effectual.
  B. The slowness and feebleness of the  contractions may likeAvise depend
 on  a sanguineous  engorgement,  or  plethora,  of  the  uterine tissue.  This
 condition, Avhen  it exists, can be recognized  by  the  folloAving signs :  the
 pains are at first quite energetic, but soon diminish, both in frequency and
 intensity; the  cervix uteri is soft, supple, and non-resistant, but  the pre-
 senting part does not engage during the pain, Avhich latter is equally diffused
 over the whole abdomen ;  the phenomena of general plethora nearly ahvays
 manifest themselves  at the same time; thus,  the respiration is laborious,
 the pulse hard and  full,  and the pains  very  irregular, both in force and
 frequency.  Bleeding in the  arm, proportioned to the general condition of
 the patient, is then the best remedy.
  c. Or  it may be OAving to a debility, or an imperfect  organization  of  the
 uterus itself,  though the patient may otherwise  be  perfectly healthy, that is,
 the muscular apparatus of the womb may be  deficient in contractile force,
 while the other  muscles  of  the organism  are endoAved  Avith  their usual
 energy.  The dilatation of the os uteri is effected sloAvly, for notAvithstand-
 ing the cervix  no longer  offers any resistance,  the organ appears incapable
 of  determining the  expulsion of the foreign  body  it  encloses.   In such
 cases, the ergoted rye is the only article capable of stimulating the enfeebled
 contractions.  The most certain  procedure Avould be to apply  the forceps,
provided the dilatation be  sufficient to permit it.
  Dr. Franck, of Wolfenbutten, has recently recommended the employment
of electro-magnetism in cases marked by Aveakness or absence of the con-
tractions, giving  four observations, in Avhich, he  states, it Avas used with
advantage.   The perusal of these cases  fails to convince me of its utility.
Besides, the  difficulty of obtaining a proper apparatus Avhen Avanted, will
render its employment a thing of rare occurrence.1
  D. According to Baudelocque, the death of the child Avould have the  un-
favorable effect of diminishing and enfeebling the  utering contractions: but
M. P. Dubois remarks, and very justly, in our  opinion,  that, if the Avoman
 is otherwise healthy, this event has  no influence  over  the progress of  her
 labor; and that, if it sometimes happens that the delivery is more painfully

  1  The author's apparatus is composed of a concave metallic plate, moistened with
 salt water, applied upon the lumbar region, and connected with the positive- pole of a
 rotating electro-magnetic machine.   The  negative conductor is attached to a hollow
 cylinder filled with salt water, and passed into the  vagina to the neck  of the womb.
 The electro-magnetic current  is  applied for five or six minutes between the contrac-
 tions, and suspended during their continuance. 
EXTREME SLOWNESS  OF  THE  LABOR.
609
 accomplished where the infant has been dead for some time, it is only because
 the disease of the mother has been the occasion of its  death, and that her
 forces are Aveakencd by the antecedent malady.
   E.  Finally, a premature rupture of the  membranes may have the same
 effect, in relaxing' and weakening the  pains, as their more retarded rupture;
 and the folloAving phenomena may then take place:  if the head happens to
 be very large, and is low doAvn when this occurs, it becomes applied directly
 to the orifice,  and retains a great part of the Avaters  behind  it, and if the os
 uteri is sufficiently dilated to permit  the  head to engage freely, no water
 escapes, even during the contraction ;  but if the dilatation is still imperfect,
 the Avaters leak aAvay drop  by drop,  it is said, at the commencement and
 termination of each pain, AA'hich  latter is Avholly employed in thus gradually
 expelling the  amniotic liquid, without  contributing  in any wise to the
 enlargement of the  cervix.   The  same phenomenon is observed when the
 membranes  yield at a higher point of the pouch, one not corresponding at
 all to the neck of the uterus, for in such cases but little water escapes at the
 moment of  the rupture, and each  pain is likewise accompanied  or folloAved
 by a greater  discharge without  accelerating the dilatation  in the least.
 However, this circumstance,  according to M. P. Dubois, does not merit all
 the importance usually ascribed to it, since, properly speaking, the expul-
 sive process has not commenced, and the foetus, protected by the surround-
 ing liquid, cannot suffer in any Avise  from the slowness of the labor, and
 therefore, in most cases of this kind,  there is nothing to be done.  If, how-
 ever, the labor lingers too long, Ave might folloAv the plan generally advised.
 and introduce two fingers into the cervix uteri, and push  up  the  child's
 head, for  the  purpose of promoting a more ready escape of the waters, or,
 indeed, of lacerating the inferior segment of the membranes, if the original
 rupture had occurred at a much  higher point.  Nevertheless, this manoeuvre
 is only to  be resorted to Avhen the dilatation is already Avell advanced, for it
 is evident that, if all the Avaters should escape a long time before  the
 enlargement of the neck, the infant might suffer from  the  prolonged and
 direct compression of its body.

   § 2. Relaxation or Suspension  of the Pains.
   It is not at all unusual to find  a  labor Avhich has heretofore been progress-
 ing favorably to become at once arrested, and the pains, which up to that
 time were strong  and frequent, to  relax or even disappear altogether.   Of
 course, the indications  Avhich these phenomena present will necessarily vary
 with the causes that have given rise  to them, and therefore the physician
 ought to search them  out with  the greatest  possible care.  Among those
 which may thus diminish or suspend  the  pains, the  following are  usually
 enumerated, namely:
   A. Any vivid  moral  impressions operating  during the labor, any unex-
 pected neAvs or sharp  discussions, the announcement of a child of an un-
 wished-for sex, and the arrival  or presence of persons  disagreeable to the
lying-in  Avoman, may determine a cessation of the pains; and in these cases
the removal of the cause is the only remedy.  But, unfortunately, it is not
ahvays an  easy matter to ascertain  what that cause may be, and it is left to
      39 
610
DYSTOCIA.
the prudence and sagacity of the medical attendant to penetrate the mj atery
and relieve the trouble.
  B. A pain  caused by the coincidence of some malady, either existing an-
tecedent to, or appearing during the labor, such as distressing and repeated
vomitings, sharp pains in the muscles of the  back and abdomen, gripings in
the intestines, &c, &c.   In all such instances, the Avoman, experiencing an
intense  pain, which is further heightened by the uterine contraction, en-
deavors to suspend  the latter as much as possible, and  hence the accoucheur
should try to remove the cause which thus  interferes Avith the labor.   For
instance, where the emesis obstinately persists, he ought, if the patient bears
opiates  Avell, to administer a  feAV drops of  laudanum, and if not, some
aromatic drinks or antispasmodics, accompanied by narcotic lotions over the
epigastrium.   In case of acute muscular pains, embrocations Avith an opiated
liniment might  be practised over  the affected part, or a change of position
is sometimes  all that is  requisite to calm them.   If, hoAvever, as often hap-
pens, this  pain, Avhich is wholly foreign  to the uterine  contraction, cannot
be relieved, then the poAvers of nature must  be assisted  by an artificial ter-
mination of the labor.
  Those violent cramps,  which are occasionally produced by the pressure of
the child's head on  the sacral nerves, should  certainly be classed among the
circumstances  that  may relax or even suspend the uterine contraction
altogether; as occurred in three cases of the kind observed by Prof. Meigs,
of Philadelphia, where the pain was so violent that it caused the patient the
most inexpressible  anguish. The Avomen  describe this pain as similar to
Avhat would be  produced by the  pinching or twisting of a  large nervous
trunk;  they incessantly demand a prompt deliverance, and the physician is
often obliged to yield to their entreaties; besides, his  intervention may be
further  necessitated by the more or less  perfect  suspension of the contrac-
tions of the Avomb; for the  organ seems paralyzed by the violence of these
nervous pains, and Ave are  often constrained to  apply the forceps for the
double purpose of relieving the patient  from the frightful  sufferings that
torment her,  and of supplying the want of power  in the uterine efforts.
  The use of chloroform might, in all these cases, have a happy effect by
paralyzing the  animal sensibility and thus alloAving the uterus to resume its
functions.  The English accoucheurs have often used it successfully in this
way.
  c. We have already alluded  (page 393)  to the unfavorable influence that
a distended bladder might have over the progress of parturition ; and there-
fore, if the suspension of the pains could  be justly attributed to this circum-
stance, the catheter should evidently be  resorted to  at once; but if  this
operation  is  rendered impossible by the  engagement of  the head in the
excavation, recourse should be had to the application of the forceps; for the
administration  of ergot here Avould appear to be very  imprudent, to say the
least.
  D. If caused  by general plethora, Avhich  is characterized and is  easily
recognizable  by redness  of the face, headache,  throbbings in the head,
vertigo, dimness of vision,  tinnitus aurium,  agitation,  unusual force  and
fulness of the pulse, and by weariness of the limbs, it must be relieved by
general venesection. 
EXTREME  SLOWNESS  OF  THE  LABOR.
611
   E. Debility of the uterus itself is also mentioned  as a cau.c, since there
 are some women in Avhom  the  contractile force of this organ  is so easily
 exhausted that the contractions, after having proved  quite sufficient for the
 earlier steps of  the labor, diminish, or disappear  all at once, Avithout any
 other appreciable  cause than this feebleness of the organ.  In such cases,
 the patient  should be  advised to rise up and walk about the  chamber for
 some time, and it is also necessary to rub her abdomen, to titillate the cervix
 uteri, and to make pressure on the perineum; and then, if  all these means
 fail, to administer the ergot or uterine douches, and finally apply the forceps
 if necessary.

   § 3. Irregularity of the  Pains.
   The contractions may be irregular in their, progress, or they may be par-
 tial in their operation : that is, only one portion of the uterine walls contracts,
 the  rest of the organ  remaining in a state of inaction;  which irregularity
 is sufficiently explained by the  muscular structure of  the  womb.   In the
 first variety,  the  pains are recognized by the folloAving signs  : there  is not a
 complete and perfect interval between  them, they  are _ continuous, and only
 interrupted  by the paroxysms, during Avhich the intensity of suffering  is
 horrible.  In the second variety, the pain returns, it is true, at intervals,
 but sometimes it  is only the fundus, again one of the  angles, and at others,
 some part of the  body, Avhich contracts  spasmodically, Avhilst the remainder
 scarcely does so at all.   The pains  are, hoAvever, no less acute than if the
 whole organ  Avere involved; often, indeed, they are  more so, though  even
 then  they are easily  recognized by the fact of occurring  almost  Avithout
 effect, or at least  Avithout having a decided influence  upon  the progress of
 the labor.  For  during  the pain, and  even at the very moment Avhen the
 woman suffers the most, Ave may ascertain, by applying the  hand  on the
 hypogastrium, in the case of partial contraction, that the uterine ovoid does
 not present its normal regularity, and that it exhibits instead various bosses
 and inequalities;  besides, Ave can readily assure  ourselves, in all cases, that
 no impulsion  is given to the foetus, and that the presenting part does  not
 advance; as, also, that Avhere the membranes are  still unruptured  they do
 not bulge out, nor indeed  scarcely become tense during the pain.   At the
 height of the  latter, just at the moment of the paroxysm, the  presenting part
 seems, at times, to advance a little; but this progression does  not correspond,
 on the one  hand,  Avith the A'iolence of the pains, and, on the other, it is  not
 kept up, though the pains continue.  The patient is then suffering from an
 extreme agitation, she weeps and becomes despondent, and very often  her
 pulse is frequent,  developed, and febrile;  the face red and flushed ; the skin
 hot; the mind confused, and the limbs convulsively contracted.  These irre-
 gular  contractions, which have  been designated under  the  title of uterine
 tetanus, sometimes disappear of their oavh accord, though they may be  pro-
 longed for  an  indefinite length  of time.  It is  then  highly important to
 remedy them  as soon as possible, Avhich  is best done by a general bleeding
 where the Avoman is plethoric, the  pulse full  and Avell developed, and  the
face red and  flushed;  but as this is not practicable in nervous  and very
irritable Avomen, avc should  then resort  to tepid  baths, emollient injections, 
612                           DYSTOCIA.
and opiated lotions  over the abdomen, and more especially to laudanum,
given once or twice  as an  injection, in the dose of tAventy to forty drops,
diffused in three or four ounces of some mild vehicle.
  Under  the  influence of these measures, the last  particularly, the  pains
almost entirely disappear in the course of half an hour or an hour; during
which period the patient  generally slumbers, and then the good pains, that
is the natural  and  regular ones, come on, and the labor terminates happily.
  The action of opiates is occasionally much  more prompt, being felt in the
course of  ten  minutes or a quarter of an hour after their administration.  I
witnessed  this  fact  in a young primiparous lady,  Avhose labor commenced at
ten o'clock in  the morning, and the  pains progressed slowly but regularly
until  four the next morning, Avhen they assumed the  peculiar character
under  consideration; and from that moment, notwithstanding the almost
continuous suffering  and permanent contraction of the womb, the head did
not descend.   At six, I  administered opiates;  and in the course of ten
minutes, the excessive agitation Avas calmed, the  pains disappeared entirely,
then returned again a few minutes  after, at first slow and feeble, but soon
regular and energetic enough to effect the delivery in a short time.  When
the cervix participates in this  state of spasm, the employment of the oint-
ment and  extract of  belladonna, as we shall have occasion hereafter to  point
out, will be found decidedly useful; though Ave  ought to mention that the
employment of belladonna has been  objected to on the ground that it sus-
pends the pains, and paralyzes the exercise  of the contractility of  tissue
after the labor is over ; but this is an  error, for  its action is ahvays limited
to the neck, and the  latter, at most, may be paralyzed for some time.
  In the case before  us, M. Velpeau says he has used the folloAving potion
with advantage: R.—Lettuce, or wild  poppy Avater, fsiv; orange-flower, or
mint water, fgj; syrup of Avhite poppies, f|j ;  extract of opium, gr. j.
  It appears to me that inhalation of anaesthetic agents might be used with
advantage in  all  these cases  of  partial or irregular  contractions.   They
would seem  adapted to calm the over-excitement of the uterus Avith which
the pains are generally associated.  In several cases  they acted like opium,
by suspending the  contractions  for the moment,  and then enabling them to
resume their normal  regularity and efficiency.

  § 4.  Effect of Contraction  of the Abdominal  Muscles.
  The second stage of labor  is  sometimes exceedingly  slow  in very fat
women ; in whom the contractions do not cease altogether, but appear to be
ineffectual, and do not force the child's head to advance ; this impotence of
the uterine efforts has appeared to me to be much less  dependent on resist-
ances from the loAver part of the  pelvic canal, than on a default of action
in the abdominal muscles; because the thick  layer of fat, Avhich lines the
anterior walls  of the belly, must paralyze, to a certain extent, the synergic
action of those muscles, and thus deprive the  uterus of the aid Avhich  they
habitually render.   The abdominal compression, Avhich is so  much extolled
as a remedy, would then  appear peculiarly applicable; for a  circular band-
age, applied around  the body, Avould effectually replace the point d'appui,
which the contracted muscles usually furnish to  the womb; besides, as Vel- 
OF TOO  RAPID  LABORS.                    613
peau observes, this  is  too  innocent  a remedy not to be employed before
having recourse to  ergot, or to an artificial termination of the labor.

  [Admitting that contraction of the uterus is the principal efficient cause of de-
livery,  a fact proved by vivisections  practised upon animals and pathological cases
occurring  in women, it  is nevertheless true that the contraction of the abdominal
muscles and the exertions of the female assist powerfully in the expulsion of the
foetus.   Some cases would even seem  to  show that paralysis of the abdominal
muscles, making a strong voluntary  effort impossible,  has sometimes delayed de-
livery very considerably.
   A paraplegic woman attended by  M. Depaul had to be  delivered by the forceps
on account of  the slow progress of  the labor.   In  her case, the uterus contracted
regularly, and there Avas no obstacle to the expulsion of the foetus.  M. Depaul Avas
sure that the extreme slowness was due to the paraplegia.   I have myself met with
a, similar case  in a multipara whose labors before becoming paraplegic had always
been easy.  Notwithstanding the paralysis, she became  pregnant;  but  this time,
 although  the  uterine contractions Avere rapid  and powerful, it was necessary to
 deliver her by the forceps.
   The unfortunate effect of an impossibility of making sustained efforts from other
 causes is shown  by a case  of a different character witnessed by M. Depaul.  A
 young lady whose thigh had been amputated became pregnant, and during labor
 was, consequently, able to take the usual fixed support with but a single  foot.  The
 consequence was, that the necessarily badly directed  exertions which  she made
 seemed to weaken the uterine contractions.  The pelvis was well formed,  and there
 was nothing to obstruct the passage of the foetus, yet it became necessary to apply
 the  forceps and deliver her.
   To the cases just related, some of a directly opposite character may be produced;
 and I have myself  seen  delivery accomplished in  a paraplegic woman with the
 groatest facility.  The difference is  due to the fact that cases are subject  to infinite
 variety; pathological phenomena, instead of appearing separately,  are associated
 in a thousand different ways; so that in one woman the uterine contractions alone
 are sufficient to expel the foetus, whilst in  another they require to be assisted by
 the contraction of the abdominal muscles.]


                             ARTICLE  II.

                           OF TOO RAPID  LABORS.

   Although  these  are much more  rare than  the preceding  class, yet the
  accidents that may result in consequence of too prompt a delivery,  are quite
  as serious as those  produced by excessive sloAvness ; and, therefore, we must
  endeavor to supply an important omission made by most  authors, and our-
 selves likewise in the  first edition of this Avork, by devoting a feAV lines to the
  consideration of the attendant circumstances.
   Some Avomen have  the unfortunate privilege, if it  can be called such, of
 being delivered with only a feAV  pains;  and  this extreme rapidity is apt to
 characterize  every  subsequent labor.  What is still more singular, this pecu-
 liarity even seems  to be hereditary in  certain  families, in which  it is  per-
 petuated for  three  or  four generations.
   In  such cases, the rapid  termination is ahvays to be attributed either to an
 excess of energy and  frequency  in  the  uterine contractions,  or to a Avant of
 resistance in the Avails of the canal which the foetus has to traverse. 
614                           DYSTOCIA.
  Certain Avriters have attempted  to  establish  a relation betAveen tl e phe-
nomena that precede or accompany the menstrual discharge in the non-gravid
state, and the activity or sloAvness of the  contractions of the womb during
the labor;  for they say, should the periodical Aoav be difficult, laborious, and
painful, and the patient be tormented every month Avith violent colicky pains,
either before or during her terms, the irritability of the uterus,  and the
energy of the contractions, will almost invariably be  excessive in the hour
of childbirth;  but, on the contrary, there  is reason to anticipate  the  occur-
rence of sIoav and feeble pains,  Avhere the woman is advised of the return of
her menses only by the appearance of blood, and Avhen they pass off Avithout
suffering.  We do not knoAV exactly to Avhat  extent  this approximation is
true; yet Ave believe that it  is far  from  being Avithout  exceptions.   But,
hoAvever this may be, it is generally found that these very poAverful contrac-
tions are most likely to be observed in nervous and excitable  persons;
appearing  to depend, says Wigand,  upon a high  grade of irritability, the
source of Avhich, especially in hysterical patients,  seems to be centred  in the
uterus.  The moral affections are often found to have a great influence over
the  progress of labor;  and everybody knows  that where  an application of
the forceps has been seriously proposed to  the Avoman, this of itself has often
proved quite sufficient  to bring on strong  and  powerful contractions  of the
Avomb, by the fears which the instrument gives rise to, even though they had
been languishing before.
   In certain eruptive fevers, scarlatina especially, the  pains very frequently
exhibit  this character, and the  child is then expelled  with an unusual
rapidity; but it is difficult to decide Avhether this circumstance is not  rather
OAving to a Avant of resistance from the soft  parts, Avhich, like all the muscular
apparatus, have been enfeebled by the disease.
   The same thing also occurs in certain strong, robust, and plethoric Avomen;
here, however, the contractions are very strong from  the commencement of
labor; they are very painful,  last for a  long  time, and  are separated  by
short intervals.  While the pain  lasts, the patient cannot resist  the urgent
desire to bear  down, and forcibly contract all  the  muscles of her body; she
is much more  irritable than usual, and there is something peculiar in her
attitude; the head is hot; the face red and puffed up; and the pulse full
and accelerated.  In some  instances, the  intervals are scarcely perceptible,
for one pain has hardly terminated before another begins; sometimes, indeed,
the Avomb seems in a state of permanent  contraction, Avhich only passes off
after the expulsion of the foetus.  The belly is then very hard; the Avhole
body rigid and contracted ; the Avoman holds her breath, seizes hold of some
neighboring object, and, making a  loud  cry, or  grinding  her teeth, bears
doAvn with incredible force, and suddenly expels the child, together with  the
 contents of the bladder and rectum.
   But, after all, however forcible Ave may suppose the uterine contractions
 to be, they will hardly explain the rapidity of the delivery, unless Ave admit
 that a Avant of resistance in the walls of the pelvic canal exists at the same
 time; but  may not  a  very large pelvis,  a premature child, or a marked
 diminution of the normal resistance of the soft parts, so often met Avith in 
OF TOO  RAPID  LABORS.
615
persons worn out by lingering diseases,1 — may they not, we repeat, be con-
sidered as singularly favoring a too early expulsion of the child ?
  Where the phenomena of parturition take  place Avith due regularity, the
infant rarely comes into the Avorld under seven or eight hours after the first
pain, and this beneficent delay enables the parts  Avhich the  child has to
traverse to become prepared  for the dilatation  they must shortly undergo ;
the uterine orifice gradually enlarges; the soft  parts, that line the excava-
tion and the pelvic  floor, being lubricated for a  long time by  the liquids
exhaled from the Avomb, or secreted by the upper part of the vagina, become
more soft and  supple and  better  prepared for the distention  they Avill be
subjected to at the moment when  the head is born ; besides, their dilatation
being effected  under the influence of intermittent contractions, alternated
by  an interval of rest, is  sIoav and gradual, and takes place without causing
the patient any very acute suffering and  without compromising  the life of
the child; but it is far different in the case before  us, Avhere the overhasty
expulsion of the infant exposes it as well as the mother to grave accidents.
Thus, not to speak of inertia of the organ, Avhich will be treated of hereafter
as one of the circumstances that may complicate the delivery, we must note
as of possible occurrence the laceration of the perineum, vagina, and vaginal
portion of the cervix, so often produced  by the rapid passage of the  foetus
through the pelvic canal; the prolapsus of the Avomb, which, not being yet
sufficiently dilated to alloAV  the child to clear its orifice, is  forced  doAvn
beyond the vulvar ring;  the serious and  sometimes fatal syncopes to Avhich
the too rapid depletion of the Avomb exposes the patient; * and, lastly,  death
itself, produced solely from  the violence of the nervous shock  caused  b)
juch  pains.
  The child  is likewise exposed to  real  danger;  for if the membranes are
ruptured and the Avaters  entirely discharged early in  the labor,  it  must be
apparent that, Avhen  the pains become permanent,  the umbilical  cord might
be compressed between the fcetal surface and the uterine Avail, or  that the
infant itself might suffer  from  the direct  pressure it  then undergoes.  On
the other hand, if the woman, supposing herself only at the commencement
of her labor, should happen  to  be still standing or Avalking Avhen surprised
by  these violent pains, the  child may be forcibly expelled, and, striking
against the floor, be killed, perhaps, by the severity of the  fall; besides

  1  This want of resistance  from the  soft parts may be  met with in women who are
otherwise healthy, as occurred in a case reported by Dr. Rigby, Avhere a patient, in the
enjoyment of good health, was delivered by two pains; the first of which aroused her
from a sound sleep, and the second expelled the child into the bed.
  2  There is no difficulty in explaining the production of  syncope in this case, for the
womb, being distended  by the  product of  conception, necessarily exercises a greater
or less degree of compression  on  the large abdominal vessels;  and when  the foetus is
slowly delivered, as in a natural labor, this compression  diminishes in  the same pro-
portion,  and the blood  returns in  a very gradual manner into the  great trunks, in
which its course was before impeded; but  in the case before us the depletion  of the
uterus is sudden, and the vessels are relieved all at once from the strong pressure they
previously experienced, the blood flows into them in abundance, and goes  in but small
quantities (o the brain:  Avhence the latter, deprived of its natural stimulus, no longer
lots  on the heart, &c, &c. 
616
DYSTOCIA.
which, the umbilical cord  is stretched  from its placental insertion to the
navel, and, if its rupture does not result in consequence, the traction made
upon the  still adherent after-birth may be sufficiently great to depress, or
even to invert the womb completely;  though this  latter circumstance is an
exceedingly rare one.   A  rupture of  the  cord has been  observed  much
oftener; but this is seldom attended Avith much danger, so  far a« the child
is concerned, because the laceration usually occurs  at tAvo or three  inches
from the navel, and because, by tearing the umbilical  vessels, it is likely to
prevent a mortal  hemorrhage, even should the pulmonary respiration not
be established immediately.
   Treatment. — Where there is reason to believe that the child is very small,
as it would be in a case of premature labor, or if previous deliveries had led
us to suppose that the  pelvis is larger than  usual, the Avoman ought to
lie  down  on the occurrence of the very first  pain, and  she should avoid
bearing down or contracting the muscles subjected  to the  influence of her
will, as much as possible, during the pain; the same object Avould be mate-
rially aided by applying a moderately drawn bandage around the abdomen
(Rigby).  Finally, every precaution is to be taken to  retard the rupture of
the membranes as long as possible.
  If, notwithstanding these precautions, it is found that the inferior part of
the uterus is strongly pressed dowmvard towards  the  floor  of the pelvis, or
even through the vulvar  orifice, it must  be carefully sustained  until the
cervix is sufficiently dilated to permit the free passage of the head.  We
might, like  M. Naegele, apply a large T bandage in front of the vulva, ex-
tending up over the prominent part of the womb, and  having an opening at
its centre corresponding to the orifice of the vagina.
   If the patient had been delivered too rapidly in  her  previous pregnancies,
opiates might be  administered, either by the mouth, or by injection, for the
purpose of calming the excessive irritability of the uterus.   Wigand recom-
mended venesection, which, perhaps, might be employed with advantage in
strong and  plethoric women, but experience has not yet  determined the
efficacy of the measure as a general remedy.
                         CHAPTER  II.

                  OF  DEFORMITIES OF THE PELVIS.

  The material obstacles Avhich too often render spontaneous labor difficult
or impossible, are exceedingly numerous, and depend either on the mother
or child.  The diseases and deformities, or faulty direction of the canal
Avhich the foetus has to traverse, are naturally included among the first; and
to the second we must refer the diseases and malformations of the infant
itself, as also the unfavorable positions in which it may  present at  the
superior opening of the pelvis.  We shall commence  our description with
the obstacles appertaining to the mother's organs, and will first treat  of
deformitM 3 of the pelvis. 
DEFORMITIES  OF  THE  PELVIS.               617
   Whenever the pelvis departs from the dimensions heretofore described as
 the normal ones, it is said to be deformed ; Avhich, as the reader will readily
 understand, may imply either an enlargement or a diminution of the average
 size;  and  this explains  the  division, admitted  by accoucheurs, into pelves
 deformed  by  excess of amplitude, and those deformed by excess of retrac-
 tion.   I say by excess of amplitude or of retraction, for it must not be sup-
 posed that a pelvis is reputed to be malformed, whenever it does not exactly
 present the dimensions before given as the  ordinary standard; because its
 development is subjected to the influence of the same laws that regulate the
 whole organism,  and Ave all knoAV  Avhat great varieties those laAvs exhibit in
 their accomplishment.  Therefore, as  a feAV  lines, more or less, do not con-
 stitute  a deformity,  we  shall  only include under the title of malformed
 pelves those Avhich, from  their excessive size or narroAvness, are capable of
 producing notable difficulties in the exercise  of the puerperal functions.

   § 1. Of the Pelvis Deformed by Excess of Amplitude.
   A  large pelvis is not ahvays a favorable  circumstance, as might at first
 sight be supposed;  because, if the  amplitude is too  great,  it exposes  the
 Avoman to  serious accident, both in the non-gravid, the pregnant, and  the
 parturient state.  Thus,  in  the unimpregnated  condition, the  uterus,  not
 deriving an adequate  support from the Avails of the excavation, and being
 free and movable  in  an overspacious  cavity, is much more liable to  the
 various displacements knoAvn as descent, anteversion, and retroversion of the
 Avomb ;  which accidents are. then the more unfortunate, as they are the more
 difficult to remedy.
   During gestation, the womb, finding more  space  than usual in  the pelvic
 cavity, remains there until a much more advanced period of pregnancy, and
 the volume of the organ, by  compressing the rectum and the bladder, often
 occasions an excessive tenesmus in these parts, Avhich proves very distressing
 to the patient; sometimes, even the discharge of the urine and fecal matters
 is impeded, besides which, varices, hemorrhoidal tumors, or a  considerable
 infiltration of  the loAver parts, are  found to be developed, in consequence of
 the mechanical obstacle to the circulation in the inferior  extremities.   If
 this excess of amplitude  is restricted  to  the excavation, Avhile the straits
 vary but little, if any, from their normal dimensions, the fundus of the Avomb
 is often  turned back  into the holbPAV of the  sacrum ;  and, someAvhat later,
 when its volume is too great  to permit a longer sojourn in the lesser pelvis,
 it meets with difficulties at the  superior strait which  it  cannot surmount;
 and the impediment then offered, in either case, to the  ulterior development
 of the  organ, frequently brings on an abortion.   At  the end of gestation,
 the head engaging early at the superior strait, gets Ioav doAvn into the excava-
 tion, and presses on the neighboring parts ;  Avhence all  the unpleasant symp-
 toms that had  accompanied the outset of pregnancy are found to be reneAved
 in its latter months.
  During labor, the excess of amplitude  of  the  pelvis exposes the Avoman
to all the dangers  that  may result from  a too rapid delivery: for, if she
brings into  play the voluntary muscles, long before the proper dilatation of
the o i u+eri, or bears doAvn too  strongly during the pain, the  organ, being 
618
DYSTOCIA
imperfectly sustained by the osseous walls of the canal, may be forced down
as far as the vulva;  and, indeed, be driven completely beyond the  parts of
generation;  or, possibly, the circumference of the cervix uteri may yield,
and thus give rise to a  laceration.  Supposing the dilatation is  already per-
fected, then the child, being urged along by the energetic and repeated con-
tractions of the Avomb, and not encountering a due degree of resistance on
the part of the straits, speedily reaches the perineum, and  tears its Avay
through, because the latter has not yet had time to become distended.  The
expulsion of the foetus may thus take place at a moment Avhen the patient
and her attendants believed it still distant;  and  hence, the absence of the
ordinary precautions, and the erect position in which she may happen to  be,
Avill expose the child to a fall on the floor, or produce a premature separa-
tion of the placenta, a rupture of the umbilical cord, or an inversion of the
womb; and, last of all, the womb, from being suddenly emptied, is some-
times affected Avith inertia, and becomes the source of a profuse flooding.
   After delivery, a very large  pelvis permits the uterus, notAvithstanding
its volume, to sink doAvn into the excavation, and the  compression thereby
produced on the adjacent organs may become the cause of an inflammation
that is always to be dreaded.   It is further evident that an excess of ampli-
tude must favor the displacement of  the organ; and  it is highly  probable
that the cases of retroversion reported  by Martin, of Lyons, and  Verman-
dois, as having occurred in  the first few days  immediately folloAving the
delivery, Avere owing to this circumstance.  (Martin, 158.)
   The indications for treatment, Avhich malformation of the pelvis, from
excess  of amplitude, present, are exceedingly simple;  for all  that Ave have
to do is to keep the patient recumbent throughout the labor, and recommend
 her not to aid the pains in any wise, and particularly not>to bear doAvn until
 the os uteri is fully dilated.  Where this process is not yet completed, and
 the cervix, pressed doAvn by the head,  appears  at the vulva, Ave  must  en-
 deavor to push it back during the interval, and then, by supporting it with
 the hand, oppose its escape during the contraction.
   For the indications  to be fulfilled during the progress of gestation, Ave refer
 to the  pages in Avhich  are studied the  rational signs of deformities of  the
 pelvis, and the indications presented by displacements of the uterus during
 labor.

   § 2.  Of the Pelvis Deformed by Excess  of Retraction.
   Among the various conditions  necessary to a spontaneous labor, there is
 one whose importance cannot be contested, namely, that a just proportion
 exist betAveen the dimensions of the canal, and those of  the body that must
 traverse it;  for whenever this relation  does not appear, Avhether OAving to a
 retraction of the pelvis or to an abnormal size of the child, the delivery is
 no longer possible; and whenever this disproportion is carried to an extreme,
 we have only to choose betAveen tAvo resources  that are equally  disastrous
 in their consequences, that is,  to diminish  the volume of the infant, or to
 enlarge the Avay  it has to pass through.   The  retractions  of the pelvis,
 therefore, are the most terrible accidents that can occur in the practice of
 our art, and their importance,  in every point of view, sufficiently Avarrants
 the detail into which  we are about to enter. 
DEFORMITIES  OF  THE  PELVIS.
619
   The various  degrees  of  retraction, the differences in  their seat, and the
 varieties of form the pelvis then assumes, are so numerous, that it is indis-
 pensably necessary to adopt some general arrangement;  to collect them into
 classes, to form groups, and then to attach these to certain principal types
 that are easily recognized ; the number of Avhich, however, to aid their acqui-
 sition by students, should not be too great.  After having thus classified the
 different varieties of deformities from retraction, Ave must study their princi-
 pal characters, and endeavor to point out their causes, their mode of develop-
 ment, the means of recognizing them, and, lastly, the indications for treatment
 that each of them presents.

                            ARTICLE I.
                        PATHOLOGICAL ANATOMY.
   As  regards their form  and external configuration, the retracted pelves
 may be divided into two very distinct groups ; for either  the pelvis, although
 greatly retracted in all its dimensions, is properly formed, and presents no
 irregularity in its exterior  aspect, or  else the retraction affects only one or
 more  of its diameters (the others maintaining very nearly their normal
 length), and this partial alteration  completely changes its form.

   § 1. Of  the Simple Contracted Pelvis, without Curvature or
 Malformation  of  the Bones.   (Absolute Contraction.— Velpeau.)
   Before the researches of Professor  Nregele, Avhose  principal Avorks on the
 pelvis  Avill soon be disseminated throughout France, by means of the trans-
 lation just published  by M. Danyau,  there Avas  scarcely any mention  made
 of this variety  of  contraction in the leading classic works ; for most of the
 French and English authors  merely stated that narroAvness  is rarely met
 with in all parts of the pelvis at one and the same time, and that it is still
 more rarely carried to a point  demanding the intervention of art.
   It was reserved  for M.  Naegele  to point out  the importance  of this par-
 ticular variety.   In his collection, he numbers four pelves that are contracted
 throughout, and  all  their  diameters  are  one  inch  less than  the normal
 dimensions; these all required either the Cesarean operation  or the mutila-
 tion of the foetus.   Three of them  Avere  obtained from Avomen  of ordinary
 stature, the fourth belonged to a dAvarf thirty-one years of  age, and only
 forty-six inches in height, though  otherAvise Avell formed.   As  regards  the
 respective  lengths of their  different diameters,  and the  form of the pubic
 arch, each  one of these presents the characters of a regularly-formed pelvis,
 Avhose dimensions  may be supposed to have been  reduced ;  and, as to the
 condition  of the  bones, that is to  say, their  color, strength, and texture.
 there is no departure  from  the  healthy standard.  In one of  them there is
 even a tendency to a greater density of the osseous tissue.   Further, these
 pelves  have nothing in common  Avith those deformed  in  consequence of
 rachitis, asjlie consistence, density,  thickness,  and size of the bones, and the
 regular shape of the pubic arch, sufficiently prove;  besides, the individuals
from Avhom they Avere procured, presented no traces of that affection during
life; and the examination of other parts of the skeleton fully confirmed this
distinction, which Ave  hope to  prove in a still more decisive  manner here- 
620
DYSTOCIA.
after, Avhen the ca ises and particular development of this species of contrac
tion shall be studied.
   M. Naegele admits two  distinct varieties in the malformed pelvis under
consideration.  In  one,  he says, the  pelvis,  Avith respect  to its thickness,
strength, texture, and indeed all the physical characters of the bones, size
excepted, does not differ from a normal one;  and it is met with in persons
of either a small, an ordinary, or a high stature, who may be otherwise avcII
formed and thin, and'whose external appearance Avould not cause  the least
suspicion of such a formation; whence it can only be recognized by a local
exploration.   In the other, the pelvis is  Avholly different; for, as regards
their volume, substance, and strength, the bones exhibit  the characteristics
of childhood;  and the same remark is applicable to their mode of union
with each  other.  This variety is  only observed in very  small  individuals,
such as dwarfs; and  the  relations of the diameters with one another, and
the form  of  the pubic arch, are such as  are found in the girl, Avhen the
sexual system has just completed  its development.   Thus, for  example, in
the dAvarf before  cited, whose height was  but forty-six inches, the  pelvis
had the following dimensions, viz.:
    From the promontory of the sacrum to the point of the coccyx,   . 3} inches.
    The antero-posterior diameter of the superior strait,    .    .    . 3^   "
    Transverse diameter           "         "    .    .    .    .  3£   "
    Antero-posterior diameter of the excavation,  .    .    .    .    . 3}   "
    Transverse diameter       "       "      ..... 3J   "
    Transverse diameter of the inferior strait,   .    .    .    .    .  3^-   "
    Depth of the spmphysis pubis,    ...         .    nearly 1 inch.

   § 2. Of the  Pelvis Contracted by the Curvature and Malfor-
mation of the Bones.   (Relative Contraction.— Velpeau.)
   In those cases where the pelvis is contracted by the curvature and mal-
formation of  its constituent  bones, the deformity may be referred to one of
the three principal  types described by M. Dubois: that is, either to a flatten-
ing from  before backwards, to a compression on the sides,  or to the depres-
sion of the anterior and lateral parts ; the first variety, or flattening, shortens
the antero-posterior diameters, the lateral compression diminishes the trans-
verse ones, and the depression of the antero-lateral Avails contracts the oblique
diameters.  Again, each of these varieties may affect either  the  superior
strait, the inferior strait, or the excavation, though frequently both straits
are contracted at the same time.
   A. The flattening from before backwards, or shortening  of the antero-pos-
terior diameter, results from a more  or less marked approximation of the
anterior and posterior pelvic Avails ; and this  species of malformation exhibits
several varieties, as regards the extent of contraction, whether in height or
width.  For instance, the superior strait alone may be contracted, Avhile the
excavation retains its  normal capacity; this  phenomenon is caused by the
unusual curvature  of  the  sacrum,  Avhich is sometimes so  bent  anteriorly
as almost to  represent an  obtuse angle at its middle part, Avhereby the
base of  the bone  is thrown fonvard  in  such a Avay as  to singularly aug-
ment the prominence of the sacro-vertebral angle.   But the contrary may
also occur, and the sacrum, instead of  presenting an anterior concavity, be 
deformities  of the pelvis.
621
 quite plana, or, occasionally, even convex in front; and then the excavation
 is contracted simultaneously with the superior strait, in its antero-posterior
 diameter, and it really seems as if the sacrum, having lost its natural curva-
 ture, had been pushed forward in totality.
   The  shortening  of  the antero-posterior diameter of the superior strait
 sometimes  accompanies an  enlargement of the  corresponding one at the
 inferior strait.   This, indeed, is the most frequent arrangement, and is Avhat
 generally takes place Avhen the  sacrum, yielding under the Aveight of the
 trunk transmitted  to it through  the spinal  column, becomes  tilted, that is,
 the base is projected fonvard, Avhile its coccygeal extremity is forcibly pushed
 backAvard.
   Lastly, the coccy-pubic and the sacro-pubic diameters may be shortened,
 at the same time, if it should happen that the sacrum, instead of performing
 the tilting movement just alluded
 to, yields in such  a Avay  that its                 FlQ'93,
 two extremities  are throAvn for-
 ward ;  the  anterior curvature  is
 then greatly augmented, and  con-
 sequently the corresponding diam-
 eter of the excavation enlarged.
   In the  approximation of the
 antero-posterior walls, the sacrum
 is nearly ahvays the displaced bone;
 but although  much more rare, a
 flattening of the anterior  Avail  is
 also met Avith; and then the sym-
 physis pubis, instead of presenting
 a convexity in front, is perfectly
 flat, or even (as  in one instance
 represented by Madame  Boivin)
 presents a depression, Avhich seems to protrude imvardly tOAvards the promi-
 nence of the sacrum.   This  double  inclination of the pubis  and  sacrum
 toAvards each other, gives to the superior strait the form of the figure eight;
 that is, its  plane is divided into  tAvo rounded portions on the sides, corre-
 sponding to the  iliac fossae, and is separated in the  middle by a restricted
 part, of variable width.   If  the depression  is considerable, the antero-pos-
 terior diameters of both  straits, and of the  excavation, must evidently be
 affected by it.
  But there is yet another way in Avhich                FlQ-94,
 the symphysis pubis may contribute to
 the narroAvness of  the pelvis; for in-
 stance, its vertical extent is sometimes
 much greater than usual, and this ex-
 traordinary length  gives  rise to Avhat
 is termed  the bar pelvis ;  or the same
effect may be produced by an excessive
inclination backAvards at its loAver end.                            ,   ^
                    .....              The shape of the superior strait in the figure
  Again, the coccy-pubic diameter may               eight pelvis.
  A pelvis, in which the contraction of the sacro-pubw
diameter is produced by the unusual prominence of the
sacro-vertebral an»le.
 
622
DYSTOCIA.
be  shortened, it is said, by an  elongation, or  rather  an  almost horizontal
direction  of the coccyx, and more particularly by  an  immobility of  the
sacro-coccygeal articulation.   This latter circumstance has been invoked in
explanation of the sloAvness  and  difficulty of first labors in middle-aged
Avomen; but, as M. A. Dubois has remarked, the delay in the delivery of
the head in such persons does not usually depend on an immobility of  the
coccyx, but upon the rigidity of the soft parts, Avhich then offer great resist-
ance.
  B.  The compression of the lateral walls, by AA'hich the transverse diameter
is shortened, is the rarest of all  the deformities, at least so far  as concerns
the superior strait and upper part  of the excavation ;  for the inferior strait,
on  the contrary, the  approximation of the two  ischial tuberosities, which
constitutes this species of deformity, is quite as frequent as the shortening of
the coccy-pubic diameter; the malformation resulting from the approach of
those tuberosities, as well as  that  of the branches of  the  pubic arch;  this
latter then assumes the triangular form peculiar to the male sex.   Besides
which, the 'loAver part of the excavation may be notably diminished in  the
transA^erse direction, by the imvard projection of the spines of the ischia.
  The transverse  contraction is seldom as Avell  marked  as  the flattening
from  before backAvards,  especially at the superior strait, where  it is, in
general, limited to diminishing the bis-iliac diameter from a feAV lines to an
inch in its length, by elongating the antero-posterior one to the same extent;
for the coxal  bones are then less curved, and the sacrum is thrust back-
Avards, Avhile the pubes are more prolonged in front.   Of course, the upper
strait will  be more or less altered in form according to the degree of com-
pression, for Avhere this is inconsiderable, its  periphery is nearly circular;
but Avhen greater,  it represents an ovoid, the larger  extremity of Avhich is
posterior.
  Another  variety of transverse  contraction  is OAving to the  fact of  the
pelvis being less developed in one of its halves than in the other, and con-
sequently to its exhibiting a  less  degree of curvature in that part than
upon  the  opposite  side.   In this case, the articulation of the spine "with  the
sacrum no longer corresponds to the middle of the pelvis, and the vertebral
column is  found  nearer to the hip of the contracted side; the transverse
diameter is likeAvise diminished at the inferior strait by reason of the obli-
quity of the entering part of the coxal bone.  The antagonism before alluded
to, as existing between the antero-posterior diameters of the superior and
the inferior straits,  Avhereby the elongation of  one most frequently coincides
with  a shortening  of the other, rarely exists in the  transverse direction;
the deformity produced  by  a  congenital  displacement  of the femurs  is
probably the only condition in Avhich the transverse diameter of the inferior
strait  augments  at the  same  time that  the  bis-iliac one diminishes;  the
enlargement in the loAver part of the pelvis, in this instance, being marked
by an unusual  Avidth in the pubic  arch, great obliquity of the ischio-pubic
rami, separation of the ischial tuberosities, &c.  (See art.  Causes.)
  C. The depression of the antero-lateral-walls, Avhich diminishes the oblique
diameters,  is much more frequent  than the preceding variety, though it is
more  rare  than the flattening from before backwards, and it may exist on
one or both sides at the same  time.  This deformity consists, essentially, in 
DEFORMITIES  OF  THE  PELVIS.
623
 the flattening, or inward  projection of the coxal  bone, at the  part  corre-
 sponding to the cotyloid cavity, and to the junction of its three constituent
 pieces; Avhence there results  at this  point a greater or less diminution of
 the curve Avhich  the pelvic circumference  usually describes ;  and  when
 existing in a  high degree, the curvature is even reversed, its convexity
 being turned toAvards the sacrum, Avhile, at the same time, the pubis departs
 from its normal transverse direction and runs almost directly fonvards ; so
 that the  deformity is produced by the coxal bones having then assumed
 the form  of an old italic S, instead of presenting a regular arch.
   Where this takes place to the same extent on both sides, the pelvis  main-
 tains a degree  of symmetry, and the superior  strait is shaped  like the  trefoil
 leaf; that is, it presents three  lobes,  one anteriorly, which  corresponds to
 the more acute angle of the pubis, and two posteriorly and laterally, formed
 by the union of the iliac bones with the sacrum.   But it far oftener happens
 that the deformity is more marked in the coxal bone of one side than upon
 the other, and then  the shape of the pelvis  is  the  more irregular  as the
 deformity of the ossa innominata is greater.
   Where this double disfiguration of the  hip-bones exists in a high decree,
 more  especially Avhen it affects
 the anterior pelvic Avail, it viti-                    fio. 95.
 ates both the oblique and antero-
 posterior  diameters at the same
 time.  In  fact, these bones are
 then approximated in a parallel
 manner,  being only  separated
 from each other by a slight dis-
 tance, for the extent of an inch
 or  tAvo, Avhile  the  rest  of the
 pelvis is comparatively regular;
 and hence, although  the  sym-
 physis  pubis  may be  at  the
 normal distance from the sacro-
 vertebral  angle, yet it is not the
 less true  that  the  antero-poste-
 rior diameter  of the  superior  strait Avill  be virtually shortened in all its
 forward part comprised in the fissure left betAveen the two deformed antero-
 lateral Avails, because this contracted portion  cannot contribute in any yvise
 to the  passage of the foetal head.
  Again, Ave may remark, Avith M. P. Dubois, that as the anterior arch of
 the pelvis  has  but very little  depth at the point  corresponding to the de-
 pression of its  lateral  Avails, and as the surface compressed by the head of
 the femur occupies the largest portion of  it, the  Avhole of that region must
 almost necessarily  be pressed in ; and, consequently, that the  shortening
 must affect  all the diameters at  once, those  of  the excavation  and of the
 abdominal and perineal  straits; though  the  retraction is in general less
 marked at the  inferior strait than elsewhere, because the loAver part of the
 ischium is not carried so far backwards as the  cotyloid region.
  As to the variety of deformity  recently described by  M. Naegele, the
celebrated  professor of Heidelberg, under the title of oblique contraction,
A pelvis in which the sinking-in of the antero-lateral w»"«
             exists on both sides. 
621
DYSTOCIA.
we may evidently refer it also to a shortening of one of the oblique  diame-
ters, and shall describe it hereafter.  (See Causes).
  This remark naturally leads us to the important observation, that hitherto
Ave  have considered  each of the  species of deformity that  may alter the
various pelvic diameters, as being separate and  distinct, since there are
some Avhich may exist alone, and only change the corresponding diameters;
but, besides the  fact that  different  points of the pelvic circle may be simul-
taneously deformed, and  thus contract the pelvis in  several directions at
once, the  form  and extent of the  pelvis  are such that it is difficult  for a
flattening, a lateral compression, or a depression of the antero-lateral parts
to take place,  even  separately, Avithout  its being  thereby contracted in
several  of its diameters.   Let  us  suppose, for  instance, that one  of the
oblique diameters has  been diminished by the depression of the bottom of
the  acetabulum; and it  must be  evident that, should  the depression be
considerable, the body of the ischium  cannot be  thus thrust inwards and
backAvards, Avithout draAving along Avith it at the same time, some  consider-
able portion of  the  anterior part of the pelvis, and of the arch formed by
its lateral half, and consequently Avithout  contracting, more or less, certain
of the antero-posterior and  transverse diameters.  Again, where the sacro-
vertebral  angle, from being projected forward, diminishes the length of the
antero-posterior  diameter of the superior strait, Ave  have supposed  that it
folloAved the  sacro-pubic line,  in its  movement  of progression;  but, as
readily foreseen, it Avould most often prove otherAvise, for the very frequent
obliquity in the direction of the  forces transmitted  through the vertebral
column, must compel it to lean toAvards the right or the left, as Avell as to the
front;  whence, the shortening of the antero-posterior  diameter necessarily
entails  that of the sacro-cotyloid interval, and, as a consequence, narrows
the Avhole corresponding half of the pelvis.
  Again, the three principal types  may be found united in the same pelvis,
whereby the latter is greatly deformed in all its diameters.  This occurs
more particularly in the deformities  produced by malacosteon, but it is also
sometimes met with, even in a high degree, in cases  dependent on rachitis,
■a6 fully proved  by the facts observed by M. Naegele.
  From all this, Ave learn Avhat  great diversities of shape may be presented
by deformed pelves.  Madame  Lachapelle has gone so far as to designate
these varieties by the titles  of the reniform, the triangular, the bi-lobed, the
rounded, the oval, the cordiform, the trapezoid, the pyramidal, and the three-
lob ed straits; but she has greatly multiplied the species Avithout any  prac-
tical utility, and she further admits that there  are  numerous undescribed
varieties for each of these orders.
   The Degree of Contraction. — The tAvo extremes of  contraction of the
straits are from  three and three-quai ters to four inches for the highest, and
from tAvo to three lines for the least, and betAveen  these tAvo the pelvis  may
exhibit all the intermediate degrees of narroAvness.  The causes which  pro-
duced the deformity greatly influence the degree of contraction, and in this
point of vieAV they may be  arranged in the folloAving order, viz., malacos-
teon, rickets,  congenital  luxations  of  the  femur, deformities of the spinal
column, &c.; we shall take occasion  hereafter to revert to the mode in
>/hich each of these acts. 
DEFORMITIES OF THE  PELVIS.
625
   Qf the Variations in the Depth of the Pelvis.—The vices of conformation,
just spoken of, rarely exist Avithout modifying the depth of the pelvis, in a
greater  or  less degree;  which  circumstance has been particularly  dwelt
upon by M. Bouvier, in  the able Avork presented by him to the Institute.
For instance, the depth may either be augmented or diminished by the vari-
able inclination of the expanded portion of the iliac bones, or of the branches
of the pubic arch, as also by the diversities  in the length of the sacrum.
   Sometimes this  latter bone is very short, its contraction being produced
either by an excess of the anterior curvature, Avhich brings the two extrem-
ities nearer to each other, or by an arrest  of  development.
   Occasionally, the  iliac fossae are elevated, as if  they had been  forcibly
pressed  from  Avithout imvards,  thus  giving  it the appearance of a male
pelvis ; and this elevation may be further  augmented by exterior and lateral
pressure, whereby the bones  are rendered quite vertical, and the normal
depth of the pelvis is greatly increased.  The  contrary may occur where
the iliac crests, from being strongly depressed and thrust outwards, enlarge
the margin of the pelvis, but evidently diminish its height.   It would  be
difficult to  misinterpret  the influence of the Aveight of  the viscera  in such
cases when there is no congenital deformity in question.   (Bouvier, op. cit.)
   In conclusion, a widening of the pubic arch  must clearly diminish its height
to a corresponding extent;  Avhile the latter, as well as the whole depth of the
pelvis, must be increased, where the ischio-pubic rami are very close together.

                           ARTICLE II.
OF THE  CAUSES AND MODE OF  PRODUCTION OF  THE PELVIC DEFORMITIES.
   For a long time the vices of conformation of  the pelvis, as also most of
the deformities occurring in the skeleton at large, Avere attributed to  the
operation of a single cause, rachitis ; but the more careful researches  of
modern surgeons enable us,  at the  present day, to ascertain  more  precisely
the effects of rickets on the osseous system, and  to appreciate the influence
that other general  or local diseases  may have over the  perfect or the defec-
tive conformation  of the pelvis.  And here I must again extract largely
from the valuable  Avorks of  Naegele, Bouvier, Guertn, Sedillot, and others.
   An examination of facts clearly proves that the pelvis may be deformed
under circumstances Avhere  there has been no rachitis  properly so called;
and Avhere causes that are purely mechanical  in their operation have altered
the configuration of its constituent  parts  at  a period Avhen  their power of
resistance Avas inconsiderable, not  in  consequence of any pathological soft-
ening, but solely from the tender age of the  patient, or the feebleness of  its
constitution.   And hence, as regards  the  causes that produce  the changes
in their form, Ave might classify all the irregular pelves  under five principal
types, namely: —
  1. Deformity from absolute contraction.
  2. Deformity from rachitis.
  3. Deformity from osteomalacia.
  4. Oblique oval  pelvis.
  5. Deformity consecutive to a previous deformity of  some other part  of
the skeleton.
      40 
626
DYSTOCIA.
  § 1. Pelves Deformed by Absolute Narrowness.
  To  complete our  remarks on  the  causes  of  pelvic deformities, Ave hav j
yet to sum up the various opinions that have been given forth concerning
those  vitiated by absolute  narroAvness.  According  to  most  authors, the
absolute contraction of the pelvis results from an arrest of development,
whereby this part still retains, after  puberty, the principal  characters that
it had during childhood, and approaches in its form more or less closely to
that of  the male.  But, as M. Naegele remarks, if this Avere really the case,
the relation of the diameters Avith each other, and the character of the pubic
arch,  should be such as are observed in the young girl and  the male. But
all the known pelves of this variety exhibit quite the contrary.  Nor are
they more in consonance Avith that of a rickety person; and, besides, the
rest of the skeleton has none of the characters appertaining to this disease.
  Wherefore, it is  certainly the  wisest plan  to say, Avith the  illustrious
Heidelberg  Professor, that we have no positive data concerning  the  causes
that give rise to the general narroAving of the pelvis;  and that such pelves,
as well  as  unusually large ones, should rather be considered as  a freak of
nature,  belonging to the same category as a Avant of proportion in the head,
which is not  unfrequently found  too  large, or too small, relatively  to the
rest of the body.

  § 2. Of  the Pelvis Deformed by Rachitis.
  We are not about to enter here  into a detailed consideration of the causes
that preside over the development of rachitis; for the general phenomena
produced by them, and, more especially, the greater softening, fragility, and
flexibility of the osseous tissue, are  so well known to pathologists that we
need  only  mention them; but  our  present duty is to study their influence
in the production of the deformities  of the pelvis.
  But this softening, or want of resistance on the part of the  bones, is not
of itself sufficient to explain the various deformities exhibited by the pelvis;
because, except  in  certain very rare cases, in which  the  osseous tissue is
almost  gelatinous in its consistence, it must be evident that the bones can
only give Avay and become distorted by the action of an exterior force, with-
out which their  conformation would  remain  intact.   For where rachitis
affects them, it has no other immediate consequence than to diminish their
solidity, and of itself contributes in no Avise to the alteration of their  shape;
we must seek in the influence of some external force, Avhich is wholly inde-
pendent of the principal disease, for the cause of the deformity.  Now, this
exterior force sometimes  resides in  the muscular action, though still more
frequently (so far as regards the pelvis) in the weight of the parts it  has to
support; for, being placed, as we have elseAvhere described, below the trunk
and directly upon the  lower extremities, to Avhich, in the erect  position, it
transmits the whole weight of the upper  parts of the body,  the pelvis  is
found in the  most favorable conditions for the  production of deformity.
The weight of the  trunk, which,  in the erect posture, is transmitted from
the lumbar vertebrae to the heads of the femurs in the direction of two oblique
lines  that intersect the sides of the superior strait, manifestly tends to aug-
ment  ihe cuivati  re of the posterior part of the ilium, and to depress the 
DEFORMITIES  OF  THE  PELVIS.                627
 osseous circle which the pelvic cavity represents; and this weight, acting at
 first more especially on the base of the  sacrum, has a tendency to push  the
 latror insensibly forwards.  The pubic  bones Avould be  equally pressed to-
 wards the sacrum, though  in  such a manner that their  posterior extremity
 (the one  nearest to the acetabulum, AA'hich supports the weight) gets some-
 what nearer to the sacro-vertebral  angle than  does their anterior or sym-
 physeal extremity ; Avhence we may learn Avhy the contractions of the pelvis
 oftener affect the superior strait than other parts; and  why, at this strait,
 the antero-posterior and oblique diameters, and the sacro-cotyloid  interval,
 are far more frequently contracted than the transverse ones.
   And it will be equally evident why, Avhen the weight acts more particu-
 larly on one side of the pelvis, the collapse is more marked in that direction,
 if Ave bear in mind the change that then takes place in the centre of gravity
 from the  inclination of  the  spine, the curvature of Avhich so often  precedes
 the deformity of the pelvis, as also the very unequal  pressure of the weight
 of the body on  the  tAvo sides of the pelvis, where a difference of length in
 the lower extremities  depresses one of the coxal bones more than the other;
 whereby  the acetabulum of one side is throAvn almost  directly under the
 sacrum, and at the same time receives the Aveight very obliquely. (Bouvier.)
 It is further evident that the customary attitude of the  individual, and  the
 nature of her exercises,  must likewise add to the irregularity in the figure
 of the pelvis.
   If the child is in the habit of sitting much, the weight transmitted by the
 lumbar vertebrae may likeAvise press the sacro-vertebral angle fonvard;  but
 the sacrum also often yields, and its base is carried forward simultaneously
 with  the  point of the coccyx, and the antero-posterior diameters of both the
 superior and the inferior straits are affected.
   The lateral compression, operating from  one side to the other,  Avhich is
 far less common than the preceding, or the shortening of one or more of the
 transverse diameters, supposes an action  diametrically opposite, and it gen-
erally results from a lateral force acting from without inwards; Avhich force
 may be referred  either to the Aveight of the body, Avhere the child uniformly
 reposes on its side, or to the unequal pressure of some improperly  adjusted
 bandage,  or  the  arms of an  awkAvard  nurse.  But if, on the contrary,  the
 infant habitually leans  more toAvards one side than  the  other Avhen seated,
 one of the ischial tuberosities, having to support a more considerable weight
 than  its fellow, may be distorted inwardly; sometimes even the pressure Avill
 he applied successively to each, Avith the effect of bringing them very near
 to each other.
   Kachitis affects first the bones of the loAver extremities, and ascends gradu-
 ally to the upper parts;  in a Avord, it has an  upAvard  tendency.  From this
 results a  most important  practical  consequence, namely, that a deformity
 of any part of the  skeleton from  rachitis implies,  almost necessarily, de-
 formity of the bones situated below it.
   Rachitis is a disease peculiar to infancy, and this peculiarity of only  ex-
 erting its action  during the early years of life, satisfactorily explains how
 the affection  may have tAvo different modes of acting  on  the pelvis;  one of
 which consists of a s rftening of the bones, and their consequent yielding, 
628
DYSTOCIA.
and the other, of a sort of arrest in their development.   " Thus," M. Guerin
says, "it would appear from  my researches that most of the bones of a
rachitic skeleton, when compared with those of a normal one, exhibit an
arrested development as  regards their different dimensions; Avhich reduc-
tion, independently of what results from  the deformity of the bones, may
amount to one-half of their ordinary size;  and further, that this reduction
is generally greater in the lower parts of the skeleton, and gradually dimin-
ishes from below upAvards, from the bones of the legs to the femurs, from
these latter to the  pelvis, and from the pelvis to the upper extremities and
spine, &c."  It  is, therefore, on the  lower  extremities  particularly, and  on
the coxal bones, which are appendages of them, that this arrested develop-
ment exerts its action.  " Whence," says M.  Dubois, " it necessarily results
that  the ossa  innominata  are generally much less developed in rachitic
pelves  than  in others; and  this disposition must  powerfully  contribute,
together Avith  the  deformity that usually  accompanies it, to contract the
limits of the cavity, which these bones, in a great measure, circumscribe;
and I am the more convinced  of the  importance of this fact, since, in several
instances of deformity occurring in individuals  known  to be rachitic during
infancy, it has appeared to me that  the yielding of the bones to the degree
in which it existed would have been wholly insufficient to create such in-
surmountable difficulties, if the bones themselves had been as fully developed
as they ought  to have been."  (These de Concours.)  And we may mention,
as another fact bearing on the same  point,  that the pelvis of the patient on
whom  M. Moreau  performed  the Caesarean operation, had experienced the
double influence of rachitis j-ust mentioned ; for, though but little deformed,
its antero-posterior diameter was only tAvo  and  three-eighths of an inch in
length.
  This influence over the development of the pelvic bones is dependent
solely on the tender age at which the affection appears, since it occurs in
childhood, as stated, that is, at a period when the pelvis is far from having
acquired its perfect organization ; whereas malacosteon  does not appear until
after puberty, in other Avords, at an age when the ossa innominata have
reached their normal development; and, therefore, although it may soften the
bones,  it cannot oppose their groAvth.
   Lastly, this action is not  set aside by the cure of the disease, but it con-
tinues  to be felt during the whole period  of development, so that, says M.
Guerin, the sum of reduction  exhibited by the bones  of rickety  adults, is
made up of two successive results, namely, of the reduction dependent on an
absolute arrest, or a mere diminution of groAvth during the disease, and  of
that caused by a  retarded  growth  subsequent  to the  malady.   This is an
important practical remark, showing how far the influence of rachitis over
the osseous system may extend.
   To recapitulate,— rachitis produces deformity of the pelvis in two ways:
   A. By altering the shape of the bones.
   b. By arresting development.
   The most striking characters of a rachitic pelvis are as follows: —
   1. The antero-posterior diameter of the superior strait is always shortened,
and  the same is  generally true for the oblique diameter.   The transversa 
DEFORMITIES  OF  THE  PELVIS.
629
Pelvis deformed by rachitis.
diameter  is  less frequently shortened;  sometimes  it is normal oi  even
lengthened.                                       FlG 96
  2. The sacrum is less curved.
  3. The  diameters of the in-
ferior strait are usually normal,
and the transverse diameter, in
a certain proportion of cases, is
lengthened.
  4. The  angle formed by the
pubic arch is increased.
  § 3. Deformity from Osteo-
malacia.
  Osteomalacia, like  rachitis,
by producing softening of the bones, diminishes  their power of resistance.
Instead of appearing during infancy, it occurs only in adults, often attacking
women  who  have previously had one or several children.   The softening
produced  by osteomalacia is generally much greater than the loss of resist-
ance occasioned by rachitis, whence it follows that, aside from some excep-
tional cases, such as the one mentioned by Naegele, the greatest contractions
of the pelvis are due to osteomalacia, which sometimes deforms the skeleton
to an incredible degree.
  This  disease  may attack any  of the bones  of the skeleton, though it
usually  begins with the pelvis.
  When their  softening has occurred, the bones forming the cavity of the
pelvis have  their  shape changed as  in rachitis, under the influence of two
causes, namely, the weight of the parts which they are obliged to support, and
the contraction of  the muscles attached to them.   In this case, hoAvever, as
the weight of the body is greater, and the  muscular action stronger, the
deformities are greater also.  We Avould add that the development of the
bony system is not arrested by osteomalacia, and that the conditions arising
from the various habits and motions  of the patient are liable to produce
peculiar deformities Avhich have been successfully  studied  by Stein and
Kilian.
  It may be stated, in  a general  Avay,               FlQ-97-
that a pelvis deformed by osteomalacia
is characterized  by compression of  its
lateral  parts Avith  projection of the
pubic symphysis Avhich is  pressed for-
ward by the  approximation of the tAvo
horizontal branches of  the pubis.  The
iliac fossae are croAvdod inward, and
the curvature of the sacrum is always
greater  than in the normal condition.
The inferior  strait  is more deformed
than the superior one ; all its diameters
are altered,  but there occurs  more
especially  a  considerable  approxima-
tion of  the tuberosities of the ischia
and of the ischio-pubic rami.
Pelvis deformed by osteomalacia. 
680
DYSTOCIA.
   To  recount the  peculiar characteristics of the iielvis deformed by oste>
 malacia, we should say: —
   1.  All the diameters of the superior strait may be shortened, though the
 deformity is least in the antero-posterior direction.
   2.  The  concavity of the  sacrum  is  increased, and the  coccyx projects
 greatly toAvard the axis of the inferior strait.
   3.  All the diameters of the inferior strait  are contracted:  the  approxi-
 mation of the tuberosities of the sacrum is, hoAvever, the-principal feature.
   4.  The angle formed by the pubic arch is far less open than in the normal
 condition,  and may even be almost effaced.

   § 4. Oblique Oval Pelvis.
   The variety of deformity recently described by M. Naegele, the celebrated
 Heidelberg professor, under  the title of oblique contraction, may evidently
 be referred to a shortening of one of the oblique diameters.   His  book on
 the subject has recently been translated Avith the greatest care by M. Danyau,
 who  has enhanced the value of this admirable Avork  by the addition of
 learned notes ; but as we had induced Dr. Steege, before the publication of
 Danyau's  translation,  to prepare  for  us the  chapter in Avhich M. Naegele
 describes the principal characters of his oblique pelvis, Ave submit the fol-
 loAving translation of it, which we owe  to the courtesy of  our professional
 brother.
   " The principal characteristics of these deformed pelves are  the folloAving,
 namely: —
   " 1. A complete anchylosis of one of the sacro-iliac articulations, or a per-
 fect fusion of the sacrum and one of the iliac bones together.1
   " 2. An arrest of development, or an imperfect development of the lateral
 half of the sacrum, and deficient size or contracted opening of the anterior
 sacral foramina on the anchylosed side.
                                            " 3.  On the same side, a reduced
                  *ia-98-                  size of the os  ilium, and, conse-
                                         quently, a diminished  extent  of
                                         the ischiatic notches of this latter;
                                         that is to say, the distance betAveen
                                         its anterior superior and its pos-
                                         terior superior  spinous process, as
                                         Avell as an imaginary line, draAvn
                                         at the entrance of the pelvis, com-
                                         mencing at the  spot Avhere  the
                                         sacro-iliac symphysis Avould be (if
                                         it existed), and running along the
                                         linea innominata  and  the linea
                                         ilio-pectinea as far  as  the  pubic
                                         symphysis, is shorter here than  on
 A figure taken from  M. Naegele's work  which exhibit.   the  oppOSite S1de.   Further,  the
the characters ot the oblique-oval pelvis in a high degree.        rl
                                         part corresponding to the articular
  1 We retain the expression anchylosis on account of brevity, and because it is the one
generally used to designate the condition under consideration ; hut we formally protest
 
DEFORMITIES  OF  THE  PELVIS.                631
surface, on the ancnylosed bone, Avhich is here  continued intu the sacrum
without any transition, extends  neither  so high  up, nor descends sc Ioav, as
upon the opposite side, or as it Avould in a well-formed ilium; or, to explain
myself more clearly, if Ave suppose the ilium and sacrum of the anchylosed
Bide to be temporarily separated, and then reunited through the  interven-
tion of a fibro-cartilaginous disk, as occurs in the natural state, the articular
surface or the junction of these two bones Avould be found shorter, and, of
course, Avould not descend so low as on the opposite side, which is exempt
from fusion, or as it does in a well-formed pelvis.
   " 4.  The sacrum seems to be distorted toAvard the fused side, and it also
has its anterior surface  turned  more or less tOAvards this side, whilst the
symphysis pubis is pressed over to the opposite one; in consequence of which
arrangement the symphysis is no longer found directly in front of the pro-
montory, as it ought to be, but is caused to assume an oblique position.
   "5.  The  internal surface of the ilium, on the anchylosed half, is more
flattened in that part which contributes to the formation of the pelvic cavity,
and sometimes even (in cases of great deformity) is almost entirely plane ;
so that, for  example, a line drawn  from the middle, or even the posterior
extremity of the linea innominata,  and running along the body and  hori-
zontal branch of the pubis as far as the symphysis, will be nearly a straight
line; but Ave have never seen an inclination imvards at this part, nor have we
particularly observed that imvard projection of the horizontal branch of the
pubis that is found in pelves deformed in consequence of mollifies ossium in
the adult.
   " 6.  The other lateral half of the pelvis,  or the one where the sacro-iliac
articulation still exists, likeAvise departs from the normal condition; although,
where the obliquity is inconsiderable, Ave may easily deceive ourselves at first
sight, and be induced to  suppose that there is a natural conformation of the
non-anchylosed  half; such, however, is not the fact, as can be proved by
supposing two pelves to be similarly deformed, Avith this difference only, that
in one the fusion of the  sacro-iliac  articulation  takes place on the left side,
while in the other it is on the  right;  and  then making a section of each
through the symphysis pubis and the middle line of the sacrum ;  Avhen, by
attempting to fit the right half of the first of these pelves  to the left half of
the second,  by bringing  the  cut surfaces of the  tAvo sacrums against each
other, we shall find  that the pubic bones  are separated  by an interval of
from three to four inches.
   " Consequently, the lateral half of the pelvis, exempt from fusion, not only
participates  in the abnormal situation and direction of the bones, but also in
their irregular form ;  and this to such  an extent that, if a line should be
drawn  on the non-fused side from the middle of the promontory, along the
linea innominata and  linea  ilio-pectinea as  far as the symphysis  pubis, it
would  be more curved in its  posterior, and  less so in its anterior half, than
in a normal pelvis."
against the imputation of having admitted that these  bones had originally been well
formed, and had only contracted this continuity of structure in consequence of some
disease'.  Perhaps the term synostosis or synezizis would better  designate the perfect
fusion here alluded to. 
632
DYSTOCIA.
    Thence it follows:
    7. A. That the pelvis is contracted obliquely, that is to say, in the direc-
tion of one of the ordinary oblique diameters, while in the other (Avhich runs
from the point of anchylosis to the opposite  cotyloid cavity) it is not at all
diminished, but may even be larger than usual, when  the obliquity of the
pelvis is greater.
   "Wherefore, the superior strait, or, in other words, the surface limited by
a line traced along  the spines of the two pubes, and thence along the lines
innominatae and prolonged on the sacrum, as well as the imaginary plane at
the centre of the pelvic excavation (in the place where Ave usually admit the
middle opening of  the  pelvis, apertura  pelvis media,) Avill resemble, strictly
speaking, an  oblique oval when viewed  in front;  the  transArerse or small
diameter of which  will be represented  by the contracted oblique diameter,
and its great,  or longitudinal one, by the opposite oblique diameter.1  There-
fore, as regards their form, the pelves  in question  might very properly be
designated by the title of the oblique-oval pelvis (pelvis oblique-ovata.)
   " b. That the  distance  from  the promontory of the sacrum to the point
corresponding to either cotyloid cavity (the sacro-cotyloid interval),2 as well
as that from the apex of this bone to the spines of the ischia, would be less
on the side where the anchylosis exists.
   " c. That the distance from the tuber ischii on the anchylosed half to the
posterior superior spinous  process of the opposite ilium, as also that between
the spinous process of the last  lumbar  vertebra  and the anterior superior
spine of  the ilium on the  anchylosed portion, are  smaller than the corre-
sponding dimensions of the  opposite side.
   " d. That the distance from the inferior border of the symphysis pubis to
the posterior superior spinous process of the ilium is greater on the anchy-
losed bone than on the opposite side.
   " E. That the Avails of the pelvic excavation converge someAvhat obliquely
from above dowmvards, Avhereby the pubic arch is more or  less narroAved,
and therefore made to approach in a measure to the form of the male pelvis,
as a natural consequence of  the improper direction of its ramus Avhich is
turned towards the flattened pelvic Avail.  Of course, these tAvo dispositions,
as also the narrowing of the ischiatic notch, the diminution of the  distance
betAveen  the two ischiatic  spines and the one-sided  and  defective develop-
ment of  the sacrum, will be in direct relation with  the degree of obliquity.
   " F. And finally, that on  the  flattened side the acetabulum is  inclined
much more anteriorly than in the normal state, whilst on the opposite side
it  is turned almost  directly outwards ; and hence, when examining the pelvi?
from in  front we can  look  directly into the first  cotyloid cavity, but the
view will only graze the second, or possibly may embrace a  small part of

  1 From  this it is evident that  the lines connecting those points, between which we
are accustomed to imagine the antero-posterior and transverse diameters as passing,
do not cross at right angles in the oblique-oval pelvis, and that the latter cannot be
regarded as possessing oblique diameters such as are attributed to symmetrical pelves.
  2 For sake of  brevity, we use  this  expression here in order to indicate the distance
referred to, it being one which J. Burns thought it necessary to measure and establish,
for te.e purpose of assisting in an exact representation of the form of the pelvic opening 
DEFORMITIES  OF  THE  PELVIS.
633
 rts excavation.  Further, to give as clear an idea of the deformity as possible
 10 those Avho have never seen a pelvis of the kind, we will  observe that at
 first sight  the pelvis looks as if  it had  been pressed in by some external
 force acting in an oblique direction  from below upAvards and from without
 inwards, and  making its  influence  felt on the anterior pelvic Avail at the
 cotyloid  region, whilst the other half of the lateral Avail  has been simulta-
 neously pressed from Avithout inwards, at its posterior part.
   "Another peculiarity of these  pelves is,  that they only differ from  each
 other by the degree of obliquity, and on that side  only Avhere the anchylosis
 takes place; Avhereas, in all other  points,  that is, in the principal character-
 istics of  their  malformation, they  are as similar as  tAvo eggs.  This remark
 is so true, that an experienced person, who Avas unaAvare of the circumstance,
 would be disposed to take two different specimens, if presented to him sepa-
 rately, for  one and the same, and it would even be difficult  to persuade him
 of his error ;  an instance  of which we shall presently give.
   "As to the  other conditions of the bones in the oblique-oval pelvis (laying
 aside the deviations just enumerated), that is, as regards their strength, size,
 texture,  color, etc., they do not differ in  any  Avise from healthy bones, such
 as those  met with  in young persons exempt from  all deformity.  Thus, for
 example, none of those signs are observed in them, neither as to their form
 nor in other respects, which are so often found after rachitis or malacosteon;
 for if the existing deformities were disposed to disappear, all the  pelves Ave
 have yet had an opportunity of examining Avould bear a general resemblance
 to well-formed ones; most of them were of the medium size, and the others
 were either above or below it, but in no one of the cases that we  have par-
 ticularly traced out  has there been rachitic diathesis, and in no one did the
 phenomena, symptoms, or morbid modifications  exist,  which  would have
 either preceded or followed the English  malady, or mollifies ossium, after
 puberty ; and  further, in no instance could the action of external prejudicial
 influences,  such  as falls or bloAvs, etc., be detected, and there were never any
 antecedent  pains or lameness ; although, in  one instance, Ave  suspected  a
 slight limping, from seeing the patient  walk, but other skilful persons, Avho
 Avere present at the examination, did not detect it, and the relatives and all
 the family of  the woman  in question positively  declared they had  never
 remarked anything of the kind.
   " In tAvo  of the specimens of this variety in our  collection Avhich have the
 loAver vertebrae attached, the spinal column is straight in the lumbar region;
 but in the others it is inclined on the side exempt from anchylosis.   In all
 that are provided Avith the lumbar vertebrae, the anterior face of the bodies
 of these bones  is more or less directed towards the anchylosed side."
   One circumstance yet remains  to be explained,  that is,  the  complete
 fusion of the sacrum and  ilium together, and the consequent disappearance
 of the sacro-iliac articulation  on the  contracted side.  Now, is  this anchy-
 losis congenital?  Is it the result of  some inflammation  occurring after
 infancy?  or is  it to be attributed to the  curvature  of the vertebral column?
 We confess that sufficient  materials are  yet Avanting to  decide the question;,
although  M. Naegele  seems t.> think that  this  fusion, as Avell as the defonr 
631
DYSTOCIA.
ity of Avhich, in his estimation, it is the essential character, rest ItJ from an
anomaly of original development; " but," he adds, in conclusion, " I am not
prepared  to  decide  positively."   (For   further details, see M. Danyau's
translation.)
   Whether congenital, or the consequence  of an accidental  disease, Pro-
fessors Gavarret and Paul Dubois regard this anchylosis as the cause of the
flattening of the ilium upon the same side.  When, says M. Dubois, one of
the sacro-iliac symphyses is  affected Avith  anchylosis, the corresponding
coxal bone becomes flattened, and the same alteration is produced on both
sides Avhen the two  symphyses are ossified.  For  my OAvn part, I cannot
admit this relation of cause and effect, for there is nothing to prove that in
M. Noegele's oblique oval pelves, the deformity of the  ilium had been pre-
ceded by anchylosis.   On the contrary, Ave have shoAvn that, as M. Naegele
himself acknoAvledges, there are pelves Avhich present  all the characters of
the oblique oval ones, excepting the anchylosis of the  sacro-iliac symphysis.
Hoav, then, can the anchylosis be regarded as causing the deformity ?
   Dr. Falri thinks that this deformity is  occasioned by compression of the
pelvis during intra-uterine life, during labor, or during early childhood.
   The reader Avill see, by the translation just given, that M. Naegele  attaches
a very great degree of importance to the anchylosis of the sacro-iliac articu-
lation, Avhich he makes a  pathognomonic  character of the deformed pelvis,
described by him under the name of the oblique oval; but, if I might hazard
an opinion after such high authority, I  should unhesitatingly  reject this
proposition, because there are numerous pelves which present all the charac-
ters of these oblique ones, described in the monograph of the Heidelberg
professor, and yet in which there is no fusion of either sacro-iliac articulation
to be found.   M.  Naegele himself, with that candor  characteristic of the
truly learned man, speaks in his admirable \vork of pelves that Avere similar
to those previously described by him, and which only differed from  them by
the absence of anchylosis.  He alludes to several others, and states that he
knoAvs of the existence of many more, the exact description of which  has
been promised  him.   I shall have occasion  hereafter to revert to this sub-
ject, but I cannot  refrain  from saying noAV, that if the anchylosis is no longer
to be considered as a constant  phenomenon, as a pathognomonic character
of the pelvis in question,  if it  is nothing more than a  pathological coinci-
dence,  happening  in most cases, then I  can only see in  the  oblique-oval
pelvis the association of tAvo of the three types, to Avhich Ave have  referred
all the varieties of pelvic  malformation; for,  in considering it in a practical
point of  vieAV, and laying aside its extraordinary anatomical  peculiarities,
it  Avill exhibit, simultaneously, the compression of one of the antero-lateral
walls, and the oblique  prominence of the sacro-vertebral angle.

   § 5. Malformations  dependent upon a Previous  Deformity i>'
another Part of  the  Skeleton.
   We have already alluded, in advance, to the  influence that a malforma-
tion of the spinal column, or of the loAver extremities,  might have over the
shape of the pelvis, and we noAV proceed to illustrate the mode of action in
both cases. 
DEFORMITIES  OF  THE  PELVIS.
635
  A. Deviation of the Vertebral Column.— For a very long period ah the
leviations of the spinal column Avere attributed to the baneful influences of
rachitis; but OAving to the able researches  of  Bouvier, of Guerin, and many
others, this opinion is no longer tenable, since it is  noAV Avell ascertained
that seA-eral other diseases may produce abnormal curvatures in this column;
and this  distinction  is quite as important to the accoucheur as it is to the
orthopedists, for it establishes at once a line of division between those devia-
tions which nearly always coincide Avith  an  imperfect conformation of the
pelvis, and those which often exist, even Avhere the latter is well  formed.
The former are of a rachitic nature; but the latter are developed under the
influence of some  other affection.   For instance, in sixty-nine  cases of
deformity in the vertebral column, described by M. Bouvier,  the pelvis was
in a normal  condition, and the extremities Avere nearly all exempt  from
alteration in fifty-seven, and bute twelve Avere accompanied by a malforma-
tion of this cavity, and by an incurvation of the limbs.
  It must not be supposed, however, that the deviations of the spine which
are not dependent on rickets, have no influence whatever over the direction
and shape of the pelvis.  It is only in subjects of advanced age, as a general
rule, that curvatures of this column, happening after infancy, will ultimately
determine changes in the form and direction of the pelvis; and, therefore.
they have but little interest for the accoucheur.
  As regards the curvatures produced by rickets, though they be not the
essential  cause of  pelvic deformities, yet they do not the less exercise an
unfavorable influence over the degree of contraction, and the irregularity in
the shape of the pelvis ; for the  same action which gives rise to these deformi-
ties in old persons, also produces them,  in  a great measure, in rickety
children.  In either case, the pelvis yields under the influence of the spinal
deviation;  Avith this  difference only, that Avhat takes place slowly in the
aged, is rapidly effected in the  child, because in the latter the  softening of
the bones favors the action of the cause.
  The principal alteration  consists of  an increase of the angle formed by
the junction of the lumbar column with the base of the sacrum, which gives
the pelvis  a  figure  more or  less similar to  that described by Professor
Naegele, under the title of the oblique-oval.
  b. Congenital Luxations of the Femur. —M. Sedillot, in a very interesting
memoir on the congenital luxations of the femur, first called attention to
the influence Avhich  these displacements might  exercise on the conformation
of the pelvis.  The  effects of  this accident  are manifested both in the
greater and lesser pelvis, as may be seen from the  folloAving distances Avhich
he obtained in a case of  double dislocation upwards and outAvards, into the
external iliac fossae, by measuring the principal dimensions of the pelvis : —

    1. From one anterior superior spinous process to the other, .    . 8 inches.
   2. From the middle of  one iliac crest to  the same point on the
       opposite side,   .    .    .     .   .    •     •    •    •    • °f  "
   3. From the middle of the iliac crest to the margin of the abdomi-
       nal strait,..........3J  "
   4.  From the middle of the iliac crest to the tuber-ischii,   .    . 6£  " 
636
DYSTOCIA.
                          Superior or Abdominal Strait.
    5.  Antero-posterior diameter,....... 4J inches
    6.  The same  diameter taken from the pubis to the articulation of
        the first piece of the sacrum with the second,1     .    .     . 4J-   "
    7.  Bis-iliac or transverse diameter,     .    .    .     .    .     . 4J-   "
    8.  Oblique diameter,.....         .    .     . 4|   "
                                 Perineal  Strait.
     9.  Coccy-pubic diameter,......
    10.  Transverse diameter,   ......
    11.  Oblique diameter,       ......
    12.  Summit of the pubic arch,   .....
    13.  Base  of the arch (taken on a level with the inferior
         of the oval foramen),      .....
                               Pelvic Excavation.
    14.  Depth of  the posterior wall,      ...... 5    "
    15.  Depth of-the anterior wall,       ......1J   "
    16.  Thickness of the pubic symphysis,.....\ inch.
    17.  Depth of  the sacral concavity,    .     .    .    .     .     . 1\ inches.
    18.  From the  summit of one ischiatic tuberosity to the same point
         on the opposite side,      .    .     .    .    .     .     . 5£   "

  From these measurements it appears  : 1st. That the transverse dimensions
of the  greater  pelvis are  considerably lessened by the vertical elevation of
the iliac fossae, Avhich approximate each  other to  such an extent as only to
leave  an interval of eight and  a half inches, Avhereas the normal distance
is ten and a half inches.    2d. That the relations Avhich exists, in the normal
state, between the antero-posterior and transverse diameters of the superior
strait  is  changed; since  the transverse diameter is somewhat shorter here

  1  The antero-posterior diameter is generally  measured from the upper and internal
part of  the symphysis  pubis to the superior  border of the sacrum: but M  Sedillot
very justly remarks, that in  many of the  pelves which are the seats of a double con-
genital  luxation, the upper margin  of the sacrum, in consequence of the great promi-
nence of the  sacro-vertebral angle,  is found far above the pubis, and the articulation
between the first two pieces of the sacrum is then on a level with the superior surface
of this bone.   Now, in  such  a case, the true antero-posterior  diameter of the abdomi-
nal strait would extend from the upper border of the pubis to the part of the sacrum
found on  the same level, and this interval,  therefore, is the only important  measure-
ment.   But this observation  is not new, as it had previously been made by Bland, and
repeated by Merriman, in the following  note: " Although the  sacrum be carried so
far  forward that  it seems to reduce the antero-posterior diameter at the entrance of
the excavation to two  or three inches, it is necessary in  determining  the degree of
contraction to observe the  difference in elevation between the sacro-vertebral angle
and the upper part of the symphysis.  The pubes being placed something lower than
the greatest projection of the sacrum, and  opposed to a part of that bone  that is di-
rected  strongly backward, the real distance between them  may be much more consid-
erable  than it may seem to be to the touch.  Whence it happens that in cases where
the projection of the sacrum has occasioned exceeding great difficulty in  the begin-
ning of the labor, opposing  an almost insuperable bar to the entrance of the head of
the child into the pelvis, by directing it too far forward over the pubes, yet when that
direction has been altered by the use of instruments, or by any other means, and the
head brought into the line of the centre of the pelvis, the conclusion of the labor has
been frequently effected with very little exertion or force." — Bland's Observations.
 .     . H   "
 .     . b\   «
      . 4|   «
 .     . n   ««
border
      . 4£   « 
DEFORMITIES  OF THE  PELVIS.               637
 than the antero-posterior one;   Avhereas, in the ordinary state, it is nearly
 an inch longer.   3d. That an  inverse  change takes place at the inferior
 strait, the  bis-ischiatic  diameter being five and a quarter inches, Avhile the
 coccy-pubic one is but three and a half  inches.
   These last modifications, says M. Sedillot, are easily explained, being the
 consequence  of the  natural position of the  femurs  in  the  external  iliac
 fossie; for individuals afflicted Avith a  double luxation of this  kind, Avalk
 with the legs wide apart, so as to bear and rest the heads of the thigh-bones
 against the sides of the ilia; though the effect Avould still be the same, even
 if their  progression Avere not performed in this manner, because the  external,
 lateral and superior surfaces of these bones, which usually incline outAvards,
 will ahvays be pressed upon to a certain extent, by the heads of the femurs,
 Avhich have  a  tendency to  straighten and carry them  inwards.  Whence
 the pelvis, from being thus compressed laterally, is elongated from behind
 fonvards, and  forms, in this latter direction, a more or  less acute angle.
 The iliac fossae, experiencing the pressure more directly, have yielded in a
 marked  degree, though more at  their middle than  in  front, because  the
 head of the thigh-bone is thrown far back, and compresses the middle more
 than  the anterior part  of these fossae.   The  ilium  is often rendered more
 straight and nearly vertical, instead of being inclined outAvards; and, should
 this phenomenon  exist on  both  sides, it  might interfere  with the regular
 development of the Avomb;  but if on  one side only,  it  might occasion an
 obliquity of this organ in the opposite direction.
   The anterior margin of the ilium also presents  a singular disposition;
 for the  conjoint tendon of the psoas magnus and iliacus internus muscles,
 which is inserted  in the lesser  trochanter, is then changed  from  its usual
 direction, and is carried upAvard by the  ascent of the thigh-bone, and, as a
 consequence, this tendon  deepens and changes the direction of its  groove;
 Avhereby the  anterior inferior spinous process is turned  aside in a more or
 less sensible degree.
   The shortening of the transverse diameter of the upper strait is evidently
 due to the lateral pressure made  by the  heads of the femurs almost perpen-
 dicular  to  this strait; and, as  a flattening in the transverse direction is
 necessarily  accompanied by an elongation antero-posteriorly, the sacra-pubic
 diameter is found augmented  in a corresponding degree.
   The examination of the inferior strait also exhibits a very curious phe-
 nomenon, just the reverse of what Ave have met with at the abdominal one;
 that is, there is a considerable increase in the extent of its transverse diam-
 eter, with a notable diminution in  that of its coccy-pubic one.  Here, also,
 the situation of the femurs  must  be  referred to in explanation of the cir-
 cumstance;  for these latter are carried far upAvards, outAvards, and back-
 wards, since their superior articular extremities have escaped up  into the
 external iliac fossa);  and they keep the surrounding muscles constantly tense
 (more particularly the  quadrati,  the gemelli, and  the  internal obturator
muscles,  Avhich run from the  ischiatic tuberosities to the extremity of the
thigh-bones), and thus  drag the  ischium outAvards;  the lower fibres of the
obturator externus and the adductor muscles, and the internal part of the
articular capsule, act in the same manner on the columns of the pubic arch, 
638                             DYSTOCIA.
thereby producing a wide separation of the tAvo ischia.  The latter, in turn
drayv on  the greater and  lesser sacro-sciatic  ligaments, thereby creating a
greater curvature in the inferior bones of the sacrum and coccyx, and con-
sequently  the diminution  of the coccy-pubic diameter, as  also a greater
depth  in  the concavity of the sacrum.   The Avant of depth in the pelvic
excavation depends on  the  same cause;  for, Avhen the ischium is draAvn
toAvards the external  iliac  fossa, the lower part of the  pubic arch is neces-
sarily bent out, and, as a consequence, the depth of the pelvis anteriorly is
diminished.   (Sedillot.)
  The Aveight of the body Avhen erect, is the principal agent of this deformity;
which  essentially results, as just stated, from the tension exerted from Avithin
outAvards on  both  sides by  the capsular ligaments  of the two deformed
articulations, which hold the trunk suspended, as it  Avere, betAveen the thigh-
bones ;  and the force exerted  by these ligaments  on the pelvis is equal in
power  to the tendency of the Aveight of the body to elongate  them.  Lastly,
the contraction of  the cotyloid  cavity has some  little influence over the
change in extent, which  the pelvis undergoes, though it explains but a very
small part of the deformity.   (Bouvier.)

  [Dr.  Lefeuvre (Paris, Thesis, 1862) very properly insists upon the changes  pro-
duced in the inclination of the pelvis.   Tlie most constant effect, says this physician,
of congenital luxations of the femur, is a deviation of the normal inclination of the
pelvis.   The position which the femurs occupy in the external  iliac fossae so alters
the conditions upon which  the stability of the body depends, that the pelvis, pressed
from above by the weight of  the parts above  it and supported only  from behind,
becomes tilted forward. To  this inclination of the pelvis is due the lumbar depres-
sion, which is  increased still  more by the  posterior  projection  of the shoulders
required for the maintenance of equilibrium.  The normal inclination of the supe-
rior strait, which Avas  estimated  by Osiander at 30 degrees, and  by  Levret at 23
degrees, was studied  very carefully by Naegele, who brought it  to 59 degrees.  In
congenital luxations  the inclination, may amount  to 80 or 85 degrees, as is shown
by  the specimens, Nos. 739, 744, 763 C in Dupuytren's museum.  It  may even be
still greater, become  vertical, or even go beyond the perpendicular.
  The  inclination of  the inferior strait is increased at the same time, though not
always in  the same  proportions, on account of the variable  depth of the cavity of
the pelvis.
  This forward inclination of the pelvis causes the anterior face of the sacrum  to
become inferior, and it may happen that  the vertebral extremity shall be found
lower than the coccygeal.  The symphysis of the pubis becomes at the same time
horizontal instead of vertical.
  When the luxation is double, the inclination is  nearly uniform on both sides, and
the vertebral  column presents an antero-posterior curvature.  When the luxation is
single, at the same time that the  pelvis is inclined forward, a lateral inclination
also takes place, due to the lowering of the luxated side on account of the want of
support from the head of the femur.   In this case the vertebral column will exhibit
an  antero-posterior  curvature, with deviations  toward the side  of  the  luxation.
(Lefeuvre.)]

   The deformity is often irregular, or non-symmetrical, because the changes
effected in the pelvis are more marked on  one side  than on  the other;
though, generally speaking, they are found to bear a relation to  the degree 
DEFORMITIES  OF  THE  PELVIS.
639
of organization  in  the new joint;  and  if any  accidental articular  cavity
exists, they are more developed on that side.
  A pelvis, Avhich has  been referred to by M. Gerdy in his learned report,
read before the Academy, on congenital  luxations, and which presents some
very singular modifications, may be seen at the Musee Dupuytren; it only
has one  femur  attached, Avhich  is  fused  outside of  the  anterior inferior
spinous process of the  ilium  on  the left side.   The anterior superior spine
of the opposite coxal bone is tAvo inches  higher than the left one, and both
bones are fixed Avith an equal  degree of solidity in these relative situations;
the sacrum, though very short, is quite broad, and the superior strait exhibits
u modification  similar to Avhat  has just been described; as to  the inferior
strait, it is very  large in every direction, because the sacrum  is  exceedingly
short, and the anterior pelvic Avail is  bent, as it Avere, forward and  down-
Avard, on the same transverse and vertical plane, instead of being curved or
bent doAvn wards and backAvards as in the normal state.   (See No. 252, Musee
Dupuytren.)
  We have extracted from the memoir of M. Sedillot only those peculiarities
that seemed important to be known, though we trust  that enough has been
given to prove that Dupuytren was greatly mistaken Avhen he asserted that
ihe phenomena of primitive  luxations had no influence Avhatever over  the
development of  the pelvis, and that the latter offered no  greater obstacles
to delivery than it does in well-formed persons; the incorrectness of  Avhich
assertion is doubtless sufficiently proved  by the details into Avhich Ave have
entered.  HoAvever, it  must be acknoAvledged that in such cases  the delivery
is seldom impossible, although it  may be attended Avith some difficulties ; at
least, no instance has yet been recorded in Avhich the expulsion  of the foetus
could not take place without having recourse to a bloody operation  on the
mother or child, which is most certainly OAving to the fact that, in congenital
luxations, the contraction takes place in the longest diameters,  both  of the
superior and inferior straits.
  In a recent publication, M. Lenoir expresses an opinion so  far contrary to
that of M. Sedillot, as  to suppose that double congenital luxations produce
no notable  alteration of the shape of the pelvis;  and he mentions, in sup-
port of his vieAV, the pelvis of a young Avoman,  the dimensions of Avhich he
gives.  These dimensions hardly differ  from those  of the normal pelvis,
except as regards the inferior strait, where they present an increase in extent
of rather less than half an inch.
  The observations of M. Lenoir  prove merely  that >the remarks  of  M.
Si'dillot are not applicable to all cases ; still, the facts observed by the latter
surgeon are of great value, shoAving as  they do that  congenital  luxations
may in some cases produce a marked change  in the form and  dimensions
of the various parts of the pelvis.
  M. Lenoir insists  much more strongly than M. Sedillot upon the effect of
simple congenital luxation.   The latter  is, he states, accompanied  by an
arrest in the development of all that side of the pelvis corresponding  to the
luxation, Avhich  atrophy produces so great a deformity of  both  straits and
the  excavation,  that  Ave  may be  certain,  that although  delivery  is not
ahvays rendered impossible thereby, the  labor will at least  be  longer and
more difficult. 
640
DYSTOCIA.
  The latter proposition is, I think, by far too absolute, and facts are want-
ing to prove it.   The deformity which follows simple luxation is much less
than  that  resulting from  a double displacement, and the specimen of M.
Pacoud, described by  M.  Lenoir, seems to me in no wise to  justify his
assertions.
  Is  M. Lenoir more  fortunate  in his endeavor to trace a resemblance
betAveen a  pelvis deformed in  consequence of a simple luxation than the
oblique oval pelvis of M. Naegele ?  The points of difference between these
two pelves are so numerous, that  he has  seemed  to  me to  force whatever
analogies may exist, by placing  them in the same category.  The  anatomical
characters  do not justify it, and the prognosis especially is  much less seri
ous;  finally, the  indications to be fulfilled jn both  cases  are  essentiallj
different.
  C.  Non-congenital Luxations.—The atrophy of the  iliac bone  corre-
sponding to the  dislocated femur may also be met with in luxations occur-
ring after birth, whether the luxation be the result of an  accident, or con-
secutive to an organic  alteration of the articular surfaces, as in coxalgia.
To  produce this effect, all that is necessary is, that  the luxation  should
remain  unreduced, and that it should  have occurred Avithin the  first years
of existence.  Noav, as this  atrophy  Avas the cause of the deformities of
the pelvis  studied  in  the  preceding  paragraph, it  may have the same
consequences in the  case  under  consideration.  It  is  also  plain that the
pelvic deformity will be great in proportion as the luxation  shall have
occurred at a very early  age.

  [As M. Depaul  observes (Bulletin  de la Societe de Chirurgie, annee, 1865), the
cause  of these luxations  ought also to be  taken into serious consideration.   AVhen
traumatic, it is much  less likely to  occasion deformity of the pelvis than when
consecutive  to disease of the bones.  In the same  paper are found two cases men-
tioned by M. Blot of unilateral luxation, caused by coxalgia in early childhood,
giving rise  to difficult labor.  Omphalotripsy Avas  necessary in the first case: the
antero-posterior diameter  measured three and  a quarter inches; the right oblique
diameter corresponding to the shortened member had its length notably diminished.
In the second case, the antero-posterior diameter measured three inches, but as the
patient was deliA^ered prematurely, the foetus was extracted with the forceps.]

  D. Lesions of the Inferior Extremities.—The curvatures, so often met
with in the lower limbs, do not ahvays diminish  their  length in an equal
degree; and this unequal shortening determines a variation  in the pressure
they make on the bottom  of the cotyloid cavities; and, consequently, may
affect the pelvis on the side Avhere it is the greater.  It  is so true that the
imperfect conformation of the pelvis is then  dependent on  a difference  in
the length of the lower  extremities, that the latter  may often be  curved
(provided  they maintain the same length), Avithout the pelvis being  neces-
sarily vitiated;  and also,  that where any  inequality  does exist betAveen
them, there is quite  a  constant relation  betAveen the  deformed iliac bone
and  the longest limb.   When  a  Avoman Avith deformed  pelvis  limps, she
always does so on  the sound and not on the diseased side, as one Avould be
led  to suppose at first thought.
  It is further possible, that a shortening  of  one of the legs, whether result- 
DEFORMITIES  OF  THE PELVIS.
641
 ing from a fracture, a luxation, or  an atrophy of the  limb, may  produce
 the same result;  more especially if these accidents take place in early child-
 hood, when the pelvis is still far from having acquired its full development.
 Persons  affected with chronic  diseases of one of these limbs, and therefore
 under the necessity  of walking Avith crutches, and of  bearing  the whole
 weight of the body on the sound leg, incur the same danger.  Nevertheless,
 this latter circumstance has not  ahvays such an unfortunate influence; for
 Dr. Campbell mentions that he had an opportunity of examining the body
 of a Avoman who  had made use of  a crutch since  the fourth year of her
 age, in consequence of a disease in her right  lower extremity;  this  person,
 who died some time after delivery, had a perfectly formed pelvis.  ( Campbell,
 page  249.) _
  Amputation of the thigh, in a young girl, particularly in early childhood,
 is likewise  capable of  deforming the pelvis:  thus, for example, Madame
 Lachapelle found the superior strait,  in  a female  aged  eighteen  years,
 reduced  to  a moiety of its extent  on the  right  side only, and  pushed in
 totally tOAvards the left thigh, Avhich  had been amputated  four  years pre-
 viously.   Indeed, we can readily imagine that, as the artificial  limb only
 derives its point of support from the ischium, the acetabulum of the sound
 side will alone continue to be compressed by the Aveight  of the body.1

                          ARTICLE  III.

  INFLUENCE OF  DEFORMITIES  OF THE PELVIS UPON PREGNANCY AND
                              PARTURITION.
  The deformities may certainly have an  unfavorable influence over the
 progress  of gestation;  for, as we have  already  stated  in the  article on
 abortion, Avhere the contraction  of the straits accompanies an enlargement
 of the excavation, the womb, finding a more considerable space than usual
 in the cavity of the lesser pelvis, may become developed, and remain there
 beyond the ordinary period ; and we  have considered this circumstance as
 one of the causes of abortion, from the impossibility of its getting subse-
 quently  above the superior strait; and, when treating  of retroversion, Ave
 remarked that this displacement was singularly favored by an increased
 depth in  the concavity of the sacrum.
  Even in cases of slight contraction of  the superior strait, the sort of im-
 paction Avhich  the uterus undergoes  from  the early  stages  of pregnancy,
  1 According to Campbell, the deformity of the pelvis may also be produced by con-
 tusions received on the  dorsal region during childhood.  I have, he says, met with
 several examples of the kind. A few years  ago, I saw a patient who, when three
 years old,  received a violent blow upon the lumbar region ; the pelvis was in her case
 bo deformed, that I thought, it right to induce labor at the end of the seventh month.
 Although the pains were powerful, the head remained for seven  hours in the excava-
 tion, but the child was nevertheless expelled.  It  lived eight days, and died  in con-
 vulsions.   Several fractures of the cranium were discovered at the autopsy, and several
subcutaneous  ecchymoses,  caused evidently by the pressure to which the foetus had
been subjected during labor.  (Campbell, Introduction to the Study of Midwifery, p. 248.)
  This observation is too incomplete to justify the opinion of the author. Was the
pelvis really contracted?  Was not the woman  rachitic? &c, &c.
      41 
642
DYSTOCIA.
may produce a violent compression of the organs situated in the excavation.
Van Doeveren mentions a very curious case, in  which the patient  expe-
rienced such acute pain in the hypogastric region from the third  month of
gestation as at first to excite fears of abortion.  The  symptoms continued,
notwithstanding the use of the most rational  means.  By careful  examina-
tion, he detected an oval tumor, painful  to the touch, and extending above
the umbilicus.  The patient urinated frequently, though in but small quan-
tity at a time.  He suspected a dropsy  of the uterus.  The  suffering con-
tinued in spite of all  that could be done, and the patient greAv Avorse and
worse,  until one morning when he found her  much better and relieved of
her excruciating pains.   She no longer  had  fever  nor difficult respiration,
and the tumor had disappeared;  the abdomen was flatter, softer, and pre-
sented an obscure fluctuation.  He thought that the uterus  had been rup-
tured,  and, notwithstanding the contentment of the patient, gave  the most
unfavorable  prognosis.   She  died, indeed, two days  afterward.  At the
autopsy it Avas discovered that the greatly distended bladder  had given Avay
at its upper part. The uterus filled the lesser pelvis so  completely as to leave
no space between it and the walls  of the pelvis.  It compressed the vessels,
the pelvic  nerves, and the rectum, as also the urethra, against the  pubis.
The sacro-pubic diameter was but three inches and eight lines in extent.
  When the transverse diameter of the  greater pelvis is contracted by the
straightening out of the iliac crest, as occurs  in double congenital luxations
of the  femur, the development of the uterus is considerably impeded during
the latter months of pregnancy; and this difficulty, according  to  Ant. Du-
bois, may prove a cause of premature labor.   Where the straitening exists
on one side only, the inconvenience is less;  but still it may possibly con-
tribute to the production of considerable uterine obliquity on the  opposite
side.
  In general, hoAvever, with the exception of certain inconveniences, which
evidently depend more on the extraordinary obliquity of the planes of the
pelvis  than on a diminution of its cavity, and  to Avhich  we shall take occa-
sion hereafter to revert, such contracted pelves rarely interrupt the course
of gestation;  but they have a  far  different  influence upon the  labor,  to
which  we  now ask the reader's attention more particularly.
  The impediments to the delivery Avill  usually be greater as the deformity
of the pelvis  is the more considerable;  however, this proposition, although
true in the majority of  cases, is not absolutely so, since the degree of nar-
rowing is not the only point thac demands the  accoucheur's attention; for
the child's  position, the size of its head,  the flexibility of the cranial bones,
the power of the uterine contractions, and the variable degree of relaxation
of the pelvic  articulations, are  so many important circumstances which
claim his consideration.   One woman, perhaps, is happily delivered at term,
whilst  another, Avhose pelvis  offers  the  same dimensions, will  require the
intervention of art  for her relief.  The same woman may be spontaneously
delivered of her first child, and  yet present  such  difficulties at the second
labor that the mutilation of the  foetus may be deemed  to be the only remedy
for sparing her a bloody  operation, without our thereby concluding that her
pelvis  had  become contracted between these tyvo pregnancies ; for  these dif- 
DEFORMITIES  OF  THE  PELVIS.
613
 ferencts might depend  solely on the greater volume, or a less degree of
 reducibilitv of the head, or the bad position of her second child, &c.  Most
 accoucheurs have observed facts of this  nature, but we only present the fol-
 loAving: A patient  presented herself at the Clinique, in 1838, whose  pelvis
 was only tAvo and three-quarter inches in its sacro-pubic diameters ; she Avas
 delivered  in eighteen hours of a living infant, at term, the dimensions of
 which Avere nearly normal, and Avhose head was scarcely deformed.  Baude-
 locque relates having seen, at the amphitheatre of Solayres, the head of a
 fetus Avhich was elongated to  such'  an  extent that its  greatest  diameter
 measured nearly eight and a half inches, whilst the bi-parietal one was  re-
 duced to two and three-eighths, or tAvo  and  three-quarter inches; and  he
 speaks of another very similar instance; but in neither of these cases was
 the child's life  compromised for a single instant.  M. Martin, of Lyons, has
 knoAvn a rachitic Avoman to be  delivered of a  healthy infant at term, by the
 efforts of nature alone; where the  autopsical  examination showed that the
 antero-posterior diameter Avas only tAvo  and a half inches in extent (page
 270.)  AVhat rendered this case still  more  extraordinary Avas  the existence
 of scirrhous tumors in the substance of the uterine Avails.  The reductibility
 of the head, therefore, is sometimes excessive, but unfortunately it is almost
 impossible to appreciate this in a positive manner beforehand.
   To this source of uncertainty, says Madame  Lachapelle, let us add that,
 in certain Avomen, the degree of mobility of the  symphyses does not permit
 a general separation of the bones (which, even if it existed, would scarcely
 enlarge the area of the strait or of its diameters) ; but rather a mutual glid-
 ing of the  articular surfaces upon each other, an overriding of  the pubes,
 so that one of the innominata advances to a range with  the  sacro-vertebral
 angle, Avhilst the other recedes to a greater or less extent.  It folloAvs from
 this mechanism that one of the oblique diameters at the superior  strait, the
 one corresponding to the long  diameter of the  head, is notably increased;
 and the sacro-pubic  one is also found augmented  by the advancement of
 one of the coxal bones.  Finally, continues this skilful midwife, it may be
 possible for both hip-bones to glide forward simultaneously, thereby enlarg-
 ing still more the antero-posterior diameter.
  In most cases of deformity, the child's position is far from being an indif-
 ferent matter; for Avhen the sacrum, in being carried forward, is at the same
 time turned to one side, Avhereby one of the lateral portions of the pelvis is
 more contracted than  the other, avIio  does not foresee, that the labor may
 then be accomplished  spontaneously, if the head presents in such a way as
 to offer its  great occipital extremity to the Avell-formed  side; and that, on
 the contrary, it Avould become  impossible, if the occiput should correspond
 to the contracted one ?
  Where the contraction is so limited that it might possibly permit a spon-
 taneous  delivery, any unfavorable position of the foetus Avould greatly add
 to the existing difficulties caused by the  malformation of the pelvis; if, for
 example, instead of presenting by the vertex, the child should offer its pelvic
extremity, there Avould be  reason to fear an arrest of the head  above the
superior strait, after the escape of the trunk ; the sloAvness of its passage
through this strait Avould not often Avarrant the abandonment of the delivery 
644
DYSTOCIA.
to the resources of nature, both from the dangers the infant  /ncurs from a
compression of the umbilical cord, and from the feebleness of the contrac-
tions of the womb, Avhich, being almost entirely emptied  and retracted, no
longer retains its contractile properties.   (See  Presentation by the Breech.)
  We need scarcely  add,  in conclusion, that a proper degree of energy in the
uterine contractions  bears so prominent  a part in the accomplishment of
labor that it cannot be overlooked.   In certain cases, for instance, Avhere
the pelvis is so little contracted that the child's delivery is still possible  by
the application of the forceps, it is evident that frequent and strong contrac-
tions of the womb Avould render this  instrument useless ;  again, the labor
will terminate alone, in a case  Avhere the  physician Avould have been obliged
to interfere, if the pains had been too feeble or too slow.
  We may conclude, therefore, that, in the question  before  us, there are a
number of elements which may influence  the result;  and that, if the degree
of narrowing of the pelvis is the most important point to be Avell ascertained,
it is not the only circumstance upon Avhich  the  obstetrician  ought to  base
his  determinations.  For although the means of arriving at an exact knowl-
edge of the extent of contraction are almost  sure, yet, unfortunately, the
same does not hold good with regard to the volume and the reducibility of
the fcetal  head, or the mobility and possible separation of the pelvic sym-
physes ; and it is impossible to calculate in advance  all the resources of the
organism, or to  know how far the uterine efforts will go.   From our igno-
rance, on  most of these points, arise the uncertainties and hesitations which
so often prove fatal either to  the mother or the child; uncertainties and
hesitations that never influence persons that are not versed in all the difficul-
ties of our art, but which are Avell understood  by learned and  experienced
practitioners, AA'ho have frequently been under the paiiiful necessity of making
a decision and of determining a question whose solution might cost the lives
of tAvo individuals whom  our mission is to save.
  The foregoing reflections will, I hope, be sufficient to show that Avhat Ave are
about to say concerning the influence of the pelvic deformities upon the labor
is not positive and absolute, but is only applicable to the majority of cases.
  Under  the  head  of  the difficulties and indications presented by these
deformities, Ave  shall admit, with M. P. Dubois, three principal  divisions.
The first is composed of pelves in Avhich the contraction, in whatever part
it may exist, still leaves at that part an opening of at least three and three
quarter inches in all its diameters; the second comprises those in which the
contraction  leaves, at the point of the canal it  occupies, a passage, one or
more of Avhose diameters  Avill be three and three-quarter inches as a maxi-
mum, and two and a half inches as the minimum; and, lastly, we shall in-
clude in the third all the cases where the narroAving is such, that the dimen-
sions of the resulting space Avill be under tAvo and a  half inches.
  A.  Of the Pelvis having at least three and three-quarter inches in its Con-
tracted Part.—Here the  labor, although in general  longer,  more difficult,
and therefore  more dangerous, both for the mother and child, than in ordi-
nary cases, may, ho\vever, be accomplished spontaneously; and, indeed, we
might hope for such an expulsion in most cases.  The sloAvness of the labor
is observable in the dilatation of the os  uteri, as Avell as in the expulsive 
DEFORMITIES  OF  THE  PELVIS.                645
stage :  for, during the first stage, the uterine contractions, though energetic
and ci'ten  regular, have but little action on the dilatation of the cervix; the
head is high up, and has  no tendency to engage in the excavation, and it
remains above  the  symphysis  pubis, against yvhich  it is strongly applied,
being throAvn  forwards by the prominence  of  the  sacro-vertebral angle.
Indeed, it is highly probable that the extreme slowness of the dilatation is
attributable to this latter circumstance ; for the lower front part of the Avomb
is so compressed betAveen the child's head and the pubic symphysis, that the
longitudinal fibres of the  body can  scarcely act  at all on the circular ones
}f the cervix,  notAvithstanding the energy of their contractions;  for we
often find, after the size of the  head has been diminished by a perforation
of the  cranium, whereby  this  compression is relieved, at least  in  a great
measure, that  the dilatation that  Avas hitherto  stationary now progresses
very rapidly.
  As to the modifications that take place  in the period of expulsion, they
vary according to the seat of the contraction ; for instance, Avhen the supe-
rior strait is the place of the deformity, the engagement of the  head might
be so much retarded that it could only succeed in  clearing this obstacle
under the influence of the most powerful contractions; though, should these
he sustained, the labor would  terminate happily.  But if,  as is sometimes
observed, the corresponding diameter of  the inferior strait is simultaneously
enlarged, the child's head, after having surmounted the difficulties offered at
the upper one, will  not find a sufficient degree of resistance at the perineal
strait  to moderate the rapidity of its descent; and, consequently, it might
strike violently against, and  lacerate  the  perineum ; the  disastrous conse-
quences of which are Avell known.
  Where  the superior strait retains its normal dimensions, the inferior  one
alone being contracted, the head descends  rapidly enough into the excava-
tion, but it can only clear the last parts of the canal Avith the greatest diffi-
culty ;  for, as the dimensions of the loAver strait are in general someAvhat
smaller than those of the  upper, it  folloAvs  that the same degree of contrac-
tion here is much more unfavorable to the delivery, and oftener requires the
application of the forceps.
  Finally, Avhere the tAvo  straits are contracted in the same degree, all the
causes of difficulty just mentioned  are found conjoined.  Most frequently,
the head succeeds in passing the superior strait; but,  having reached the
excavation, and being  unable to  advance  any further, it there remains
Avedged in until the exhausted  or enfeebled forces are sufficiently renovated
to effect its delivery.  During all this  time, the head, which had been  for-
cibly compressed in order to  clear the upper strait, and had its dimensions
reduced by the overlapping of the parietal  bones, gradually  regains  its
natural size, iioav that it has entered a larger space, departing also from the
conical shape it had acquired in the first stage, as its delay there is the more
prolonged, and, consequently, meeting Avith neAV obstructions at the inferior
6trait, which are so much the more difficult to overcome as the uterine forces
are already the more exhausted^
  These differences in  the seat of the contraction ought to be knoAvn, foi
they will enaole the accoucheur to avoid an error in diagnosis which other- 
646
DYSTOCIA.
wise he  might very readily commit; for example, in  the cases where th-
superior strait alone is contracted, the head gets  into the excavation only
after very long-continued pains, but then  it clears the inferior one  almost
immediately afterwards;  Avhereas the  contrary happens when this latter is
the only one contracted, and the attending physician, judging of the future
by the past duration of the labor, announces that it AviU terminate sooner
or later, according as the head has descended more or  less rapidly into the
excavation;  but  he will almost always deceive  himself;  because  in the
former instance, the termination will  be very rapid, though he believed it
still  distant; and, in the.latter, it will  be delayed far beyond the time that
he had fixed.
  B. Where the Pelvis  has at least two and a half inches  in its Contracted
Part.—A spontaneous expulsion of the foetus is still barely possible, Avhere
there are from three and one-eighth to three  and three-quarter inches in the
contracted part;  though, in reflecting on the length of the  head's smallest
diameter, which at  term is at  least three and one-half inches, it must be
evident that, in order to render  the delivery practicable under such circum-
stances, the diameters of the cranial vault should present a great reducibility,
and  the contractions of the Avomb  be strong and prolonged.  But in an
immense majority of  the cases under three  and  one-eighth inches, the
resources of art become indispensable, unless the  child's  parts should be
softened by putrefaction, or the infant itself not have acquired the develop-
ment it usually exhibits at the ordinary term of gestation.
  C. Where  the Contracted  Diameter is less than two  and a half inches.—
This degree of contraction renders a natural labor at term  physically impos-
sible ; because  too great a disproportion  exists between the dimensions of
the  canal  and those of the body Avhich has to  traverse it;  and  no other
alternative remains for the accoucheur than  to augment the former by sym-
physeotomy, or to diminish  the latter by embryotomy; unless, indeed, he
should rather prefer to open for it a new and more easy route by practising
the Caesarean operation.
  M. Depaul, it is true, mentions in his lectures two cases, in Avhich delivery
was  safely accomplished although  the pelvis had only two and a quarter
inches in its antero-posterior diameter.  They are, hoAvever, such rare ex-
ceptions  that they might be  forgotten, so to speak, in  ordinary practice.
Safe delivery ought not to be counted on with a diameter less than twb and
five-eighths  inches.
  As regards the prognosis,  it is  very important to  distinguish  a pelvis
deformed by rachitis from one  whose  contraction is dependent on mollities
ossium ; for  although, in the former case, the gravity of the prognosis is only
in proportion to the  degree of contraction, yet it is not exactly or ahvays so
in the latter.  Here, indeed, arises the  important  consideration that  the
first  effect of malacosteon is to produce an excessive softening of the osseous
tissue, the  deformity of  the  skeleton  being consecutive thereto:  but this
softening only reaches  its summum of  intensity by degrees, and the disease
may be arrested in its  progress,  may be ameliorated, or even entirely cured,
under the influence of a proper treatment.  Whence it  is  evident that,
during the period of increase and that of its amelioration, Avhich may extend 
DEFORMITIES  OF  THE  PELVIS.
647
 over several years, the softening passes successively through different degrees,
 and where it happens to exist at the time of labor, furnishes the practitioner
 a very valuable resource, AA'hatever may be the degree of contraction.  In
 fact,  it would appear, from  the  cases reported in  the  dissertation of M.
 Bpengel, that the bones often retain, at the time of labor, a sufficient degree
 of suppleness to enable them  to dilate spontaneously, and to alloAV the ex-
 pulsion of the foetus, or, at least, its artificial extraction.   Thus, in a case
 furnished by Homberger, the sacro-pubic diameter Avas scarcely tAvo inches
 in length ; nevertheless, after having  ascertained the  flexibility of the bones
 caused by the malacosteon, he declared that the delivery might be effected
 by the poAvers of nature. He ruptured the membrane^ at the end of tAventy-
 four hours ; then, after Avaiting as  much longer ;  the engagement  Avas suffi-
 ciently advanced to enable him to apply the  forceps; when, by the  aid of
 poAverful tractions, he  succeeded  in  bringing aAvay a  girl Avho lived  four
 weeks.   In  another woman,  whose  sacro-pubic diameter  was tAvo  and  a
 quarter inches (French measurement)  at the most, Hasslocher, a physician
 of Landau, was enabled, by the aid of external pressure, to make the child's
 head engage in the cavity of the pelvis; he then  applied  the forceps, and
 found that only a moderate  effort Avas required  to deliver  a dead  child
 Aveighing six pounds and a half.
   Lilian mentions other-cases of  safe  delivery during pregnancy, and  Dr.
 (Jollineau Avitnessed another,  an  account  of Avhich  will  be  found  in  his
 excellent thesis.
   Facts of this nature are certainly consolatory, and they well merit atten-
 tion ; but, unfortunately, it is a very difficult matter to recognize that precise
 degree of flexibility in the bones, under Avhich there is no  reason to hope for
 a spontaneous dilatation ; for,  betAveen  the first stages of softening in them
 and that advanced period  when  they scarcely have the consistence of  a
 gelatinous  pulp, there are numerous  intermediate  degrees; and  the great
 difficulty consists in  determining  the  cases  in Avhich Ave can trust to  the
 efforts of nature, and those in Avhich nothing can be hoped from this source.
 A misplaced confidence might be attended  Avith  the  most  seriou^  conse-
 quences ; for, on the one hand, a prolonged delay may compromise  the
 child's life, that might have  otherwise been saved, by  resortb   to  the
 Caesarean operation at  the most favorable  moment; and on the other,  the
 tentatives uselessly  made Avith the forceps expose the mother to the greatest
 dangers ; for bones affected by this disease are, it is  true, most generally soft-
 ened, but sometimes it happens that  the affection  has only rendered them
 more friable, and, of course, any tractions made by the instrument, in such
 cases, might give rise  to dangerous  fractures.  It Avould, therefore, be highly
 desirable to have a  rule of procedure,  but in the present state of our science
 it is impossible to  lay doAvn any positive one;  and  the  accoucheur must
 found his opinion on the Avhole of the  phenomena exhibited in the particular
 case.  " Without supposing," says  M. Spengel, "that it will  be possible to
 ascertain, positively, to  Avhat extent the softening  of the  pelvic bones has
advanced, wc believe that, by paying  attention to the symptoms which pre-
ceded and those that accompany the labor, it may be determined in quite a
probable manner.  We have collected forty cases of general mollifies ossium 
648
DYSTOCIA.
 that occurred in females; in nineteen of AA'hich the time when the pains first
 began is not noted, and no conclusions therefore can  be draAvn from them ;
 but, in twelve cases, the  first  pains  appeared during the lying-in, in tAvo
 others, shortly after the accouchement,  and in the remaining seven, during
 the course of gestation;  and, whenever the period has been carefully noted
 when  the  pains, after having  been once calmed, were aggravated  aneAv, it
 has  been found that  this exacerbation  came on  during a neAV pregnancy.
 Whence we may suppose that the softening of the bones is more considerable
 toAvards  the end of gestation than it Avas before its commencement.  There-
 fore, Avhen the alteration progressively increases until  term, and the difficulty
 in the patient's movements or the pains exhibit no  diminution, we believe
 the degree of softening may be regarded as bearing a  relation to the violence
 and duration of these symptoms.   Further, by  resorting to the  manual
 exploration,  we are enabled to detect in some cases a softening to  such an
 extent that the bones yield to  the pressure of the fingers.  Under such cir-
 cumstances the accoucheur may doubtless rely on a spontaneous delivery, or
 at least on the success of a prudent application of the forceps; Avhich  latter
 should then be made rather than resort to the Caesarean operation, which is
 so grave at all times,  but is still more so when practised  on Avomen  affected
 with malacosteon."
   Independently of the difficulties which the contractions of the  pelvis give
 rise to in the accomplishment of the mechanical phenomena of  labor, they
 often become the source of serious accidents to the mother, and  subject the
 foetus to  the  greatest dangers.   For,  by forming an  invincible obstacle to
 the passage of the head, they expose the woman to a rupture  of the Avomb
 or bladder, to a violent contusion, and the consecutive inflammation of those
 organs and of the peritoneum,  and, lastly, to a febrile or  adynamic  state,
 Avhich is serious enough of itself to cause her death  before the  delivery is
 effected; since this  condition  is the most frequent source of mortality in
 those patients who are not relieved.   Again, even Avhere the  delivery has
 taken  place either spontaneously or artificially through the natural passages,
 the duration of  the preceding  travail and the pressure of the  child's  head
 upon all the soft parts lining the straits and excavation, expose these latter
 to prolonged contusions, Avhich are most  frequently folloAved by gangrene;
 whence we have following in  their train  utero-vesical,  or vesico-vaginal
 fistulas, etc.,  etc., according to  the  point that  has been  more particularly
 compressed.  The forced  engagement of the head in a contracted pelvis
 often determines the separation of the symphysis, from which inflammations
 and  suppurations, that are often very tedious in their cure, result as the
 immediate consequences, and a great mobility of the pelvic articulations,
 limping,  and sometimes  even an  inability to Avalk or stand, as  the ren ote
 lines.   (Lachapelle.)
  As regards the child, the slowness of the labor may evidently occasion its
 death; for, in the case  before us, the head being retained above the superior
 Btrait does  not prevent the discharge of the amniotic liquid by plugging up
 the os  uteri, and this nearly all  escapes ; consequently, the foetus is subjected
6con after the membranes give  way to the direct pressure of the  contracted
uterine Avails during all the time necessary to the termination of the labor. 
DEFORMITIES  OF THE  PELVIS.
649
The cord also is very frequently compressed, either in the uterine cavity,
between its parietes and the body of the child, or subsequently in the excava-
tion into which it may have slipped; the descent of the cord is here singu-
larly  favored by the elevation of the head.   This latter itself, having to
support all the pressure from the resistance offered by the pelvis,  is exposed
to very unequal compressions, Avhich may  fracture  the  cranial  bones or
Avound the cerebral matter.  Lastly, when the foetus presents by the pelvic
extremity, the violent tractions sometimes made on the trunk, for  the pur-
pose of disengaging  the  head, may produce luxation or  fracture of the
cervical vertebrae or stretching of the spinal marroAV, both of Avhich speedily
prove fatal.
                          ARTICLE IV.
                  DIAGNOSIS OF PELVIC DEFORMITIES.
   The circumstances  Avhereby the existence of a deformity of the pelvis may
be recognized, have been  divided  into  the  rational and  the sensible signs.
The first include all those that may be  learned from the previous history,
and a general examination of the individual—her constitution, height,  and
physical strength; and the second, on the contrary, are  deduced  from an
external and an internal examination of the pelvis.

   § 1.  Rational Signs.
   The accoucheur Avho may be called upon to decide  on the good or imper-
fect conformation of a female, should, before proceeding to an exploration
of the pelvis, inform himself minutely of all the  antecedent circumstances
which might throAV any light  on his diagnosis, or direct  his subsequent re-
searches.  He ought to ascertain from the near relatives, all  the accidents
Avhich the young girl submitted to  bis care may have met Avith in  infancy:
at Avhat age she began to Avalk; Avhether standing in the erect  position Avas
easy, or even possible, in  the  early years of life ;  or  Avhether,  after having
Avalked Avithout  any marked difficulty, she Avas  subsequently afflicted Avith a
Aveakness in her loAver extremities; and, should there be an existing curva-
ture of the spine or limbs, the  period at Avhich  such incurvations appeared
is to be carefully ascertained ;  as, also, Avhether those in the loAver  extremi-
ties preceded or followed that of the spine.  Where any limping is observed,
he will endeavor  to  verify the  information derived from the family, by
examining Avhether this depends on a difference in the deformity  of the two
limbs; on the atrophy of one of them ; on the flattening of the antero-lateral
pelvic Avails ; on an old or a recent affection of the femoro-coxal  articulation;
on a spontaneous or a congenital luxation, folloAved by the  permanent  dis-
placement of the head of the femur; or Avhether upon an old and imperfectly
consolidated fracture ;—because the answer to all these questions AviU render
the examination, which is aftenvards to  be resorted to, much easier.

  [A first general glance will, in the majority of cases, render  it  possible to estab-
lish a differential  diagnosis in respect to the two most frequent causes of deformity
of the skeleton, in rachitis and flexures of the vertebral column by scoliosis, cypho-
sis, or lordosis.
  In a rachitic skeleton, the diminished stature of the individual is due, on the one 
650
DYSTOCIA.
hand, to arrested development of the bones, and on  the other, to their curvature
which is more especially observed  in  the lower extremities.  Hence it results that
the skeleton of a rachitic woman has  special characteristics.  Owing to the curva-
ture of  the lower extremities, the pelvis descends with them, and occupies a lower
level than  it would in the  normal  condition, and  is contracted besides. ■  The ver-
tebral column, though less deformed,  appears long in  comparison with the inferior
extremities.  The arms are short, though less on account of their  curvature than
in consequence of arrested development.   We shall see hereafter that the deformi-
ties in cases of spinal distentions are  of an entirely different character.
Fig. 99.                                   Fio. 100.
  Fiu. 99.  Skeleton deformed by rachitis.  The low stature is due to curvature of the inferior extremities.
The pelvis is deformed.  Drawn from nature.
  Fig. 100. Skeleton deformed in consequence of flexure of the vertebral column.  The low stature ia due to
curvature of the spine.  The lower extremities'are normal; they look very long. The pelvis is well formed.
Drawn from nature.
  When deformity of  the skeleton is due  to  curvature of the vertebral column,
occurring  at the  age of puberty, the  stature  of  the individual may be greatly
lessened, but then  the result is due almost entirely to the affection of the spine, the 
DEFORMITIES  OF  THE  PELVIS.
651
 lower limbs preserving their usual  length and direction.   The well-formed pelvis
 is at the same  elevation as in a normal skeleton.   The vertebral  column, on the
 contrary, is folded, as it Avere, upon itself.  The upper extremities are well formed,
 but lowered Avith the upper part of the body, often causing the hands to reach to
 the lower part  of the thighs, or even to the knees.
   ft is very important not to confound rachitic deformity Avith distortion  of the
 Bpinal column  by scoliosis, cyphosis, or lordosis.   Delivery, in the first case, is
 often difficult  or impossible; in  the  second, on  the contrary, it is almost always
 easy.  (See figures 99 and 100.) ]
   The history of the earlier years  of life is particularly important, as it will
 not only enable  us to divine the  perfect or defective conformation of the
 pelvis with a  tolerable degree of certainty, but  will even serve to enlighten
 us as to the nature of the general affection that has produced the deformity.
 In fact, it Avould appear from the researches  of modern  pathologists that
 rachitis, properly so called, is a disease of childhood, though  it is seldom
 observed in the infant at term;  it generally begins about the eighteenth or
 twentieth month, and is rarely  found after the age of puberty.   Thus, in
 three hundred and forty-six  cases, examined  in this respect  by  M. Jules
 Guerin, its invasion took place  as follows : in  three cases, before birth ; in
 ninety-eight, during the course of the first year ;  in one hundred and seventy-
 six, during the second ; in thirty-five, in the third ; in  nineteen, in the fourth;
 in fifty, in the fifth ; and in five  children from  the sixth to the  twelfth year
 of life.
   From these and  numerous other cases reported by Bouvier,  Ruff, etc., it
 is apparent that deformities occurring  in  infancy are  nearly  ahvays  of a
 rickety nature; Avhilst all the varieties of softening that take  place in adult
 bones, as  also all  the  disfigurations  occurring exclusively in  young  girls
 about the period of puberty, are not caused by  this disease.  (Guerin.)
   A rachitic  origin of the  deformity can, therefore,  be almost constantly
 relied on where the disease  that determined the  latter existed during the
 early years of life; and this suspicion will be confirmed, if it should appear,
 conformably to the laAV laid doAvn  by the orthopedists, and stated  formally
 by M. Guerin, that the malformation proceeded  from beloAV upAvards, and
 that the tibias, the  femurs, and the spinal column were successively affected.
   On the other  hand, should the first ten  years of life pass  aAvay Avithout
 accident, and  the deformity of the skeleton occur only at puberty, it would
 be Avrong to attribute it to rachitis, and  the  pelvis will probably  be  unaf-
 fected.
   If, however, the deformity occurs during  adult age, especially if the pa-
 tient has been safely delivered before, and  has   since  that time  had all  the
 symptoms of  acute  softening, the  entire difficulty should  be attributed to
 osteomalacia.
   Alter attending to all these points, the accoucheur might proceed  to a
 more careful  inspection of the individual;  and the  vertebral column and
 loAver extremities should  particularly claim his attention.   He  ought to
 bear in mind that rachitic deviations of the  spine (and, when dating from
early infancy, they Avill  be nearly ahvays rachitic)  are almost constantly
accompanied  by deformity of the pelvis; and that,  on the contrary, the
other varieties, more especially when  they first occurred about the age of 
652
DYSTOCIA.
puberty, do not affect the normal regularity of the pelvis.  It is also to be
remembered  that  rickets may possibly give rise to curvature of the loAver
extremities without altering the pelvis, though these tAvo parts of the skele-
ton are most  generally affected at the same time.
  In  a feAV rare cases, rachitis affects but one  lower  extremity, the other
retaining its normal proportions, and yet the pelvis may be deformed.
  An attempt has been  made to establish  a certain relation between  the
direction of the curvature of the spine or loAver extremities, and the  par-
ticular species of malformation the pelvis may  exhibit.  For instance, the
sacrum, being an assemblage of vertebrae, Avhich are naturally consolidated
together, is occasionally modified  by incurvations that  are continuous Avith
those  of the spine, and these are further kept up  by the coccyx.   Sometimes
the lateral inflexion of these tAvo bones is continuous Avith the lumbar curve;
though, more frequently, they describe an inverse  curvature Avith  one or
tAvo of the last lumbar vertebrae, and the point of the coccyx is then turned
aside.  According to M. Hohl, the  lateral inflexion of the lumbar column
often  determines a greater contraction of the pelvis on the side  toAvards
which these vertebrae lean.
  Agreeably  to the same author, the curvature of the femurs occasions a
transverse contraction of the  pelvis, and a consequent elongation antero-
posteriorly, when  these bones  are  curved fonvard; whilst their outward
curvature is followed by a transverse enlargement; but if one bends outAvard
and the other forAvard, a corresponding shortening will thence result in the
latter direction.  However, all these approximations must be substantiated
by a  more extended experience to  render  them deserving of  confidence,
although it would be improper in practice to neglect them altogether.
  The relations  that  M. Weber  has endeavored to establish between  the
dimensions of the cranium and those of the pelvis are not constant enough
to merit  any  consideration whatever in an examination which  requires so
much precision.
  Quite recently, M. Guerin, after having ascertained that rachitis proceeds
from  below upwards, and that the reduction in the dimensions of the bones
follows the same progression, attempts to prove further that the dimensions
of a rickety bone being known, the size of other parts  of the skeleton may
be approximately determined; and that the  reduction, in the three diameters
of the pelvis in  rachitic Avomen folloAvs  the diminution in the size of its
component parts ;  also that the degree of this  reduction is intermediate to
what  takes place in the femur and in the humerus.
  These  results, so valuable in themselves, had  they been deduced from a
large  number of cases, are, unfortunately, based upon  a very limited obser-
vation ; and, consequently, have not all the Aveight that  I hope they will
hereafter acquire;  for the great importance of being able to determine, Avith
certainty, from the degree of shortening of the femur and humerus, not only
that the pelvis is deformed, but even the extent of the malformation must
be self-evident.
  In  conclusion, it is  apparent that the  rational signs just spoken of can
only  give us probabilities or  approximations.   Noav, the indications  pre-
eented by the deformities of the  pelvis  demand an exact and a  rigorous 
DEFORMITIES  OF  THE  PELVIS.
65b"
solution of all the questions of diagnosis appertaining thereto ;  because it is
not on  a mere  probability that an accoucheur can venture to prohibit a
young girl  from marriage, or decide on  the performance of an operation
that mutilates the child, or exposes the mother to the most serious dangers.
Such  a decision  can only be made after a thorough and minute examination
of the external  form, and the internal dimensions of the pelvis;  and  this
examination alone can enable him to detect those sensible signs Avhich afford
a positive certainty.

  § 2. Sensible Signs.

  The accoucheur should not content himself, therefore, Avith the foregoing
characters, but  he ought to  seek, in the mensuration of the pelvis, for the
elements necessary to his diagnosis.  This process is performed both on the
exterior and interior of the  pelvis; in  the former  case  it constitutes what
obstetricians have termed external,  and in the latter, internal pelvimetry.
  When Ave described  the pelvis,  in the  early part of the Avork, Ave  only
pointed out the  dimensions that Avere absolutely necessary to the full com-
prehension of the mechanism of natural labor; but Ave  must  noAV  supply
that voluntary omission;  for, in addition  to the distances then  given, there
are several others which are  indispensable to the  practice of pelvic men-
suration ; and Ave give the folloAving as the average  of a Avell-formed pelvis,
viz.:
    1. From  the anterior inferior spinous process of one  ilium to the
       same point on the opposite side,   ......   8J inches.
    -. From  the  anterior  superior spinous process of one side to the
       same point on the other, .    .         .....   9J   "
    3. From  the middle of the iliac crest of one side to the same point
        opposite,  ..........     10£   "
    4. From  the middle of the iliac crest to the tuber  ischii,    .    .   7j   "
      The superior strait divides thie distance into  two equal parts,
       whence the lateral portions of  the greater or lesser pelvis are
       each.....* .    .     •    •    .    .   3|   »
    5. From  the anterior superior part of the symphysis  pubis to the
       apex of the first spinous process of the sacrum,    .    .       7£   "
      From  which 2\ inches are to be deducted for the  thickness of
       the base of the sacrum,  and £ an inch for that of the symphy-
       sis;  therefore leaving for the sacro-pubic interval .    .    .   4 J   "
    6. From  the tuber ischii of  one side to the posterior superior spi-
       nous process of the opposite ilium, the mean extent," in an ordi-
       nary pelvis, is .     .     .    .    .    .     .     .    .    .   7   "
    7. From  the anterior superior spine on one side to the posterior
       superior spine of the other, the mean is .     .     .    .    .   8J   "
    8. From  the  spinous process of the last lumbar vertebra to the
       anterior superior iliac side of either spine, the mean is  .    .7   "
    9. From  the trochanter major of one side to the posterior superior
       spinous process of the opposite one,    .     .     •    •    .   9   "
   10.1 From the middle of the lower border of the symphysis pubis to
       the posterior superior spinous process  on either side,   .    .   6|   '«

  1  The last five measurements are taken from the Memoirs of M. Naegele, translated
Dy M.  Danvau.  We shall hereafter revert to their  importance, in connection with the
diagnosis of the oblique-oval pelvis. 
654
DYSTOCIA.
Fia. 101.
 Baudelocque's callipers applied to the mea-
surement of the antero-posterior diameter of the
superior strait.
  For the purpose of ascertaining the dimensions just given, in tie living
female,  as  Avell as the principal modifications they may have  undergone,
                                 accoucheurs have invented a  great num-
                                 ber of instruments,  to Avhich the title of
                                 pelvimeters has been applied; but I  can
                                 only allude  here to those in most com-
                                 mon use.
                                   The pelvimeter, or callipers, described
                                 by Baudelocque (Fig. 101), consists of tAvo
                                 metallic  blades  bent  in a semicircular
                                 form, so as to embrace the largest part of
                                 the  pelvis in  their  concavity.  The ex-
                                 tremity of each  one is terminated by a
                                 lenticular button,  Avhich is  intended to
                                 be applied at the  end of the line to be
                                 measured ;  a  small rule,  marked by a
                                 graduated scale, traverses  the  branches
                                 just at the point AA'here the curved blade
                                 joins the straight handle, and sIioavs the
                                 degree of separation at the points exactly.
                                 This rule shuts up in a deep groove along
the handle of the callipers.  The instrument is applied externally, and may
prove very useful in estimating the measurements  above given.
  In skilful hands, the pelvimeter of Baudelocque may furnish very satis-
factory results; but it must be acknoAvledged that it is far  from affording
the degree of certainty Avhich its inventor anticipated, even in the determi-
nation of the antero-posterior diameter of the superior strait, the one, of all
the pelvic diameters, which seems the best adapted  to this mode of explo-
ration ; for, although one of the buttons can readily be applied at the upper
front part of  the pubic symphysis, after haA'ing carefully pushed aside the
soft parts, yet it is far othenvise with regard to placing the other one just
over the point corresponding to the spinous process of the first piece of the
sacrum.1   The difficulty of determining this latter point exactly, and the
thickness of the soft parts, render this mode of mensuration very uncertain
in  its results.  But, even supposing the instrument could be properly ad-
justed, the results thereby obtained would be scarcely  more conclusive.
When the pelvis is  Avell formed, there should be, it is  said, seven and a half
inches betAveen those two points; from Avhich tAvo  and a half  inches for the
thickness of the sacrum at its base, and half an inch for that of the sym-
physis pubis,  are to be deducted.   But, the question  at onccarises, are the
pelvic  bones  ahvays uniform in thickness? or must Ave  still deduct  three
inches for the substance of the bones,  in cases of rachitis, Avhere the skeleton
  1 I have repeatedly made such attempts, and  have  so  rarely succeeded in adjusting
the point, of the callipers over the spot behind where it is directed to be applied, that ]
have rather  attributed those cases to chance, in  which the touch did not set aside my
 first diagnosis; and I will add, further, that I have often known M. P. Dubois to abandon
 *>his mode of exploration after frequent ineffectual trials, and to rely wholly upon th€
vaginal examination. 
DEFORMITIES  OF  THE  PELVIS.
655
exhibits a more or less marked arrest  in  its development?   Hoav are Ave to
know to Avhat extent this influence of rachitis over the groAvth of the osseous
Bystem is carried ?   And may not the thickness of the sacrum  at its  base,
instead of exhibiting the normal average of three inches, be reduced to tAvo,
one and a half, or even one inch?1
  If such sources  of uncertainty exist in respect to the measurement of  the
sacro-pubic diameter,  Avhat must it be Avith regard to determining the trans-
verse or oblique ones by the pelvimeter ?   For, is  the interval betAveen  the
anterior iliac spines  always the same ?  In the normal state, that extending
from  the  middle of the iliac crest on  one side to the same point opposite is
ten and a half inches, just double  the length of the  transverse diameter of
the superior strait;  but it is Avell knoAvn the iliac fossae may vary in  their
concavity, and that the crests may  approach more or less closely tOAvards a
vertical or a horizontal direction, Avithout altering  the form of the abdominal
strait.  Therefore, the supposed relations betAveen these two distances exhibit
such frequent anomalies that we cannot place any confidence in the conclu-
sions endeavored to  be established therefrom.
  Again,  where one point of the callipers is placed on the external surface
of the trochanter  major, and the  other on the  salient part of the opposite
sacro-iliac articulation, Avith a view of determining the oblique diameters, no
account is made of the numerous variations in the length and inclination
of the cervix femoris,  in the depth of the cotyloid  cavity, or in the thickness
of the soft parts behind.
  Consequently, the employment of Baudelocque's pelvimeter can only give
approximate results;  but it is not the less a useful instrument in those cases
where it Avould  be impossible to introduce a foreign  body into  the vaginal
cavity; for instance, the internal  exploration  is  not  permissible  in young
girls, and then Ave must resort  to  the use of the callipers.   Fortunately, at
such times, the diagnosis need not  be very precise, and a few lines more or  N
less cannot affect the decision of the physician.

  1  We have had opportunities of measuring  a great number of pelves that were  de-
formed in various ways and in different degrees, says Madame Boivin,  in which  the
thickness of the walls in question departed from the three inches assigned to them by
Baudelocque, to the extent of a third of an inch  to an inch each,  either larger or
smaller.  This difference in thickness was sometimes observed in the pubis, at others
in the base of the sacrum, and again in both of these bones at the same time.  Besides,
in more than a hundred well-formed pelves, covered by all their tissues, which had not
been altered by disease in any way, we have noticed considerable variations both in
the volume and the thickness of the parts forming the antero-posterior diameter at the
superior strait.
  Madame Lachapelle has found  the sacrum alone nearly three inches thick, in many
well-formed pelves, whilst in some deformed ones it scarcely measured two inches.
  "I consider  the results," adds this skilful midwife, "that are obtained  in measuring
the transverse and oblique diameters of the strait, by taking certain portions  of the
iliac crests, the great  trochanters,  the ischial tuberosities, &c, for the  points  of de-
parture, as very fallacious:  Because. 1.  In the best-formed Avomen, the iliac crests are
sometimes  inclined towards each other, and at others  are turned outwards, so that
both an everted and a cylindroid variety may exist in natural pelves; 2. The great  tro-
chanters are more or less separated, according to the variable direction and length of
the neck of the femur, kc." 
656
DYSTOCIA.
  But the case is far different Avhen the Avoman is pregnant or in  labor, fot
then it is necessary to learn the dimensions of the pelvic cavity Avith  the
greatest  exactitude.  For  this purpose, accoucheurs have devised various
instruments, which they have designated by the title of internal pelvimeters.
  The most ancient of all  is the one invented by Coutouly, which closely
resembles, in its general appearance, the  instrument used by shoemakers,
some years since, for taking the measure of the foot;  it is composed of tAvo
iron rules, Avhich slide on each other, and each having a short plate fixed at
a right angle  on one  of its extremities.   AVhen  it is introduced into  the
vagina, the tAvo rules  are  slipped along each other, so as to get one of  the
plates  against the sacro-vertebral angle, and the other just  behind the pos-
terior  face of  the  symphysis pubis.  One of these  rules  is marked by a
scale, which indicates the degree of separation of the two plates, and, con-
sequently, the length of the sacro-pubic diameter.
  The use of  this instrument  is  attended with  such numerous  incon-
veniences as to have banished it almost entirely from practice.   Its appli-
cation is difficult;   it distends  the vaginal mucous membrane greatly, and
this distention  is  often very distressing to the patient.   The extremity of
the plate that  is  intended to be applied on the sacro-vertebral  angle, is
liable to slip and to become displaced; beside which, the organs situated in
the excavation  oppose its free use.
  Madame Boivin endeaA^ored to obviate most  of  the  objections against
Coutouly's instrument, by substituting a neAV one, which she called an  intro-
pelvimeter; which, although bearing a general resemblance to the former,
differs essentially, in having its two constituent branches simply articulated,
so that they may  be unfastened and introduced separately; the  one into
the rectum, the plate of Avhich is to be applied against the sacro-vertebral
angle,  and the other into the vagina, so as to place its vertical part behind
the symphysis pubis.   This instrument is perhaps less painful to the patient,
and not so liable to be displaced  as the other, but it will  not furnish us any
more accurate results.  Besides, the introduction of a foreign body into  the
rectum is so disagreeable to most Avomen that very few are willing to submit
to it;  for where, indeed,  is  the  young girl  (and Madame Boivin recom-
mends it particularly for  virgins) Avho Avould ever consent to  its employ-
ment?
  But it is unnecessary to allude here to all the other pelvimeters that have
been proposed,  and I shall  only bring fonvard the one invented by  Stein,
which  I should adopt rather than the  preceding, because it  is more simple
and more easily applied.   It is merely a metallic stem,  of the length and
size of the female  catheter, provided Avith  a slide, and having the metrical
divisions marked  on one of its  surfaces.   It is  employed by passing its
extremity along the forefinger, previously introduced into the vagina, until
it reaches the sacro-vertebral angle;  the external part is next pressed  up-
wards, so as to  bring the graduated face in contact Avith the loAver portion
of the symphysis  pubis, and  then, by means of the slide, the point on  the
stem corresponding to the symphysis is marked.  The  instrument is subse-
quently withdraAvn, and all that part of it beyond the slide shows the length
of  the sacro-pubic diameter, or  rather the  interval existing betAveen  the
sacro-vertebral  angle and the inferior part of the pubis. 
DEFORMITIES  OF  THE PELVIS.                 657
   HoAvever, Stein's pelvimeter may be replaced by any straight rod what-
 ever, upon which the finger will take the place of the slide.
   Many very ingenious  instruments have  been proposed during the last
 few years, for the purpose of obviating the various objections we have urged
 against those just mentioned ; such are Wellenbergh's, a description of which
 is given by M. P. Dubois in the tAventy-third volume  of the new edition of
 the Dietionnaire;  and, more particularly, the one announced quite recently
 by M.  Van Huevel, a professor at Brussels.   This latter, in my estimation,
 has incontestable advantages over all the  others; and I feel  Avarranted in
 recommending its more general use.
   It is composed of tAvo round rods; an internal or vaginal  one (Fig. 102,
 A a), flattened like a spatula at each
 extremity, and having, about the mid-                FlG-102,
 die of  its  upper face, a small  blunt
 hook, or catch, the concavity of which
 looks toAvards the outer extremity;
 the  other, or external  one, B  B,  is
 traversed  at the upper end,  and per-
 pendicularly to its  direction,  by a
 long scrcAv, c, which  is draAvn back
 by unscrewing.   These rods are held
 together by means of a nut,  or artic-
 ular box, thereby forming a kind of The mensuration of  the sacro-pubic diameter with
 COmpaSS, the legs of which Can be           M. Van Huevel's pelvimeter.
 lengthened out or shortened at pleasure, and  can likeAvise be moved in every
 direction.   A turn of the central screw in the nut presses them against each
 other, and retains them firmly in any desired position.
   When this instrument is to be applied, the woman lies on her back, having
 the legs, as Avell as  the thighs, flexed and separated.  We then begin by
 ascertaining, both exteriorly and interiorly, the exact situation of the upper
 border of  the pubis, marking the skin with ink at the point  corresponding
 to the middle thereof.  The ilio-pectineal eminence on each side, just beyond
 the course of the crural artery, is next sought out and marked in the same
 Avay; so that the anterior extremities of the sacro-pubic and the two oblique
 diameters  of the superior strait are indicated by the three ink-spots on the
 skin, Avhich are afterwards easily found.  This being done, one or two fingers
 of the left hand are introduced into the vagina, and placed on the angle of
 the sacrum ; and then, Avith  the other, the  curved extremity of the vaginal
 rod is conducted along and under these fingers, which  support it against the
 promontory, Avhile the thumb of the same hand, pressed into the blunt hook,
 firmly retains it on the exterior.  The right  hand, which hitherto  held the
 instrument, noAV turns the long  screw, c, in the external branch, the button
 of Avhich rests on the ink-spot  made upon the mons veneris.   While the
 operator thus holds the tAvo branches in their respective positions, an assist-
 ant tightens the screw in the articular nut; when the instrument, being thus
fastened, is carefully withdraAvn (Fig. 102),  and the  distance between the
two points, that is to say, the interval which separates  the  promontory from
tlie anterior face  of the pubis, is ascertained by  a scale.  This  distance
      42 
658
DYSTOCIA.
 being knoAvn, the branches are rendered movable by unfastening the artic
 ular screw; and the operator again carries the left forefinger into the vagina
                                               behind the symphysis pubis,
                                               to which point  he  conducts
                                               the extremity of the vaginal
                                               branch (its concavity being
                                               in front), by slipping it along
                                               the  palmar  surface  of this
                                               finger,  and  he sustains  it
                                               there by one hand,  whilst
                                               with  the other  he replaces
                                               the  screw of the  external
                                               branch  upon the  ink-spot
                                               on the mons veneris ;  taking
 The mensuration of the symphysis pubis by the same instrument.  Care to avoid pressing more
                                               firmly than in the  first op-
 eration ; for it is only requisite to graze the skin without depressing it. The
 assistant again tightens the screw in the nut, and the operation is completed.
 (Fig. 103.) 1
   In order to withdraw the instrument, which now comprises the thickness
 of the pubic region, the screAV c of the external branch is unfastened, and
 again exactly replaced in the same  position after it is withdraAvn.   This
 distance is also measured, Avhich, deducted from the first, gives a remainder
 that  extends from the sacro-vertebral angle to the posterior  face  of the
 pubis, or, more properly speaking, the sacro-pubic diameter.
   The oblique diameters  can be obtained precisely in the same Avay.  The
 index and middle fingers are carried  into the vagina, and their extremities
 placed  on one of the sacro-iliac articulations,  or even, if this cannot be
 reached, on the  promontory of the sacrum; the end of the vaginal branch
 is slipped up there  in turn, and then  the button of the screAV c  is fixed on
 the ink-spot corresponding to the right or the left ilio-pectineal eminence,
 The branches having been fastened in this position, are gently Avithdrawn
 from  the Avoman's parts, and the distance betAveen their points is taken by a
 graduated scale.   In a second  operation, the thickness of the cotyloid Avail
 is ascertained by conducting the vaginal branch along the  fingers behind
 this cavity, as far as the brim of the pelvis, and by replacing the button of
 the external branch over the ink-spot corresponding to the ilio-pectineal
 eminence.  Is it necessary to repeat, that the soft parts in the groin are not
 to be  depressed, and that the direction must  correspond with the plane of
 the abdominal strait?  The branches  are subsequently fixed, and extracted
 by turning back the screAV c, as described  above;  when, by  deducting this
second thickness from the first, the remainder will shoAV the extent either of
the oblique diameter, or  that  of the  sacro-cotyloid  interval, according as
the vaginal branch had originally been placed on the sacro-iliac symphysis
or upon the promontory of the sacrum.
   We may observe here that the opening between the promontory and the

   1 If the hook should impede the sliding of the branch b b, it might be  removed.
 
DEFORMITIES  OF  THE  PELVIS.               659
 cotyloid wall is the most essential to be knoAvn in cases of oblique deformity ;
 for the sacro-iliac articulation is never deformed (saving where  an exostosis
 or some  other tumor is developed  on its  surface);  but it is rather the base
 of the sacrum, or the cotyloid cavities which project into the holloAv of the
 excavation.  In fact, the pelvis sustains the vertebral column behind, Avhile
 in front and laterally it rests on the thigh bones; and, therefore, it  lies betAveen
 two forces, which, in the  erect  position  and  in  Avalking, have  a  continual
 tendency to depress this osseous ring at the three points indicated.  Whence
 it follows that, if there is any  softening, there will  be a forward projection
 of the sacral angle, or a pressing backAvard of the acetabula; that is to say,
 a contraction  of  the antero-posterior  diameter,  and of  the right  and  left
 sacro-cotyloid intervals, Avhich,  in the normal  state, are  only from three to
 three and three-quarter  inches in extent.
  As regards the  external measurement, we can convert the pelvimeter into
 a common compass  for the inferior strait, by taking the  handle  part of the
 two branches, and properly adjusting  the  nut; these  being  placed on the
 tuberosities of the  ischia, or one  at the  point of the coccyx, and the other
 under the pubic arch, we are enabled to take the transverse and the antero-
 posterior diameters  of this strait directly.
  Lastly, by adding a piece to the
 apex of the vaginal branch  (Fig.
 104, D d), we form  a species of  cal-
 lipers  similar  to the  mecometer of
 Chaussier.  This  piece  is first  flat-  «
 tened  out  like a  spatula, and  then
 curved ;  and its concavity is placed
 along  the anterior  surface  of the
 pubis; the branch that supports  it
 passes backwards betAveen the  avo-
 man's thighs ; and the button of the
 SCreAV C, traversing the Other branch,    The same instrument converted into a pair of
 is pressed on the  spinous process of                 callipers.
 the  last  lumbar  vertebra.1    The
 operator holds  the extremities of the instrument in  his two hands, Avhilst an
 assistant tightens the screAV  in the articular nut.  It is disengaged by turn-
 ing the screAV c backwards, Avhen  necessary, which  is returned  to its place
 before measuring the interval betAveen the points Avith the scale.   (Extract
 from the Memoir of M. Van Huevel.)
  1 If, says M.  Van  Huevel, the tubercle of the spinous process of the last lumbar ver-
 tebra cannot be detected, the following process may be had recourse to : Stretch across
 this region a string which shall rest upon the upper and middle part of the crests of
 both iliac  bones;  then  at the distance of an inch and  a half below this line, upon the
 middle of the sacrum, make a mark, from which the string is to be conducted obliquely
 forward and downwards toward the upper part of  the cotyloid parietes and of the
 mons veneris.  The position of the  string, which should follow the inclined direction
 of the plane of the superior strait, may be rectified,  if necessary,  by the fingers.
 Then with an uncut quill dipped in ink, the  points to be preserved are marked out
along the line of  the cord.  These points should be made lower at the pectineal emi-
nences and  at the  pubis, by from one and a half to two and a half inches, than the
describe"!  limit, in order to  correspond better with the contraction of this strait.
 
660
DYSTOCIA.
  In February, 1855, the ingenious accoucheur of Brussels improved  hii
first pelvimeters, besidts suggesting another, which appears to me quite as
simple, and of more general applicability than the preceding.  I therefore
think it right to give a detailed description of it.
  It is simply a pair of callipers (Fig. 105) composed of two branches, one

                                 Fig. 105.
Fig. 107.
...^	i 2i i 3l i 4! i 5	l \
of Avhich is fixed, and the other movable.  The first, a b, is  eleven  inches
in length, slightly curved, and flattened  at its extremity; it is inserted into
tiia vagina for the internal measurement, and  bears a  hooked ring near its
ulddle, beyond which is a non-graduated arc  of  a circle.   It  articulates 
DEFORMITIES  OF  THE  PELVIS.              661
below, like an ordinary pair of compasses, with the prolongation of a sheath,
in Avhich is inserted the lower extremity of the other branch.  The curva-
ture, length, and hooked ring, are the same  as in the small  geometric pel-
vimeter.
  The second or external  branch, c B, may be lengthened or shortened at
pleasure.  It carries at its upper extremity a long horizontal  screw, like the
preceding pelvimeter, for the purpose of facilitating the disengagement of
the compass after its internal application : from  thence it curves outwardly,
and, finally, in descending becomes straight  and quadrangular, and enters
the above-mentioned sheath.  The  latter, which is open at both ends, is
furnished Avith a groove externally, for the purpose of receiving a projectior
of the branch, which prevents its escaping from the sheath.  Its inner side
is provided with a  spring bearing a point, which passes through the  side,
and lodges in a small  hole  in the branch, so as to prevent the latter  from
slipping up and down, and to keep the two extremities  of the branches  on
the same level.   When the spring is raised, the  point escapes from the hole
in the  stem, Avhich then becomes  movable;  when released, and  pressing
upon its surface, it keeps it at any height desired.
  The arc of a circle attached to the vaginal branch is applied against the
right side of the external branch.   A slide  (Fig. 106) is traversed by the
latter at right angles, and also by the arc.   On  the opposite side  is fixed a
vice, moved by a lever, Avhich presses these two pieces together, and prevents
all  motion.  Lastly, a .graduated scale  (Fig. 107) serves to measure the
distance betAveen the extremities in any given position.
  Let us noAV examine  the mode of application of the new pelvimeter.
  The compressing vice of the slide is  relaxed, and the point of  the spring
engaged in the small hole of the external branch keeps the  extremities of
the instrument on the  same  level, so as  to form a  pair of callipers.  The
extremities are applied either to the anterior superior spinous processes  of
the iliac bones, to the crest of the ilium and the tuberosity of the ischium
of the same  side, or the bottom of the horizontal screAV is placed upon the
spinous  process  of the last lumbar vertebra,  and the extremity of the
vaginal branch against the mons veneris  by passing betAveen the thighs  of
the patient; again, one may be applied to the upper,  and the other to the
loAver edge of the pubis, to the tuberosity of each ischium, or, finally,  upon
the coccyx, and under the pubic arch.
  Thus  are  obtained the  extent of the transverse diameter  of the greater
pelvis, the depth of the entire  cavity, the distance from the loins to the
pubis, the length of the  symphysis  pubis, and  the transverse and antero-
posterior diameters of the inferior strait,  the value of each of which is
determined by the scale.
  To measure the interior of the pelvis, the Avoman is placed on her back on
the bed, Avith the breech brought to the edge of the mattress.   The extremi-
ties of the diameters of the superior strait are marked in  the manner already
described, Avith the aid of a cord and a quill.  Then, one or tAvo fingers of the
left hand are  introduced into the vagina as far as  the promontory oi" the
sacrum.  The right hand holds  the callipers unfastened  and opened to its
full  extent, and with the external branch depressed  in  its sheath,  The 
662
DYSTOCIA.
extremity of the vaginal branch is next passed into the genital organs along
the previously introduced fingers, which press it against the sacro-vertebral
angle, Avhilst the base of the thumb engages itself in the hook.  The instru-
ment is held motionless in its position by a single hand.  Then, the thumb,
fore, and middle fingers of the right hand grasp the external branch above
the arc  of a circle, and raise or loAver it in its sheath until the button of the
horizontal screAV corresponds to the mark made  upon the mons veneris.  As
soon as  this is effected  by merely grazing the  skin, the ring-finger presses the
lever of the vice forwards, to fix the instrument in  its place.   It is then
withdrawn  from the Avoman's  parts, and the  distance between the  tAvo
extremities  ascertained by means of  the scale.
  The first  stage of the operation  being accomplished, the vice is relaxed,
and the extremities of the callipers again  made to correspond.  The index
finger of the left hand is again introduced into the vagina, and applied this
time behind the pubis.  The extremity of the vaginal branch is conducted
thither, with its concavity in front, by the right  hand.   As soon as it has
reached the upper edge of the symphysis, the branch is seized with the entire
hand, and the little finger passed into the ring  of the hook.  The externa]
branch is afterward seized above the arc by the three first fingers of the right
hand, and the ring-finger pushes the lever of  the vice fonvard,  as soon as
the button  of the horizontal  screAV  corresponds  to the spot on  the mons
veneris.  This  second application  should be made as  gently as the first,
merely grazing the skin.  Should any difficulty  be experienced in the with-
draAval  of the  pelvimeter, the  horizontal  screAV may be screAved back,
provided it be restored to its position after  the extraction.  The distance
between the extremities should  be again  measured by the scale, and sub-
tracted from the first result, to obtain the extent of the sacro-pubic diameter.
  The only error possible in this process results  from  the unequal pressure
upon the skin in the tAvo applications, or else upon the irregular position of
the branch behind the pubis, which may be either higher or lower than the
sacro-pubic  line  itself.   A little attention only is necessary in order to avoid
these slight causes of error.
  The proceeding is exactly the same for  obtaining the oblique diameters.
The pelvimeter is first loosened, opened Avidely, and  the external branch
loAvered in its sheath.   If the  left  sacro-pubic  space is to be measured, the
instrument  should again be taken in  the right hand;  the fore and middle
fingers of the other hand are introduced into the genital organs, and placed
to the left of the pre-vertebral projection;  then the extremity of the vaginal
branch  is passed up  to the point indicated, and  retained there by the fingers
of the right hand,  the button of the external branch is placed upon the
mark over the left ilio-pectineal eminence, and  the vice is tightened  by the
ring-finger.   The instrument,  in its  diagonal  position, is withdrawn from
the parts, and the distance betAveen the tAvo  extremities ascertained  by the
scale.
   Having  noted the latter, the vice  is unfastened, and  the tAvo extremities
of the callipers  brought together.  Then the fore and middle fingers of the
left hand are again introduced into the vagina behind the left ilio-pectineal
eminence, as also the  extremity of the vaginal branch with its  concavity 
DEFORMITIES  OF  THE  PELVIS.
663
 forward; the branch is next grasped Avith the left hand, and the little finger
 introduced at the same time  into the ring of the hook.   The thumb, fore,
 and middle  fingers of the right hand replace the  button of the  external
 branch upon the mark over the left ilio-pectineal eminence, whilst the ring-
 finger presses upon the  lever of the vice.  The same precaution should be
 taken, as in the first instance, of turning the horizontal scre-AV, if necessary,
 in order to AvithdraAV the instrument, and to return  it to its  place, for the
 purpose of measuring the neAV distance betAveen the extremities.  The sub-
 traction 01 this quantity  from the other gives  the' dimensions required.
   The right sacro-pectineal distance is ascertained in the same Avay, except
 that the fingers of the right hand are then introduced into the vagina, the
 instrument being held in the left hand.
   Finally, the measurement of the transverse  diameter of the superior strait
 is accomplished in nearly the same manner.   The callipers being prepared
 as usual and held in the right hand, two fingers of the left hand in a state
 of forced supination, the thumb being directed doAvmvards, are carried to the
 right side of the pelvis.  The convexity of the vaginal branch is directed
 toAvard that point, and held there by the pressure of  the introduced fingers,
 and by the left thumb, which is  engaged in the hook.  The free hand con-
 ducts  the  external branch beneath the left thigh,  Avhich is raised for the
 purpose, and  places it upon  the  mark made upon  the corresponding hip.
 The ring-finger of the right hand fixes the instrument in its transverse posi-
 tion by pressing upon the lever of the vice, and the distance betAA'een the
 extremities is measured by the scale after  the extraction.
   To make the second  application, the vice  is relaxed, and  the  external
 branch elongated  beyond the extremity of the vaginal one; then, the fore
 and middle fingers of the left hand are placed in the genital organs on the
 left  side of the pelvis.   The  extremity of the vaginal branch is conducted
 thither by  the right hand, and kept there by the left hand, the little finger
 of which is inserted in the ring of the hook.  The external branch is finally
 directed by the free hand beneath  the left thigh upon the  hip of the  same
 side, and fixed as usual. The horizontal screAV is next turned for the pur-
 pose of Avithdrawing  the pelvimeter.  When restored to its place, the dis-
 tance between the extremities is again taken, and this, subtracted from the
 first measurement, gives  the length of the transverse  diameter.
  The diameters of the excavation may be measured in the same manner;
 it being only necessary to take  the  precaution to mark spots around the
 pelvis betAveen the limits of the superior and inferior straits.
  But,  after  all, the  hand  of an accoucheur,  accustomed to practise the
 touch, is certainly the best  and  most satisfactory of all pelvimeters; for,
 with the exception of a feAV rare cases, in Avhich  I would give the preference
 to the instrument last described,  it is  always  possible to ascertain  exactly
 by it the external form of the pelvis, and also, by its  introduction  into the
 vagina, the perfect or defective conformation of the cavity.
  By the exterior palpation, Ave are enabled to learn the external characters
 of the pelvis,  to find out  Avhat interval exists betAveen  the  tAvo iliac crests,
 and to measure the depth of the anterior, the posterior, and the lateral Avails
of the  pelvis;  and  this  might possibly be all-sufficient;  although, in our 
664
DYSTOCIA.
opinion, it is better to resort to the callipers of Baudelocque for the external
mensuration.
   It is more particularly in the appreciation of the dimensions of the cavity,
the straits, and the excavation,  that the  hand  introduced  into  the parts
serves  as a sure and faithful guide.  It is not even necessary to pass the
whole hand  into the  vagina, for the introduction of one  or two fingers is
usually quite sufficient;  in fact, we ought to be satisfied with this, when the
Avoman is not  in  labor, since the entrance of the entire hand Avould often
prove very  painful.1
   The folloAving is the proper mode of using the finger : the index having
been  passed into the vagina, is directed upwards and backwards towards the
                                             sacro-vertebral angle, which is
                                             easly recognized by  its promi-
                                             nence, and  by the  transverse
                                             depression formed at the lum-
                                             bosacral articulation.   When
                                             the extremity  of the finger is
                                             well applied against  this part,
                                             the wrist is carried upAvard and
                                             forward, until the radial border
                                             of the  finger  comes  into  con-
                                             tact  with the  loAver  margin of
                                             the symphysis pubis (see  Fig
                                             108), when  the index  of  the
                                             other  hand   (the  precaution
                                             having previously been taken
                                             to separate  the labia externa
and the nymphae) is applied with its back against the vestibule upon Avhich
it is slid until the end  of the nail touches the finger in the vagina. The two

  1 It  is a great mistake,  says  M. Guillemot, to suppose that it is possible to measure
the length of the  sacro-pubic diameter, by the introduction of a single finger into the
vagina.  This result has  never been effected when the diameter has exceeded two and
a half or three inches in length ; and the dimensions of the strait can only be correctly
obtained by using the whole hand.
  Like M. Guillemot,  we believe  that the hand should  be  introduced, whenever it
can be done without causing too much suffering to the patient; but we have elsewhere
stated that it was often very painful, even at the moment of labor ;  and we will add,
that at any other  period it would appear useless, since the finger alone, by  depressing
the perineum, might measure as far  as three  and a half inches, unless there was an
unusual resistance at  this part, and beyond this a natural delivery is possible ; or, at
least, if the intervention  of  art should become necessary, it could always be termi-
nated  favorably to the lives  both of the mother and child ; and, therefore, nothing need
be done until the  time of  pi^rturition.
  During labor, says M. Velpeau,  we  can, if necessary,  introduce the entire hand into
the vagina ; the thumb and index finger are then separated, so as  to place the one on
the sacro-vertebral angle, and the other  behind the pubis; the  hand is  withdrawn
while in this  position,  and, by the aid of a measure, the dimensions of the sacro-pubic
diameter are determined with one or two lines.   I have sometimes used the index and
middle fingers, carried high up  into  the  vagina, with advantage ;  and  then,  after
having separated  them as much as possible, and placed  their extremities on the diam-
eter that is to be  measured, two fingers of the  other hand are inserted  between their
 
DEFORMITIES  OF  THE  PELVIS.
665
fingers should  come  together precisely at the lower edge of the symphysis
pubis.  Pressure Avith the nail will make a sufficient mark upon the finger
of the right hand.  The latter finger is then to be withdraAvn and applied to a
rule.  In this way the distance between the sacro-vertebral angle upon which
the end of the  finger rested and the loAver edge of the symphysis pubis is
very readily determined.   But  this oblique line is longer than the antero-
posterior diameter of the  upper strait, Avhich  terminates  in front, on  the
posterior superior part of the  symphysis;  consequently the excess must be
deducted ; and, by subtracting four or five lines for a large pelvis, and three
to four for a  small one, we shall have very nearly the extent of the sacro-
pubic interval.  With  regard to the exact number of lines to be deducted,
the attention  should further be directed to the thickness, the length, and
the more or less  marked  obliquity of the symphysis; which circumstances
can easily be determined  by the touch.
  Of all the methods,  measurement  by the  finger gives the best results;
but it should be done carefully, and precisely in the manner described above.
If the separation  of the  greater and lesser labia be neglected, or if the
nail be not applied accurately against the loAver part of the symphysis, the
measurement obtained will necessarily be inaccurate.
  The finger  introduced  into  the  parts will also be able to appreciate the
extent of the  antero-posterior  diameter of the excavation;  for it  can very
readily pass over the whole front surface of the sacrum ; and, consequently,
can judge whether its anterior concavity is augmented or diminished.
  Lastly, its extremity being applied  against  the point of the coccyx, the
accoucheur  should again elevate  his wrist until the radial border of the
hand is arrested by the  lower  part of the symphysis; then, marking this
point with  the other forefinger, he should withdraw the hand and apply it
to a graduated scale, and he can  thus ascertain very correctly the  extent
of the coccy-pubic diameter;  further, by pressing gently on the  point  of
this bone, he can judge very readily of the degree of mobility in the sacro-
coccygeal articulation.   In cases  of deformity  caused by the excessive
length or unusual obliquity of the pubic symphysis, the  direction of the
vulvar opening will  be so  much changed as to attract attention; it being
then situated much more  posteriorly than  in well-formed women.
  Although the results furnished by  the touch are perfectly  satisfactory as
regards the antero-posterior diameters, it is far otherwise  Avith the transverse
and oblique ones, particularly at the superior strait; for the extent of these

bases, to prevent them from changing their relations while being withdrawn from the
woman's parts.  But these directions, given by M. Velpeau, appear to us impracticable
at the superior strait, and equally so as regards the bis-ischiatic interval.
  Uamsbotham's  process resembles nearly  Velpeau's.  He  introduces the fore  and
middle  fingers into the excavation ; the bent extremity of the forefinger is  applied
closely against the  symphysis  pubis and the end of the strongly-extended  middle
finger endeavors to reach  the  sacro-vertebral angle;  then withdrawing the fingers in
ihe same position, the space between their extremities is, he says, to be measured by a
rule or a pair of compasses.  He states that this process has the advantage of giving
the  exact dimensions, even when  the head is engaged in the  excavation, since one
finger can be passed behind it and the other before it.  (Obstetric Med. and Surg., p. 18.)
We consider this procedure quite as unavailable as that recommended by M. Velpeau 
666
DYSTOCIA.
can only be judged of approximately, and we  can do n )thing more chan
test with the finger the dimensions obtained by the external  n ensuration.
The finger, when entered, is to be carried in the direction of those diameters,
and the accuracy of the result thereby obtained will depend on the experi-
ence and tact of the accoucheur.   HoAvever, Ave shall soon have occasion to
be more explicit on  this point,  by extracting  from the  works >f MM.
Naegele and Danyau the results of their  researches.
  As to the transverse diameters of the inferior strait, their dimensions can
evidently be ascertained by the aid of the fingers.
  Again, the educated finger will give a  very just idea of the  length of the
symphysis  pubis, the spreading and height of the pubic arch, the depth and
normal configuration  or  deviation in the lateral Avails of the excavation,
and of the inward prominence of  the ischiatic  spine.
  The existence of the various tumors that may obstruct the  pelvic cavity,
or greatly  diminish the canal intended for the passage of the child, can be
recognized by the finger alone; for it can detect their nature, their softness,
or resistance, and their mobility, or adhesion to the osseous parietes, or to
the soft parts Avhich line the latter, far  better  than any other instrument.
But during parturition, the touch, Avhich is so  often useful  at other times,
may not prove adequate to this measurement;  for, if the contraction is not
very extensive, the head, after being arrested for  a  long time, may finally
engage at the upper part of the excavation, and form a considerable rounded
tumor just below the superior strait, large enough to prevent the finger from
passing up to  the sacro-vertebral angle;  and if the sacrum should  then
happen to  be strongly pressed backwards, as is most commonly the case, so
that the antero-posterior diameters of the excavation and of the  inferior
strait are increased, the cause of the head's arrest might be misunderstood,
if the accoucheur does not bear in mind that, before engaging, it remained
for some time above the symphysis pubis.  The attention, however, will he
awakened, if the finger, in traversing the anterior surface of the sacrum
from above downward, detects the absence of  its normal  curvature.  The
sacro-vertebral angle may, however, be reached quite frequently by passing
the finger  around the head;  but the tumor formed by the  cedematous scalp
sometimes  projects so far into  the cavity of the pelvis, as  to  render it im-
possible to measure a straight line from the promontory to the lower part
of the pubis.
   We repeat, that the accoucheur's finger is  the  most perfect of  all instru-
ments, though its importance must not be overrated.  In  fact, many prac-
titioners have erred in declaring,  with Madame  Lachapelle,  that the best
proof of a good conformation of the pelvis is the impossibility of reaching
the sacro-vertebral angle with the finger.  Certain others,  while admitting
the imperfection of the other methods of exploration, equally  err in suppos-
ing that an estimate, correct enough  to  guide  us  safely in  practice, will be
obtained by employing them simultaneously ;  because, there are some cases
where the  best knoAvn methods of  exploration are inadequate,  Avhere the
finger cannot reach the promontory of the sacrum, and yet Avhere a mutila^
tion of the foetus, and sometimes  even  the Caesarean operation, have been
necessary. 
DEFORMITIES  OF  THE  PELVIS.
667
   The oblique oval  pelvis belongs to this  class; and M. Naegele, who  de-
 scribed it Avith so much care, after having  experienced the inefficiency of
 the means of diagnosis usually employed, has made  some researches, with
 the vieAV of  overcoming  this difficulty; for Avhich purpose he  has taken
 points on the pelvis  different from those described  by most authors, which
 are easily accessible and recognizable;  and  he has carefully measured the
 distances betAveen them in the normal state, as already pointed out (page
 653, Nos. 6,  7, 8, 9,  and 10).   " In forty-tAVO pelves of well-formed females,
 avc have found," says he, " in a large majority of cases, but little or no differ-
 ence betAveen the tAvo sides of the same pelvis, as respects the above-men-
 tioned distances."   M. Danjrau,  responding to the wish expressed by M.
 Naegele, has  repeated those researches in a great number of living and well-
 formed Avomen, and the following are the conclusions at which  he has
 arrived, namely, that in eighty females it appeared: —
   1. That the distance from the tuber ischii of one  side to the  posterior
 superior spinous process of the opposite ilium, Avas the same on both sides in
 tAventy-one persons; in fifty-one, the  difference between the  two sides was
 from one to three lines; and in  eight only it amounted to four, five, and six
 lines;  whilst, in the oblique-oval  pelves, the smallest difference Avas found
 to be one ineh, and the greatest tAvo inches.
   2. That the distance from the anterior superior  spinous process  of one
 side to the  posterior  superior  iliac  spine  of the  other,  was the  same in
 both halves of the pelvis  in  tAventy-two females;  in fifty-one there was a
 difference of one to six lines betAveen the tAvo; and in seven women only Avas
 this difference from seven to eleven lines.   In the oblique-oval  pelves, the
 smallest difference between these  sides Avas  three-quarters of an inch, and
 the greatest two inches.
   3. That the distance from the spinous process of the last lumbar vertebra
 to the anterior superior iliac spine, was the  same on both sides, in tAventy-
 nine instances ; in fifty-one, there Avas a difference of one to seven lines be-
 tAveen  the tAvo.   But in the  oblique-oval pelves, the least difference  Avas
 eight lines, and the greatest an inch and a third.
   4. That the distance from the trochanter major of one side to  the poste-
 rior superior  iliac spine of the opposite one, was the  same in eighteen cases;
 Avhen measured comparatively on the two sides of the pelvis, a difference'of
 one to six lines in this distance Avas found in fifty-seven; and in five only it
 ranged  from seven to nine lines;  whilst, in  the oblique-oval, the smallest
 difference Avas half an inch, the greatest an inch and a half.
   5. That the distance from the loAver border of the symphysis pubis to the
 posterior superior iliac spine, Avas the  same on both sides  in thirty-two
 Avomen; in forty-six, the difference betAveen the two  halves of the pelvis, in
 this respect, Avas from one to six lines; and in tAvo, from eight to nine lines;
 but, in the oblique-oval  pelves, the least difference in this distance, taken
 on both sides, Avas seven lines, the greatest one inch.
  it will, therefore, appear that, by a proper degree of care, and the aid of
the measurements just given, Ave would be able to recognize the deformity
in question, by measuring the aforesaid distances on each side, and  then
comparing the results obtained from both. 
668
DYSTOCIA.
  But there is yet  another method for detecting  the oblique-oval pelvis,
says M. Naegele; that is, if a woman, having a well-formed pelvis, be placed
with her back against any vertical plane, as a Avail, for instance, so that the
shoulders and upper part of the buttocks be in contact with this plane, and
then two plumb-lines be  dropped, the one from the point corresponding  to
the spinous process of the first sacral or the last lumbar vertebra, and the
other from the lower border of the symphysis pubis, it will be found  that
the latter nearly or quite covers the  first; that is to say, that a line perpen-
dicular to the wall would intersect both of  these plumbs at a right angle;
but this is not the case in the oblique-oval pelvis.   In fact, one of its essen-
tial characters is, that the symphysis pubis  is deviated  towards  one side,
and the sacrum toAvards the other, whence the middle of the pubic symphy-
sis is opposite to  the anterior sacral  foramina, or even to the sacro-iliac
articulation on the  non-anchylosed side.   Consequently, when a woman,
whose pelvis is thus deformed, assumes the position just indicated, and the
plumb-lines are dropped at the designated points, the operator Avill find, by
bringing his view perpendicular to the wall, that the line  placed  in front
does not  cover the posterior one; for the latter will deviate to the right or
the left, according to the anchylosed  side, and this deviation will be the more
considerable, as the pelvis is the more deformed.  (M. Danyau's.Translation.)

                           AETICLE  V.
    INDICATIONS  PRESENTED BY THE DEFORMITIES OF THE PELVIS.
  It is not our intention to-treat, in this place, of the measures that it would,
perhaps,  be advisable to employ for the purpose of remedying deformities
of the pelvis  when they  exist, for this subject belongs exclusively to the
surgery of the  osseous system; besides which,- the various  mechanical  and
gymnastic means hitherto used for correcting the deformities of the skeleton
have had no efficacy in changing  the form of the  pelvis.  But, if nothing
can be done by the physician  to cure, he is,  at least, not wholly destitute of
resources  where there is  still a possibility  of preventing such deformities.
Thus, during the earlier  periods of  life, especially, he  ought to watch over
all the circumstances that might influence the regular development of the
skeleton, with the most tender solicitude; he should relieve rachitic children
from constriction or  pressure of every kind,  which  might, in  their variable
attitudes, modify the pelvic circumference; they ought  to be left in  the
recumbent position as much as possible;  the nurse must not  always have
the child in her arms, as she is very apt  to have,  if not  cautioned ;  and
great care is requisite not to permit them to walk too soon, not, indeed, until
their  bones  have acquired  a proper degree of solidity; and even  then  it
should be by degrees, and  only in  proportion as their strength  increases.
We must not yield, says  M. Bouvier, to the chimerical  fears of augmenting
the debility by depriving children of a necessary exercise; for repose, on
the contrary, is much better suited to that state  of languor  which they
generally exhibit; and,  besides,  we may  obtain,  by passive motion, by
exposure to sunlight, and by general movements in the horizontal position,
a sufficient compensation for  the  state of inaction  in  which they are kept
luring a part of the day. 
DEFORMITIES  OF  THE PELVIS.
669
   The indications presented by the deformities in the pelvis, considered mly
 with regard to the unfavorable influence they may have upon the puerperal
 functions, will evidently vary Avith the degree of deformity.  When studying
 this influence, we classified all the  malformed pelves in three categories,
 namely: all those having three  and three-quarter inches, at the least, in
 their smallest diameter, were placed in the first; in the second, we  have
 included those presenting two  and a  half inches,  at least;  and in the third,
 those whose smallest  dimensions are under two and  a half inches;  and,
 following the  example  of Professor Dubois,  we  shall still preserve this
 division in the study of  the indications offered by the deformities.1

   § 1.  What is to  be done when  the Contraction is such, that
 the Pelvis  measures at  least  three and  three-quarter Inches
 in its  smallest Diameter?
   In such a case, the child may evidently present either by the vertex, the
 pelvic extremity, the face, or  the  trunk.
   A.  Where the  Child Presents by the Vertex. — We  have elsewhere stated
 that a spontaneous delivery is possible under such circumstances; and, con-
 sequently, that the wisest course is to wait and trust to the efforts of nature.
 But where  the uterine  contractions are exerted in vain for a long  time
 after the membranes  are ruptured,  and the amniotic waters are  partially
 discharged without the  head  making any  progress, an application of the
 forceps  is the only remedy to  Avhich we can resort.8  But the exact moment
 for the employment of this measure is to be determined Avith greater pre-
 cision.  As  a general rule,  we may wait six, seven, or even eight hours after
 the membranes give Avay, and after the os uteri is fully dilated; and then,
 if energetic contractions have  been uselessly exerted during all  this time to
 overcome the  obstacle,  it Avill be necessary to interfere, and to apply the
 forceps; though  it will  be advisable to act a little more promptly where
 the head, after having  been  engaged for some  time in the  excavation, is
 arrested by a  contraction  of  the inferior  strait; and the same would be
 true if  this  strait Avere  regularly formed, and  the arrest of the head Avere
 dependent on a feebleness of the uterine contractions occasioned by the pre-
 vious efforts on  the part of the  organ  to force  it through  the  contracted
 superior strait.   It  is unnecessary to add, that if any  accident whatever,
 grave enough to endanger the  health of the mother or the life of the child,
 should occur during the  labor, it Avould demand a more prompt intervention

  1 I am  happy to state that most of the following considerations and practical views
 are deduced from the  excellent thesis which M. P. Dubois sustained with so much
 credit in the concours, at the close  of which he was nominated.  I congratulate myself
 on being the  first to give publicity to a  work that is, unfortunately, but too  little
 known.
  ' It is highly important not to confound in practice the constantly increasing tume-
 faction of the hairy scalp with an actual descent of the head.  For, when the labor
 is retarded, the sero-sanguineous  tumor,  formed by the soft parts, continually  aug-
ments in  volume, and its summit gets nearer and nearer to the vulva; and, therefore,
unless the precaution is taken to get an osseous portion of this  region as a point of
departure, the accoucheur might suppose that the head was traversing the excavation
and approaching the inferior strait, when, in reality, it did not move. 
670
DYSTOCIA.
of art.  Most generally, the frequently repeated  auscultation of the pulsa
tions of the heart would be satisfactory as  to the child's  condition, though
even here only a certain degree of confidence can be reposed in this  sign.
  B. Where the Child Presents by the Pelvic Extremity.— When  describing
the mechanism of natural labor, we expressly recommended that no  trac-
tion should be made on the pelvic extremity in breech presentations, with
the view of  avoiding the straightening out  of the arms and  an extension of
the head; and we still insist  on the same precept here.   Nevertheless, in
the case before us,  if the largest part of the  trunk is delivered, and the
expulsion of the head is unusually delayed, it  would  be  proper to hasten
the termination of the labor by a moderate traction on  the  body; for  such
attempts, if well conceived and well directed  in the line of the pelvic  axis,
would prove sufficient in most  cases to accomplish  the delivery.  If,  Iioav-
ever, they are ineffectual, it will then be  necessary to apply  the forceps.
(See Version.)
  c. Where the Child Presents by the Face. — Although face presentations
may terminate naturally in the majority of cases Avhere the pelvis is Avell
formed, it is not the less true, as elseAvhere demonstrated  (p. 345) that the
labor is somewhat more painful to the mother, and is, besides, more danger-
ous for  the child than in  others.   If,  therefore, these  difficulties, resulting
from the position itself, are superadded to  those which exist as a necessary
consequence of the contraction, there can be no doubt  that  a delivery, left
entirely to nature, Avould be attended with  a  very considerable risk to the
foetus.   Under such  circumstances, M. P. Dubois recommends the conversion
of the face position  into  one of the vertex, by flexing the  head, and  then
the application  of the forceps, if the uterine efforts remain fruitless  after
the change.   It appears to us  that this cephalic version would be quite as
difficult as the pelvic, if attempted long after the membranes are ruptured,
and we  should give preference to the latter, Avhich, generally, would enable
us to dispense with the use of  the  forceps.   (See Forceps.)
  D. Where the Child Presents by the Trunk. — If the contraction is dis-
covered before the membranes are ruptured, or very shortly after, and the
foetus is very movable, we should endeavor to convert the presentation of the
shoulder into one of the vertex, and  then leave the expulsion to the efforts
of the womb; but after the Avaters are discharged, the contraction of the
organ renders the introduction  of  the hand and the  cephalic version  so diffi-
cult, that I consider turning by the feet much easier and less dangerous.
  The pelvic version, in the case before us, is attended Avith some peculiari-
ties that ought to be mentioned.   For instance, where an undue development
of the sacro-vertebral angle is the cause of  the narrowing, it often happens,
as before shoAvn, that the base of the sacrum is turned  a little to the one or
the other side  at the same time that it is projected fonvard, thereby con-
stricting one half of the pelvis much  more than the other; and hence, in
performing the evolution of the foetus, and  drawing on  its pelvic extremity,
under such circumstances, it would e\ddently be requisite to turn its posterior
plane towards the larger half of the pelvis,  so that, when the head presented
at the superior strait, its large occipital extremity yvould correspond to the
non-retracted side. 
DEFORMITIES  OF  THE  PELVIS.
671
  It was stated above that when the foetus presented by its flexed cephalic
extremity, it Avould  be  necessary to apply the forceps, if the uterine efforts
were incapable of terminating the labor; but the particular variety of mal-
formation that we are noAV treating of may modify the rule laid down, Avhich
Avas perhaps a little  too absolute; for, in this case, the position of the head
must greatly influence the accoucheur's determination.  Let us take, for
example, a pelvis Avhose sacro-vertebral angle while projecting forward is
turned to the right, so as to diminish the sacro-cotyloid interval very con-
siderably on this side;  noAV, the intervention of art being judged  necessary,
if the head is placed in the left occipito-iliac position, an application of the
forceps Avill  be the  only practicable measure; Avhereas, on the contrary, if
the occiput is directed  to the  mother's  right, Ave  should preferably resort to
the pelvic version.  This last operation, by converting a second vertex posi-
 ion into the first of the feet, Avould have the advantage of bringing the great
occipital extremity  of the head to the  largest side of the pelvis, and Avould
thus place the foetus in a much more favorable position.
   The delivery  has frequently been rendered comparatively  easy by the
pelvic  version Avhen resorted to under such conditions;  and  M. Velpeau
relates a case which he  terminated successfully by this manoeuvre, though
other practitioners  had deemed craniotomy to be indispensable in a former
labor of the same woman.
   The recommendations  just  made have the double object of sparing the
mother from useless suffering, and  more particularly of relieving the foetus
from  the  danger it would incur  from a prolonged labor.  Whence, it  is
evident, that the accoucheur's course will be  someAvhat  different  in those
 cases Avhere there is a certainty that  the child is  not living; for, having
 nothing to fear on its account, he might accord a much longer time to the
 uterine contractions, especially as the  head,  Avhich is then softened  and
 reducible, contributes  far more to an easy expulsion than under other cir-
 cumstances.   Consequently, he ought not to interfere in such cases, until he
 has ascertained positively, by a proper  delay, the absolute inefficiency of the
 natural forces.
   The child's death may also modify the precept above given in the trunk
 presentations, since the cephalic version was only recommended  because  it
 is more advantageous  for  the infant;  therefore, after  its death, the pelvic
 version Avould be preferred as being less painful to the mother.

   § 2. What is to be done avhen the Degree of Contraction is such
 that the Pelvis  measures three and three-quarter Inches at the
 most, and tavo and a half inches at the least, in its smallest di-
 AMETER ?
   If the foetus dies before or during the labor, and  the uterine contractions
 are ineffectually prolonged, Ave should, doubtless, prevent the dangers the
 mother might undergo from the delay,  by resorting to embryotomy, and the
application  of the ordinary forceps, or  even of the embryotomy forceps.
   Again, if when the accoucheur is summoned to the patient, the membranes
have been ruptured for some time, and the waters are partially or Avholly
evacuated ;  if the uterine contractions are exerted on the child's body alone, 
672
DYSTOCIA.
or repeated attempts at extraction have been made without success; if, in
a word, the child's life  has  been compromised, either by the length of the
labor or the useless intervention of art,—in all such cases it may be regarded,
though still living, as non-viable, and embryotomy is considered by most
modern accoucheurs to be the only proposable measure.  We ourselves held
this opinion for a long time, but being rather  less fearful of the  probable
consequences of pelvic version  in  contractions of the pelvis, Ave noAV think,
that so long as any chance  remains  in favor of the child, the latter opera-
tion should first be attempted.   Craniotomy can always be had recourse to,
if, after the disengagement  of the trunk, it should be found impossible to
extract the head.
   But where the degree of contraction alluded  to  is  detected at  the com-
mencement  of the labor, before the membranes are  ruptured, and  conse-
quently at a time when there is no reason for supposing that the viability
of the foetus has been compromised,  what ought to be done ?
   Following the example of M. P. Dubois, we shall  here  admit a further
subdivision into two classes, namely: one, where the pelvis has an extent of
three and three-quarter inches  at  the  most, and three inches at the least;
and the other, where it has but three inches at the most, and tAvo and a half
inches at the least, in its smallest diameter.
   In the former case,  after having waited for all that can reasonably be
expected from the uterine contractions, the forceps are to be applied Avhen the
vertex presents favorably.  Should the attempt prove fruitless, the contrac-
tions may be alloAved to continue for an hour or  two longer, Avhen,  if inef-
fectual, the instrument is again to be had recourse to.   If moderate tractions
are found to be insufficient,  the  instrument should be withdraAvn, and pelvic
version attempted, in  the  hope of extracting  a  living child.  (See Art.
Forceps, Appreciation.)   If no favorable result follows this second applica-
tion of the forceps, Ave are in the conditions above mentioned, and the life
of the child being certainly compromised, Ave are authorized in preferring
craniotomy to an operation which might prove disastrous to the mother; I
allude to the symphyseotomy or the Caesarean operation.
   But should the child present by the face, trunk, or breech, turning  is to
be preferred.   (See Appreciation of  the Forceps.)
   When the pelvic  diameters afford  but from two  and three-quarters to
three and a quarter inches,  the indications to be fulfilled remain the same;
but the difficulty experienced in executing the manoeuvres leaves no alter-
native but a bloody operation.   (See Symphyseotomy,  and Embryotomy.)
   The various degrees of contraction,  when ascertained  long before the ter-
mination of pregnancy, present new indications to the  practitioner; these,
in fact, are the cases in which the  induction of premature labor is to be
resorted to.   The recommendation to subject  pregnant women  with  con-
tracted pelves to a restricted diet and repeated blood-letting during gesta-
tion, applies also to the degree  of narrowing under consideration, and more
especially to those' cases in  which the  smallest diameter  amounts to at  least
three  and a quarter inches.  The value of these two methods will  be dis-
 cussed hereafter. 
DEFORMITIES  OF  THE  PELVIS.               673
  § 3.  What is to be done when the Dimensions of the Pelvis are
un dei. tavo and a half inches ?
  If the child is living, Ave  have, evidently,  only to choose between the
Cesarean operation and the mutilation of the foetus, for apart from  some
exceptional cases (see page 646), its spontaneous  or artificial expulsion  is
here physically impossible.   (Sec Cozsarean Operation.)  But if it is  dead,
or if, in consequence of the duration of the labor, and the repeated attempts
at extraction which have been made,  there is reason to believe that its via-
bility is so compromised that it might be considered as incapable of surviv-
ing after its birth, the  indications Avill vary according to the degree of con-
traction.
  Where, under  these latter  circumstances, the  pelvis offers enough  space
in its  smallest diameter to enable us to hope that, by reducing the size of
the parts by craniotomy, the delivery can be accomplished without subject-
ing the mother  to any very serious dangers, the  mutilation  of the  foetus
should be resolved on, and its extraction effected by aid of the embryotomy
forceps.  But when the diameter is barely over an inch, we can  no longer
think of extracting the child by the natural passages; and the Cesarean
operation is  then alone admissible.   It is very important to knoAV that Avith
less than tAvo inches, cephalotripsy becomes very  difficult, because then the
extraction of the base of the cranium,  after the perforation of its vault, and
the evacuation of its cavity, requires such numberless  gropings and violent
efforts, such  repeated and grievous pressures and distentions, that the chances
for the mother's safety after  these painful attempts, Avhich are sometimes
made without any benefit, are  not  more favorable than those Avhich follow
the Caesarean operation.  Under these  circumstances, M.  Pajot proposes
crushing simply, without traction.   (See Cephalotripsy.)
  In  our remarks, thus far, Ave  have  supposed that the child always pre-
sented bv its cephalic extremity; but, in order to fill up the outline Ave have
traced, it is noAV necessary to point  out what must be done Avhen the pelvic
extremity presents, the pelvis affording two and a half inches at the  most.
Under such  circumstances, the head still  adhering to the  trunk after the
escape of the latter, or entirely separated from it by decapitation, may be-
come arrested above the superior strait.  If, then, the least diameter of the
pelvis amounts to tAvo inches, craniotomy, and the  application of the  embry-
otomy  forceps, will evidently be indicated.   But  if the contraction be still
greater, it Avould  be necessary, after having diminished the volume of the
parts, and attempted in vain every effort at extraction  compatible Avith the
mother's safety,— it would be necessary, I repeat, to separate the head  from
the trunk, by dividing the neck,  and  to abandoi.  its  expulsion  entirely to
nature; for, notAvithstanding  all the  dangers  to Avhich the woman would
then be exposed, this Avould be better than the Caesarean  operation, per-
formed after the almost total contraction of the womb.
  If nothing has hitherto been said concerning  a faulty direction of the axis
of the  pelvis, it  Avas only because, like Professor Naegele, Ave do not attach
to this  particular variety of defective conformation all the importance that
Lohstein a~id  many other accoucheurs have attributed to it.  The degree
of inclination of the superior and  inferior straits  may depart widely  from
      43 
674                           DYSTOCIA.
 the figi re before given as expressing the average normal condition.  Thu.-,
 the plane of the abdominal strait  may be so inclined dowmvards  as to be
 sometimes quite vertical, as in a Avoman described by M. Naegele;  while, at
 others, there is no inclination at all, being then almost  horizontal; finally,
 the upper part of the symphysis pubis may be more elevated than the sacro-
 vertebral angle, the plane being inclined from above doAvmvards, and from
 before backwards, as in the  case  reported  by M. Bello.  (Transactions
 Medicales, t. xiii. p. 285.)  The plane of the inferior strait  may present the
 same irregularities of inclination; indeed, the direction of both straits is
 most frequently changed at the same time.
  But excepting some inconveniences Avhich the Avoman suffers during ges-
 tation, that  are more particularly dependent on the wrong direction of the
 uterus, whose displacement is  often a consequence of the faulty direction of
 the axis of the superior strait, the puerperal functions are scarcely  troubled
 by the anomaly mentioned;  for although this abnormal direction of the
pelvis has  appeared  in some feAV cases to present a serious obstacle to the
delivery, it  Avas only because it happened to coincide yvith  a deformity of
the bones and a contraction of the cavity.  The facts  reported by Moreau
and Bello, yvhen carefully  examined, fully confirm the second part of this
proposition, while the first is  proved by the  curious  observations of M.
Naegele.
                         CHAPTER  III.

                  OF BONY TUMORS OF THE PELVIS.

   The tumors that may obstruct the excavation take their origin in the bones
or in the soft parts, and are extremely numerous and varied ; and, Avhere they
have acquired a considerable volume, they constitute one of the most serious
difficulties in the  practice of midwifery.   It will not be in our poAver, in
this work, to enter into all the  details which the importance of the subject
demands ; besides, all that relates to the etiology, the pathological anatomy,
and the symptomatology of these.tumors, rather belongs to surgery than to
the  obstetrical art; and Ave must  confine  ourselves  more particularly to
pointing out to the practitioner those signs by means of Avhich their diag-
nosis is established, as also to bringing into view the different indications
they present  for  treatment.  It is proper  to  state at the'outset, that, in
compiling this article, we have freely extracted from the learned dissertation
of M. Puchelt on the subject, whose classification  we retain.
  The tumors, whose influence over parturition is  about to claim our atten-
tion, may have their origin either in the Avails of the canal which  the foetus
has  to traverse, and  therefore  appertain to the soft  parts or to the osseous
parietes, or they may be a dependency of the neighboring organs.
  Tumors of the soft  parts will be studied hereafter.  At present we shall
treat of those bony tumors which occasion, in many respects, a resemblance
to contractions of the pelvis. 
BONY TUMORS  OF  THE  PELVIS.              675
  ^ 1.  Exostosis.
  If Ave lay aside, says M. Danyau, all those cases in which an unusual
prominence of the sacro-vertebral angle has been mistaken for a true ossific
tumor,  as Avell as those where there is an uncertainty Avith regard to their
character, from the insufficiency of  the details in the Avritten account, there
positively remain but tAvo  examples of exostosis, the authenticity of Avhich is
incontestable, namely, those reported by Leydig and Mackibbin.   Though
some doubts  may still exist as  to  the value of  many assertions that have
not been subsequently confirmed by the autopsy, yet  I do not believe that
we can thus  strike  out, by a dash of  the pen, most of the observations re-
corded in our  science.  For  example, it Avould  really be  difficult not to
admit  the  authenticity of the one reported by  Gardien, since Duret pre-
served  the pelvis of the female who Avas the subject of it for a long time in
his cabinet.
   The  facts reported by M. Puchelt  prove that  most  pelvic exostoses  arise
from the  anterior face of the sacrum.  Nevertheless, several other points
of the  pelvis  have likewise been their seat;  thus they have  been knoAvn to
spring  from the sacro-vertebral articulation, from the  last lumbar vertebra,
or the  first bone of  the sacrum, and  from  the posterior face of the pubis,
either from its middle part, or on one of the sides, as also from the internal
face of one of the ischia.
   What has  been stated respecting the uncertainty of the published obser-
vations, foreAvarns us of the difficulty  that is at times experienced in diag-
nosticating the pelvic exostoses, and in distinguishing them from the various
prominences  caused  by deformities of  the  pelvis.   The  hardness of the
tumor, and its original adhesion to the osseous parietes, are given as char-
acteristic  signs; its  unevenness and  immobility are also  important to be
ascertained.  Being  ahvays covered by the vaginal Avail, it projects into the
interior of this canal, by pressing aside the organs situated before it.  When
arising  from  the anterior face of the  sacrum,  it impinges on  the posterior
wall particularly; and, if the rectum be  then explored,  the latter Avill be
found slightly pressed fonvard by the tumor, which is  itself located behind.
This last sign is very important, for nearly all the other tumors are situated
in front of the boAvel.
   The prognosis is  necessarily  dependent on  the size and situation of the
tumor, and on the  earlier or later period  of  gestation, at Avhich the labor
takes place.   It is evidently more serious Avhen the  abnormal groAvth is
very voluminous ; Avhen it is so placed  as to diminish one of the small diam-
eters of the straits, and Avhen  the child's head is  very  large.
   The  indications for  treatment, which Avere so fully  described in studying
the deformities of the pelvis, present themselves aneAV, and demand the
employment of the  same  means, namely:  to abandon the labor to nature
when the tumor is  small and so situated as to shorten the long diameters
only; or to apply the forceps, resort  to symphyseotomy, to the  Cesarean
operation, or to embry )tomy, according to the  degree of contraction.  (See
page 668 et seq.) 
676
DYSTOCIA.
  [g 2. Enchondroma.
  Enchondromatous, or cartilaginous tumors of the  pelvis, are quite rare.  The)
were made the subject of an excellent paper published by our colleague and friend
Dr.  Dolbeau, (Journal le Progres, I860,) which contains ten cases of enchondroma
coincident with pregnancy, the one borrowed from d'Outrepont being given in tlie
fullest detail.  In this case, the tumor occupied the entire left half of the pelvis,
was hard and globular, yet became  so  much softened during labor as to permit
extraction of the child, which presented by the breech.   In connection with Pro-
fessor Depaul,  I witnessed  a case precisely similar to the one just  mentioned; but
as the patient recovered without ablation of the tumor, some doubts remain as to its
real character.
  These enchondromatous tumors seem to adhere to the bone or periosteum, either
by a large surface or a slender pedicle ; occasionally they are formed in the soft parts
in the neighborhood only of the  bony surfaces.  They sometimes become quite
large.  (See Le Traite' Complementaire des Accouchements de Lenoir, See, et Tarnier.
Paris, 1864.)
  The indications to be fulfilled in such cases are  the same as has been already
laid down in respect  to exostoses;  (see above ;) but the  possible mobility of the
cartilaginous tumors, and especially  their softening, ought to modify favorably the
prognosis in regard to the probable result of the labor.   In extreme cases only is a
bloody operation to be thought of.

  g 3. Osteosteatoma.
  The term osteosteatomatous was  applied by Lenoir to imperfectly defined tumors,
composed of fibro-fatty and calcareous  substances.   He is, however, liable  to the
charge of having confused tumors of this character with enchondroma properly so
called.  Osteosteatomatous tumors always take  their origin in the cellular tissue,
and sometimes continue entirely free from  any adherence witfi the  bones  of the
pelvis, though  most frequently they become  attached to  them.  It is very difficult
to establish a positive diagnosis between these tumors on the one hand and exos-
toses or enchondromatous tumors on  the other.   It  is fortunate, therefore, that the
conduct of the surgeon will be the same in either case.]

  § 4. OSTEO-SARCOMA.
  Osteo-sarcoma of the pelvis is a very rare disease; two instances, however,
are recorded,  in which the contraction produced by  it was extensive enough
to require the Caesarean operation.
  The tumor can scarcely  be  distinguished from that of exostosis, unless,
perhaps, by the inequalities it  presents,  and more particularly by the de-
pressibility, the semi-cartilaginous softness, and the crepitation  that  it may
offer at certain portions of its surface.
  It is evident that this depressibility of the tumor will render the prognosis
less serious than in cases of exostosis; since we may indulge a hope that the
head-being urged on by the uterine contractions, will flatten it down, and
make it disappear in part.   Consequently, it is here permissible to wait a
longer time;  but as soon as the inefficiency of  the efforts of nature becomes
apparent, we must resort at once  to the same measures as in  cases of pelvic
contraction.

  § 5. Bony Tumors caused by Fractures.
  Ossific p *otuberances in the pelvis may likewise depend on  the irregular 
       RESISTANCE OF  THE  EXTERNAL  GENITAL  PARTS.    677

consolidation of an old fracture in this part;  or may be formed by the head
of the femur, Avhich, in consequence of coxalgia, has traversed the bottom
of the carious and perforated acetabulum, and projects into the pelvic cavity.
I recollect having read in a medical journal (Avhich  I  cannot noAV find) an
account of the Caesarean operation having  been  performed in a case Avhere
the sole obstacle to delivery Avas thus formed by the head of the thigh-bone.
  A representation of a fracture is given in the atlas of Professor Moreau,
taken from the Musee Depuytren,  in which the bottom  of the right cotyloid
cavity has been driven in, the internal Avail forming a  rounded tumor  that
projects nearly an inch and a half inwards ; the ilium was at the same time
divided  beyond the right sacro-iliac symphysis;  but,  in consolidating, the
exterior part of the iliac fossa has been carried imvards in such a manner as
to approach towards the sacrum, Avhereby the tumor formed by the cotyloid
wall is brought near to the sacro-vertebral angle.
  The Journal des Progres, t. xv. 1828, contains another curious instance of
a fracture of the pelvis, with a consecutive deformity in the excavation fol-
loAved by mortal symptoms ; this Avoman had previously had five fortunate
deliveries.  The  Caesarean  operation  has frequently  been performed for
obstacles of this nature;  thus Burns, Lever, and Barlow have each reported
a case of the  kind.   A very full  account of this subject will be found in
L'Atlas et le Traitt d'Accouchement, de Lenoir.  Paris,  1864.
  In conclusion, it is evident that, from Avhatever point the osseous tumors
of the pelvis  may arise, this cause of dystocia will still  present  the same
indications for treatment.
                         CHAPTER IV.

    EXCESSIVE RESISTANCE  OF THE  EXTERNAL GENITAL PARTS.
  Even Avhen the external genital parts appear to be perfectly well formed
and the most thorough examination fails to detect a tumor or obstruction
of any kind, cases  sometimes occur in Avhich  they resist the passage of the
child.  These cases we propose studying in the present chapter.

  § 1. Smallness  and Rigidity of the Vulva.
  The  rigidity of the external parts of  generation, which is frequently ob-
served in Avomen A\dio do not become pregnant until an advanced  period of
life, as  also  in very young, muscular girls, who are somewhat fat and of a
plethoric habit, often causes a considerable delay in the progress of the head
during  the first labor.  Most commonly,  hoAvever, this narroAvness  and natu-
ral rigidity give Avay, and  the parts become  distended ; but this  distention
is not always so complete as the volume  of the head demands; and then the
latter, being  urged  on by  the violence of the uterine contractions, breaks
down the resistance before it. and a laceration of  the posterior vulvar com-
missure and of* a more or less considerable portion of the perineum results.
In certain cases, as  elsewhere described, the  contraction  is vainly exerted
for a long time  against the resistance of the  soft parts, and it becomes en- 
678
DYSTOCIA.
feebled or ceases altogether; the intervention of artificial measures is then
indicated, at first to restore  the contraction  if possible, and  aftcrAvards to
replace it by moderate tractions with the forceps.
  In cases of this nature, where the labor had been abandoned for too long
a time  to the  resources of the organism, the fourchette, being too firm to
yield, has been known to remain intact;  Avhile the perineum, distended be-
yond  measure, and  thereby  rendered  thinner, Avas perforated at its centre,
and the child expelled through an accidental opening, bounded in front by
the posterior commissure of the vulva, and behind  by the  sphincter  ani
muscle.  At the present day, this fact is well  determined.   But it may
happen that the perineum  is  perforated at  its middle, and  yet, notAvith-
standing this accident, the foetus pass out through the natural passage: this
is particularly apt to occur Avhen the accoucheur's hand, being forcibly  ap-
plied on these  parts, endeavors to press back the head  in  its normal direc-
tion, and thus replace  the accustomed resistance of the pelvic floor.  There-
fore, it does not follow that the child has escaped through the central lacer-
ation  of the perineum, simply because such an opening is met Avith after
the delivery.
  Even when every precaution is taken, there are, as Ave see, cases in Avhich
extreme smallness of  the vulva, and rigidity of the soft parts, make it  im-
possible for the head to be expelled Avithout greater  or less rupture of  the
perineum.   In order to prevent it, Michaelis advised, in 1810, incision of
the posterior commissure.  The example of Eichelbery might, hoAvever, be
folloAved, and the incision be made on one or  both sides of the vulvar  ori-
fice.   This operation should be  performed only Avhen the head is at  the
vulya, and rupture of the perineum seems imminent.  The blade of Pott's
bistoury is to be glided on its side betAveen the head of  the  child and  the
margin of the vulva, and an effort made to limit the incision to the extent
just necessary to alloAV the head to pass.   Eichelbery mentions a rapid and
safe cicatrization of the wound,- in recommendation of this incision of  the
thickest part of the  vulva.
  [We therefore prefer lateral incisions : a  single one  may prove sufficient, but it
is sometimes better to make them on both  sides.  The simplest way of doing  it is
by means of strong, blunt, pointed scissors, one of the blades of which is to be intro-
duced flat between the head of the child and the vulva, to the distance of about
three-eighths of an inch, and turned up when the  incision is made.
  The integuments are so distended when it becomes necessary to operate that very
little pain is occasioned.  The small wounds thus made are considerably shortened
by the retraction of the vulva after delivery, and heal quickly.  Incision of the edge
of the vulva is, therefore, a very good operation,  but slightly painful and devoid of
danger, yet it ought not to be had recourse to unless really necessary.]

  § 2. Resistance of the  Perineum.
  It is not at all unusual, particularly in strong and muscular primiparae,
and in those possessing considerable embonpoint, to find the labor progress-
ing very regular at  first, the head clearing the cervix and descending  into
the excavation as far as the pelvic floor, and  then its further progress to be
entirely arrested; the uterus struggles energetically for a time against  this
obstad le, but, notwithstanding the force of its efforts, the head  may remain 
         RESISTANCE OF THE  EXTERNAL GENITAL PARTS.      679

there for several  hours without advancing a single line.  This resistance on
the part of the perineum is evidently OAving either to an excessive  contrac-
tion of  the  muscular  fibres  that  enter into  its  composition, or  else to the
presence of so great a  quantity of adipose tissue, as to render this  portion of
the pelvic Avail too inextensible to permit the escape of the head.
   But whatever  may  be  the cause of  the  resistance, it affects  the ulterioi
course of the  labor in two widely different Avays, Avhich it is highly impor-
tant to  distinguish  in practice, for they require the employment of opposite
means.   For  instance, it may happen  that the  uterine contraction, Avhich
was originally strong  and energetic,  is sustained in the same degree during
several  hours, but  then, being overcome by the resistance which it cannot
surmount, it  grows weaker, is exhausted, and  finally disappears altogether.
The indications here are obvious;  to  endeavor to arouse the pains again, by
making the patient Avalk  about her chamber, by rubbing the  abdomen or
titillating the cervix uteri, and by administering the ergot: and, if all these
prove ineffectual, to apply the forceps.  But a very different case is occasion-
ally met Avith, in Avhich the  contractions, so far  from  being  exhausted, are
kept up as strong and vigorous as at the commencement of the labor;  and
yet, notAvithstanding their energy, they are  incapable of effecting the dilata-
tion of  the  soft  parts  in  the  perineum ; this proving an insurmountable
resistance against Avhich the  most poAverful efforts  are spent in vain.  Here
the accoucheur should evidently avoid the use of means calculated to arouse
the contractions, — the ergot in particular would be exceedingly dangerous,—
since the tetanic and   irregular contractions  that result from  its use,  and
which have so often been followed by the death of the child,  and even by a
rupture of the Avomb that has almost uniformly proved fatal  to the mother,
are then particularly apt  to occur.  The uterus is certainly doing all that it
can, and the physician should not attempt to arouse any more energetic  con-
tractions, but  should  rather  aid its expulsive efforts by tractions carefully
performed on  the child ; and an application of the forceps is clearly the only
resource.  Our vieAV of its particular mode of action  in the  case before us
will be studied hereafter in the article on Forceps.
   Noav, in order to illustrate this  distinction, Avhich we believe  very impor-
tant in practice, Ave "will suppose tAvo Avomen in labor, in both of whom the
child's head is properly situated, and has  rested on the pelvic floor for six
or seven hours;  but  in one of them, the  contractions, that Avere at  first
strong and frequent, have gradually become more  feeble and rare, or even
have almost entirely disappeared; while in the other, on the  contrary, they
still maintain  all their original poAver.  In the latter case, we Avould apply
the forceps immediately;  Avhilst in the former, Ave should first have'recourse
to the various measures calculated to restore the pains, and  we would only
resort to the forceps Avhen these excitations had proved ineffectual, or the
pains caused by the ergot still appeared to be insufficient.
  It is also important to remember that the life of the foetu 3 may be greatly
endangered  by the ergotic contractions.   These, therefore, should  not be
alloAved to continue too long.  If the  head is not expelled after  the lapse of
half or three  quarters  of  an  hour from the commencement  of the  ergotic
contractions, I should think it prudent to terminate the labor by the forceps. 
680
DYSTOCIA.
  This inefficiency of the pains brought on by the ergot is not very unusual
in the case before us; but, even then, the administration  of this article Avill
have been useful, though an application of the forceps be aftenvards deemed
necessary;  because the instrument will then be applied under much more'
favorable conditions;  for the contractions produced by the secale cornutum
will aid  the artificial tractions ;  and, moreover, will prevent the consecutive
inertia of the Avomb, to Avhich the Avoman would have been  exposed, if the
instrument had been applied without previously exciting its contractility of
tissue.

   § 3. Laceration or Rupture of the Perineum.
   [Smallness of the vulva and resistance of the perineum are not unfrequently the
cause of  laceration of the fourchette and of the perineum itself, to a greater or less
extent.  These lacerations may be either  incomplete, central, or  complete.  They
are incomplete when, beginning from the vulva they do not involve the sphincter of
the anus; central,  AA'hen the  rupture  occurs between the vulva and  anus, Avithout
involving  either of these openings;  complete, when  the vulva, perineum,  and
sphincter ani are torn, together with the recto-vaginal partition, to a greater or less
height.
   Incomplete  lacerations do not require  any particular treatment, as they heal
spontaneously.  The lower limbs ought, however, to be kept together by means of a
napkin tied around the knees.  Cicatrization sometimes takes  place by first  inten-
tion, and sometimes after suppuration.  In either case, the perineum will almost
always be sufficiently large after recovery.   In  cases of incomplete rupture extend-
ing to the sphincter of the anus, a few points of suture or " serre-fines " have often
been used;  but, for our own part,  we gave them both up  long ago, because  they
are painful  and liable  to give rise to  small points  of gangrene.   In all cases of
incomplete laceration, I think it best to abstain from operations of every kind.  A
few touches with nitrate of silver will be all that is necessary.
   What  has just been  said of incomplete  lacerations applies equally to the treat-
ment of  the central ruptures.
   Complete lacerations are far more serious than the preceding, being often followed
by inability to retain the faeces, which is a deplorable infirmity." It is well, how-
ever, to  know that  a certain number of these  cases of complete rupture recover
spontaneously.  This occurred in one case  under my own observation ; and  as M.
Huguier has seen  fifteen or  twenty which terminated in the same way, the natural
cure cannot be a  very rare  occurrence.  Nevertheless, spontaneous  recoveries are
far from being the general rule, and then  surgical  interference becomes a matter
of  necessity.  When perineoraphy is to be performed,  the  question arises as to the
best time for doing the operation.   Dieffenbach advises the suture immediately after
delivery, for as at that time the lacerated edges are still bleeding, it is unnecessary
to freshen  them, and the whole is resolved rather into  a  simple  dressing than a
bloody operation.   Still, this course  has  its inconveniences, for the patients are
deprived of the  chance  of a spontaneous  cure, the  lochial discharges  impede
cicatrization, and the diseases to which  the puerperal state is so liable, often prevent
a successful issue.  I think it much  better, as advised by Roux and Velpeau,  to
wait until  the  patient has  entirely recovered, and  defer operating until after the
first menstrual return.
   M. Nelaton advised that it should be done seven or eight days after delivery, and
without  freshening the edges, merely to bring together the edges of the wonnd,  at
this time covered with granulations.   This method has had both  its successes and
failures.  At  seven or eight days after  delivery the  genital  parts are often still 
         MALFORMATIONS OF THE  VULVA AND VAGINA.      681

Bwollen, so that  the  sutures then traverse  inflamed tissues, which cut  through
readily.  Lochial discharges and intercurrent puerperal diseases are, besides, liable
to interfere with the recovery.
  We therefore give preference to the later operation.]
                          CHAPTER V.

         OF  MALFORMATIONS  OF THE  VULVA  AND VAGINA.
   ihe malformations of the genital parts may be either congenital or acci-
 lental:  but, as both  offer  very similar indications  for treatment, I shall
 mclude them in the same description.

   § 1. Adhesion of the Greater and the Lesser Labia.
   This may exist at birth, or it may result from some Avound or ulceration,
 the healing up of Avhich has not been  properly attended to.  Denman  has
 remarked that this abnormal union is quite frequent in little girls, though
 it is rarely observed  at the  age of puberty, as  the free and constant  use
 made of their limbs, Avhen they begin to walk,  most probably  causes a
 spontaneous separation.   This union, when congenital, may be more or less
 complete, intimate, or resistant.  When resulting from an accident, it is
 never perfect, because the  frequent passage of the urine prevents  adhesion
 from taking place at the point corresponding to the meatus urinarius; and
 the discharge of the menstrual fluid, Avhen the courses come  on before  the
 cicatrization is completed, likewise prevents the adhesion of the labia for a
 considerable extent.

   § 2. Persistence of the Hymen.
   The hymen may occasionally persist even after copulation, and thus con-
 stitute an obstacle  to  the expulsion of  the child.   The varieties of form it
 may exhibit under such  circumstances Avere pointed  out in the anatomical
 description of this membrane.  A persistence of the hymen does not ahvays
 prevent conception, since most authors relate instances in Avhich they were
 obliged to divide it at  the time of labor in order to make a free passage for
 the child. They have even detailed examples of pregnant Avomen,  in Avhom
 a second  hymen was found some distance above the first.  Again, this mem-
 brane has persisted after the  delivery, as proved in a case observed  by
 Meckel, Sen.,  and reported by Tolberg.  A Avoman, after having expelled a
 foetus of five months, surrounded  by all its membranes,  still preserved her
 hymen intact, circular, and tense.

  § 3. Obstruction from Cicatrices.
  The smallness and rigidity of the external parts may be  occasioned either
by abnormal bands or  unyielding and inextensible cicatrices  resulting from
wounds, or more  ctmmonlv from  the lacerations Avhich  are  liable to occur
in tedious or difficult labors.
  Case* of this kin I are not uncommon.   De la Motte mentions one which 
682
DYSTOCIA.
is quit^ remarkable.  Auguste Berard relates in the Dictionary in 30 volumes
a case in Avhich  after  the operation of perineoraphy the vulva Avas so com
tracted as to render sexual intercourse impossible.  In Vol. V. of the Gazette
Medicale (April, 1837, p. 13) is reported a case of difficult  labor due  to an
operation of episioraphy.  All cases of this kind resemble each  other, and
the course of the accoucheur, under the circumstances, is very simple:  a feAV
incisions, and, if necessary, the use of the forceps, accomplish the delivery.'
  It must not be supposed that all Avomen, in Avhom the fourchette had been
destroyed in a former labor, and in whom the band resulting from the cica-
trix had constituted  the obstacle to delivery, are as fortunate as she Avhose
history I have just given;  for sometimes a fresh  laceration has occurred,
and at others  the resisting  band has  not yielded, and  the  child has. been
expelled through a central rupture of the perineum.

  1  To the numerous examples recorded in  the books, I may add the following from
my own experience: In the beginning of January, 1838, while I performed the  duties
of Chef de Clinique at the hospital of the Faculty, a woman of about thirty years of
age was brought there, who -was pregnant for the second time, and  had reached her
full term.  She had been in labor since the previous Friday evening, and  it was then
Sunday morning.   The patient informed us  that the membranes were ruptured on
Saturday at eight a. m., and that the head appeared to descend rapidly in  the excava-
tion, but was  arrested in the passage.   The accoucheur in attendance called one of his
brethren  in consultation, and  they attempted an application  of the forceps at two
o'clock in the afternoon, without any benefit.  At  eight in the evening, everything
being in the same condition, they renewed the use of the instrument, which still proved
ineffectual.  They then waited until Sunday morning, and had the patient transported to
the hospital.  As Professor P. Dubois was absent on her arrival,  I examined the woman,
and found that the head had entered the excavation and was resting on the floor  of the
pelvis, the inferior strait of which appeared to be  slightly contracted.  A transverse
band, about the thickness of a  large goose-quill, and  composed of  a very hard and
apparently cartilaginous tissue, existed at the posterior  commissure of the vulva.
(The woman then told us that her former labor could not be terminated without resort-
ing to the forceps, and that a considerable laceration of the perineum had resulted in
consequence of its use.)   At every contraction,  which, however, was feeble and  infre-
quent, the child's head pressed  strongly against this  bridle, but the latter did not yield
in the least;  and for  two hours, during which we watched the progress of the  labor
before taking  any part, the head did not advance a single line ;  besides, the vulva did
not  dilate, and the band remained  as hard,  resistant, and inelastic as ever.   I was
about to make an incision  on the anterior  commissure of  the  perineum;  but a new
examination of the parts having satisfied me that the lower strait was somewhat con-
tracted, that the pains were very feeble, and consequently that the head's arrest  might
be dependent  on'these two circumstances, as well as upon the resistance of the  band,
I resolved to  attempt a  new application of the forceps.  The  head was  then  in an
occipito-pubic position, or nearly so,  though the occiput was still a little  to the left;
the  blades were  applied  and locked  without  difficulty, but the first tractive efforts
proved to be wholly abortive ; after trying for a  quarter of an hour, I succeeded in
fairly engaging  the head in the osseous strait; the posterior part of  the perineum
began to bulge out, though the  commissure  still resisted, and the pressure thus made
on the soft parts seemed  to arouse the uterine contractions, for the woman, from that
moment, aided my efforts with all her powers.   Under  the conjoint  influence of these
two forces, the  head  constrained the vulva to dilate, the band gradually yielded, it
became thinner and more distended, and finally, after three-quarters of an  hour of
constant tractions and almost continual pains, the head succeeded in clearing the  vulva.
The  perineum was well sustained by an assistant, and did not exhibit the smallest
trace of a laceration. 
          MALFORMATIONS  OF  THE VULVA  AND  VAGINA.      683

   §  4.  Malformations  of the  Vagina.
   The entire vagina, or only its upper part, may be wanting, as in the case
 mentioned  (page 108), in Avhich  only the lower fourth  of the canal was
 present.  This  kind of deformity is  often coincident with  absence of the
 uterus, in which case it is plain that the accoucheur has nothing to do.
   It may be entirely or  partially obliterated at  some  one point, either  by
 partial or  complete adhesion  of  its Avails, or by partitions.   The adhesion
 may be congenital, and  the vagina  reduced to  a  dense, solid, impervious
 cord, composed of mere cellular tissue; or it may  be accidental, resulting
 most usually from lacerations or lesions during  former  labors, or else from
 wounds or injuries.  Thus, in the case of a woman, reported by M. Lombart,
 of Geneva, who used a pint of sulphuric acid as an injection, with the cul-
 pable design of procuring an  abortion, the bladder Avas found  to be fused
 immediately into the rectum, the vagina having been destroyed  at the cor-
 responding  part; and M.  Cruveilhier has  knoAvn  the vulvo-uterine canal to
 terminate in a cul-de-sac,  about an inch from the meatus  urinarius, in con-
 sequence of vaginal injections made Avith a solution of  corrosive sublimate.
   The partitions spoken of as  existing in  the vagina may be transverse  or
 longitudinal; and most of the cases of double  or triple hymen mentioned
 by authors  can probably be referred to the former.  These may be complete,
 that is, they may divide this canal into tAvo distinct  cavities, though more
 frequently they exhibit a  small opening  through Avhich  the liquids ooze;1
 or incomplete, only obliterating it in  part; consequently their form is very
 variable in  different cases.

   [A very singular case of dystocia, caused by a sort of  bridle in the vagina, was
 reported to me by my friend Dr.  Pignant, of  Creuzot.  When  the child Avas about
 to be expelled, the head passed above a sort of bridle or bridge, whilst the body
 was  disengagecLbeloAV it, so that the neck of the child remained  applied against the
 vulva, retained there by the  bridle.   The midwife in attendance Avould not venture
   1 In the course of the year 1837, a  young woman, who was advanced to the last
 month of gestation, presented herself  at the clinic of the Faculte.  When the vaginal
 touch was resorted to, the finger was arrested, at the depth of one inch and a half or
 two inches, by a perfectly smooth septum, in which it could  detect no sensible opening.
 T>\ a resort to the speculum, it became evident that the obstacle to the entrance of the
 finger consisted of a  membrane, which adhered to the walls of the vagina, and com-
 pletely blocked up its cavity at,this point.  Its surface appeared to be nearly an inch
 in diameter;  and, by pushing and distending it Avith the extremity of the instrument,
 a small opening was detected towards the upper third and right  portion of this par-
 tition, through which a few drops of sero-purulent liquid were  oozing.
  The extremity of a  blunt probe could scarcely  be made to penetrate the little orifice,
 which was directed obliquely from below upwards, and from before backwards; the
 instrument then entered a kind of posterior chamber, formed by the upper wall of the
 vagina.  Thus far, no accident had impeded  the course  of the  gestation, but some
 difficulty was thenceforth  anticipated at the time of labor.  This patient was taken
 during the night with pains, but they were  so feeble that a  commencement of the labor
 was not suspected; though about five o'clock in the morning very strong and frequent
 ones  came on, which effected the expulsion of the foetus.  The lying-in was very
 favorable, and two weeks afterwards I found that the septum had been split into three
distinct pieces; one inferior and two superior.   I have examined this Avoman  several
times since, and am satisfied that the flaps still remain  isolated. 
684
DYSTOCIA.
to cut the constricting part, which was rounded in form, muscular in  appearance,
and as thick as the little finger.  The child perished in consequence.   Upon exam-
ination, the bridle was found to  have a longitudinal direction, with its tvA'o end?
inserted upon the vagina.]

  Where the septa are longitudinal,  at times they only divide the vagina in
a part of its extent;  but at others, they  separate  it throughout.   In the
latter case, the continuity  of the partition  may be interrupted at some part,
and  then  the two  canals which it  forms will communicate through this
opening.   The septum, Avhen  complete,  is occasionally prolonged into the
uterus, Avhich it likewise divides into tAvo cavities, although this does not
always happen.
  The vagina may have been originally very small, or it may have  under-
gone  a remarkable diminution  or contraction.   This,  in  some  cases, has
been  carried so far as scarcely  to permit the introduction of  the  female
catheter.  M. Moreau observed a young Avoman in the fourth or fifth month
of her pregnancy,  in  whom this canal  was so  contracted that it  barely
admitted the barrel of an ordinary Avriting-quill.   Such a disposition,  Avhich
gives rise to much  uneasiness,  nearly always yields to the natural progress
of the gestation.1
  Again, the vulvo-uterine  canal may be deviated from its usual course,
and present no natural openings  at the parts of generation.   The points at
which it then terminates are very various; thus it has been known to open
below the navel by two small orifices, separated from each other by a strong
membrane, one of Avhich gave passage to  the  urine, and the other  to the
menstrual fluids; frequently, it discharges into  the rectum.  Portal  states
that a young  girl, in whose vulva there  was only a small  opening for the
passage of  the  urine, and Avhose menses  were always discharged by the
anus, became pregnant;  yet the  small opening enlarged  sufficiently during
the latter stages of gestation, and more particularly during the travail, to
permit a  spontaneous termination of the  labor.  M. Rossi reports  that,
having been called to a Avoman in labor, he discovered  a total  absence of
the external genital organs.   At first, he supposed there Avas a retention of
the menses, and, under this impression, made an  incision about  tAvo inches
long in the direction of the vagina; Avhen, instead of the menstrual blood,
he encountered a male child, which escaped through this opening, and lived
but seven hours after  its birth.   Whilst searching where  the  fecundation
could have  taken place, he  discovered, after having interrogated the hus-
band, a small orifice, near the sphincter ani and at the internal part,  Avhich
would scarcely admit a fine  probe.

  1 Plenck states that, being summoned to a woman in labor, he found  the vagina so
contracted  that the little finger could not be introduced at all.  Nevertheless, this
canal was sufficiently dilated by the end of eighteen hours, and the child's expulsion
took  place  Avithout producing any laceration of it or of the  external genital parts.
(Elementa artis Obstetricise, p. 113.)
  Merriman states that the labor  terminated  spontaneously in thirty-six hours, in a
case where the introduction of the finger was barely possible;  but the  patient died
on the third day, and a small laceration  of the  vagina was found  at the post-mortem
examination.  (Synopsis  p. f>9.) 
        malformations of the  vulva  and VAG1NTA.       685

  The  various obstacles  just studied are most  frequently surmounted by
the efforts of nature alone; and, therefore, as  a general rule, there  is no
necessity for  an early resort to cutting instruments.  If, however,  it be
deemed advisable to have recourse  to  an operation before  the  labor, for
separating the agglutinated parts, incising the hymen, or for  destroying an
abnormal  septum or  vaginal  adhesion,  it Avould  be better  to  Avait  until
the first four or five  months of the gestation have passed over; because,
after this period, there would be less reason to fear the unfavorable influence
which the shock  caused by the operation might have over its  progress.  As
the hymen and  the vaginal  septum are nearly ahvays perforated by an
opening, a director  might be  introduced into it,  along Avhich  a bistoury
should  be passed, so as to incise the  parts; Avhere it is  necessary to divide
the adherent labia, Ave  might  use the  scissors, as their  agglutination is
ahvays incomplete;  but,  in all cases, the incision must be carried as low
doAvn as possible, so  as to open a free passage for  the lochia.  When it is
desirable to destroy  the hymen  or a  septum, it is  usually recommended to
make a crucial incision, and even to excise the  flaps to  prevent them  from
afterwards reuniting.  A similar  plan Avould be resorted to, at the time of
parturition,  excepting that  the same  importance  does  not  attach to the
excision of the flaps,  as  the discharges  of the lochia Avould prevent their
reunion.
  As to the bands and  partial contractions found at some part or other of
the canal, Ave should  delay our operation, for they most  generally become
softened and ultimately permit  the delivery to take place; in the contrary
case, they must evidently be incised.
  Finally, an accidental  and complete obliteration of the vulva, occurring
during the course of gestation, Avould require the creation of  a neAV passage
for the head, as soon as the latter distends  the  perineum;  and it is advis-
able to make the incision in  the  place usually  occupied by the vulvar
orifice.

  § 5.  Inversion of the Vagina.
  Inversion of the vagina occasionally takes place during parturition; that
is, the mucous membrane of this canal  being pressed doAvn  by the child's
head, and consequently being more or less inverted, forms a livid and fun-
gous cushion of considerable size betAveen the labia, or beyond the vulva,
Avhich opposes the passage of the head.  The pressure  made by this  part
on the inverted membrane, often gives rise to gangrene ;  and,  therefore, Avith
a view  of preventing this  unfortunate result, the forceps  ought to be applied
at once.  The causes  that predispose  the  patient to an inversion of the
vagina  are: a long and difficult labor, a large head, and a marked relax-
ation of the mucous membrane.   If this affection  is detected  before the
head is engaged, the accident might be prevented by pushing up  the  mem-
brane at the commencement of  the labor, and maintaining it there until ita
close. 
686
DYSTOCIA.
                          CHAPTER  VI.

                TUMORS  OF  THE VULVA  AND VAGINA.

  The vulva and vagina are liable to be affected Avith a variety of tumors,
of Avhich Ave shall have to notice, oedema of the labia externa, thrombus of
the vulva and vagina, cysts, abscesses, fibrous tumors pediculated or other-
wise, cancerous degenerations, and all the vegetations

  § 1.  CEdema of  the  Labia Externa.
  The ozdema of the greater labia, already alluded  to, Avhen treating of the
complications of pregnancy, is sometimes so considerable at the time of labor
as to obliterate the entrance of the vagina almost completely; and, by oppos-
ing the necessary distention of the vulva, it may render the parturition very
difficult, as well as exceedingly painful.   The child's head  may  produce a
gangrene in the parts thus tumefied, by the pressure on them  during its
passage,  or, at  least, it may cause an extensive rupture.   These accidents
are to be prevented  by making punctures with the lancet  in all the sAvollen
tissues; the number of the punctures will necessarily vary with  the extent
of the SAvollen parts, and the degree  of their engorgement.
  [CEdema of the entire soft parts of the cavity of the pelvis, especially in women
Avho have naturally much embonpoint, occasions a sort of constriction of the genital
passages which obstructs natural delivery, and embarrasses much the operator when
he finds it necessary to interfere.   Although this is  quite a rare cause of  dystocia,
it nevertheless happens; indeed, quite recently, at the  Hospital St.  Antoine, it
rendered delivery very difficult in the case of a woman  attacked with convulsions,
although  she was very well formed.

  §  2. Sanguineous Tumors,  or Thrombus.
  Thrombus of the vulva and vagina consists in an effusion of blood in the soft parts
>f the lesser  pelvis or of the  vulva.   It sometimes extends above the superior strait,
.ind even  quite high into the abdomen.  Thrombus, therefore, is a true hemorrhage,
and on this account there might be some advantage in describing it in  connection
with the other losses of blood which are  liable to complicate labor, were it not that
the  causes which produce it, the tumor which it commonly forms  in  the vagina,
and the treatment which it  requires, distinguish it so clearly from uterine hemor-
rhage that it has seemed more proper To classify it with the tumors of the vulva and
vagina.   The very name of the affection also justifies the position which we assign
to it.]
  The tissue that constitutes the lips of the vulva, and lines the entrance of
the vagina, is composed of venules,  arterioles, cellular filaments, and  fatty
masses, so interlaced and  held together, that an effusion  of blood  there is
almost ahvays abundant;  besides Avhich, the stagnation  of the fluids in the
external  genital parts, and the varicose state of the vaginal veins, so frequent
in pregnant Avomen, predispose all  these  organs  to Avhat  is denominated
thrombus.   In fact, during gestation, and more particularly in the course of
its latter months, these large veins are apt to give Avay, either spontaneously,
or in consequence of some external  violence, and the blood is extravasated
into the cellular tissue, whereby a considerable tumor is developed ;  and, in 
TUMORS  OF THE  VULVA  AND  VAGINA.          687
the course of a variable period, gangrene attacks the distended parts, and
hemorrhage, Avhich is occasionally vary profuse and sometimes even  fatal,
takes place.1
  Thrombus of the vulva does not appertain to pregnant Avomen exclusively,
since it may also appear in the non-gravid condition; indeed, according to
Velpeau, it is even more frequent then than during gestation.  However, it
must be acknoAvledged that the  obstruction to the circulation in the loAver
extremities caused by the development of the Avomb, must necessarily favor
the production of this tumor; and, consequently, that, in  the non-pregnant
state, a  thrombus  of the vulva is  far less  dangerous  than in the opposite
condition.
  This tumefaction most generally affects the great labia, though it has also
been observed  in the lesser ; in most cases a single  lip  only is  involved,
though at times there is a double tumor, caused  by a simultaneous  effusion
into both of the labia  externa.   Wherefore, Boer was Avrong  in supposing
that the right one was its  exclusive seat, for it may appear indifferently on
either side.
  It is rarely present in the earlier months of gestation, but is more frequent
in the latter periods, and particularly so during the labor, or  after the de-
liA'ery.  The most  common cause of thrombus during pregnancy, are blows,
falls, violent concussions, etc., etc.  In some cases it  can be  traced  to no
external violence, and then the spontaneous rupture must evidently be re-
ferred to an excessive distention of one of the vaginal veins.   When occur-
ring during labor,  this affection  is nearly ahvays  manifested just as the head
or breech  endeavors to clear the vulva, after having reached the  inferior
strait.   The rupture of the veins is then certainly caused by the distention,
which they, like all other parts, are subjected to,  (a distention to Avhich they
yield Avith more difficulty,)  and by the great accumulation of blood produced
hy the obstruction to the circulation from the presence of the  child's head.
Therefore, an excesshre size of the latter, or  its unusual delay at the inferior
strait, a narrowing of the pelvis, and the consequent immoderate  efforts on
the part of the patient to overcome the resistance, are  its most  common
causes.  Certain authors have likewise supposed that the obliquities of  the
Avomb, and the frequent rough examinations of the parts of generation,
might produce them; but it is evident that such  circumstances cannot have
the attributed effect,  unless a varicose predisposition exists at the same time.
Ordinarily, these tumors only appear after the delivery, Avhen, indeed, they
are the  more dangerous;  first, because they may the more readily escape
unperceived, and then, because the relaxation of the parts permits them to
acquire a very considerable volume.
  The remark of M.  iK-neux should be borne in mind, that most of the cases
of thrombus Avhich are not detected  until after  delivery, really commence
during the labor, or, at least, that the rupture of the vessels, if not the effu-
sion, takes  place during the first expulsive pains.  Often, indeed,  when a

  1 This  accident was described quite accurately, in 1647, by Veslingius.   "I have
twice," says he,  "witnessed an effusion of blood betweer. the vaginal tunics, in cases
of difficult  labor.  The labia  presented a considerable tumor, which, when opened
discharged quite a large amoust of blood." 
888
DYSTOCIA.
vein is ruptured, it is so  compressed by the  head in the excavation  as  tc
prevent any effusion, a free escape of blood taking place only after the labor
is  terminated.   It  being rarely  necessary to introduce the hand into the
vagina after the delivery of the placenta, the tumor will not be discovered
until it has become so large as to incommode the patient, or the physician
is alarmed by the general symptoms of hemorrhage.  Therefore, considerable
time may elapse betAveen the commencement of the accident and its  detec-
tion.
  Still another condition may postpone  the appearance of the thrombus,
namely, the stoppage of the small opening in the vein  by a coagulum.
  Finally, it may happen, as supposed by M. Dubois, that the badly con-
tused, and perhaps even mortified walls of  the vessels,  do not  give Avay
until when,  at a later period, the part which  has  suffered the pressure be-
comes  detached.   The mucous membrane, being more extensible than the
walls of the veins, recedes, so to speak,  before the violence Avhich affects the
distended vessel, and is not, therefore, so much  injured by it.   Thus  is ex-
plained the  late effusion of the blood into the submucous cellular tissue, and
the consequent formation of a tumor.
  [M. Perret  (Paris Thesis, 1864) maintains, moreover, that the head of the child
may occasion a sort of sliding of the walls  of the vagina  upon the surrounding
tissues, and terminate in the detachment of the Avails for a greater or less extent,
with rupture of the cellular partitions.  Thus is  formed a  cavity of variable size,
which may become filled Avith blood from the ruptured capillary vessels.  In sup-
port of his opinion, M. Perret refers to an autopsy, in which he saw the water of
an injection, thrown into the femoral vein,  make its appearance over the entire
surface of the cavity ; from which he concluded that  no important vein had been
injured.]
   It is highly probable that the thrombus Avhich forms during labor is occa-
sioned by the  rupture  of one or more veins, and the same is true for that
which  makes its appearance after delivery; only, in this case, the effusion does
not occur until after the child  is born.  We can imagine, hoAvever,  that the
phenomena may  take  place  differently; for, as  the Avails of the veins are
often very much Aveakened, either by extreme distention or the stretching to
Avhich  they are subjected during the labor, it is possible that a  sudden  move-
ment, a violent inspiratory effort, or a fit of coughing, might suddenly cause
such an afflux  of fluid  into them, as to produce their  spontaneous  rupture
even after the lapse of several hours from delivery.
   The development  of a sanguineous  tumor is  generally announced by a
severe pain in the affected part, caused, doubtless,  by the  rupture  of some
of its vessels;  then one, or sometimes both of the greater labia, or, perhaps,
 mly the nymphae, soon  SAvells up, becomes  rapidly distended, and  forms a
more or less voluminous tumor.  This tumor may acquire  a considerable
size, and  the quantity of effused blood be  great enough to  debilitate the
patient, and, possibly, to produce  syncope.   In some instances, it  acquires
its full volume at once,  while  in others it goes on augmenting for tAventy-
four hours; it  may be limited to the external parts, or it may  extend deeply
 into the pelvis, and, possibly, as far as  the iliac fossae.
   In a paper published in 1860 on the seat of thrombus, M. Laborie based 
T'JMORS  OF  THE  VULVA  AND  VAGINA.          689
his classification upon an account of the aponeuroses of the perineum, and
makes the folloAving varieties :
   1.  Superficial thrombus, which may spread to  a great distance beneath
the skin, extending back near to the anus, upward in front to the abdominal
parietes, and laterally to the gluteal region.
   2.  Thrombus situated between the superficial and middle aponeuroses, and
limited  to the confines in which it occurred.
   3.  Thrombus situated between the middle and superior aponeuroses;  it is
always  very small.
   4.  Thrombus between the superior perineal and the pelvic aponeuroses.
In this variety, the blood may make its way  to a  great distance, reaching,
laterally, into the iliac fossae, and  backward to the sacrum, and even to the
lumbar  region.
   5.  Thrombus above the pelvic  aponeurosis.   Here the effusion takes place
into  the sub-peritoneal cellular tissue, and may invade the entire pelvis, the
broad ligaments, and ascend in the substance  of the mesentery as far as to
the diaphragm.
   6.  Finally, he describes, as a sixth variety, an  effusion  of blood  in the
tissue of the vaginal wall itself,  Avithout rupture  of the  fibrous tunic.   In
this  case, the effusion dissects the  vagina, and  presses it inward.
   All these  divisions are rather anatomical  than  clinical, but Ave reproduce
them, in order to shoAV clearly  hoAv  very  variable the  seat  of thrombus
may be.
   In 1846, I had occasion to Avitness a case in which the effusion had spread
very widely.  The autopsy  revealed a layer  of coagulated  blood  betAveen
the muscles  and peritoneum, spread over the  whole loAver half of the ante-
rior  Avails of the abdomen on the right  side.   The layer Avas nearly a quar-
ter of an inch thick,  and extended from below upAvard to  about tAvo fingers'
breadth below the umbilicus, besides occupying  transversely the  entire
space between the linea alba and  the crest of the ilium.
   At the latter point, the layer of blood was  continuous with  a clot  about
three-eighths of an  inch thick, also situated  beneath  the peritoneum, and
lining the entire iliac fossa.   Below and inward, it turned over the edge of
the superior strait, and was  lost  in a  large collection  of  coagulated  blood,
Avhich formed the tumor that during life had especially attracted our atten-
tion.  The clot in this place Avas at least five-eighths of an inch thick at the
centre, but it grew thinner as it spread out over the entire right side of the
excavation:   the remaining  cellular tissue of the pelvis was highly colored
by infiltrated blood.
   The disaster was not, hoAvever, limited to what we have described, for in
ascending, and  separating the peritoneum  upon  the  posterior and right
lateral side  of the abdomen, the  coagulated blood was found  to extend as
far as the right hypochondrium, and to imbue the entire cellular tissue sur-
rounding the kidney; it also passed  between the folds of  the peritoneum
forming the  origin of the mesentery, and finally extended to the attachments
of the diaphragm to the false ribs of the right side, Avhich connections seemed
to have  been the only barrier to its further progress.  The thickness of this
large coagulated  layer varied from one to tAVO-eighths of an inch.   The
      44 
690
DYSTOCIA.
total  amoi nt of effused  blood was estimated  at two pounds by those who
witnessed ihe autopsy.1
  Again : it not unfrequently happens that the effusion commences within the
pelvis, and subsequently approaches  the exterior.   The tumor shortly as-
sumes a violet or livid hue; and when the thrombus is seated high up, this
discoloration of the skin rarely permits it to be mistaken ;  when lower, and
in the substance of the  greater  labia, on  the contrary, it may neither bo
accompanied by ecchymosis, pulsation, nor throbbing.  Where the blood
infiltrates into the meshes of the cellular tissue only, the tumor is hard; but
it becomes soft and fluctuating Avhen  this texture  is  torn, and there is an
abnormal cavity formed.   Again, it is not unusual for the skin, or mucous
membrane covering it, to  give way in consequence of being gradually ren-
dered  thinner; thereby giving vent to a  considerable  discharge of blood,
with an instantaneous cessation of the pain; and this hemorrhage may be so
profuse as to speedily terminate in death, especially if the tumor be volumi-
nous,  and the rupture occurs during the efforts of parturition.  Cases have
been  knoAvn  in which the rupture Avas followed by a projection of a jet of
blood Avith such force and abundance, as to fall at  a distance of several feet
from the patient, and to be mistaken by the attendants for a rupture of the
membranes, and discharge  of a  large amount of water.   Whenever the
nature of the accident was mistaken and the proper measures were not  em-
ployed, the patient succumbed in a few minutes.
  A copious bleeding has occasionally taken place during the formation of
a thrombus.  In fact, this circumstance may occur Avhenever the mucous
membrane and one or more of the veins are  lacerated at the same time.
Should the two openings not correspond with each  other, one part of the
blood Avill  escape  into the vagina, and the other be infiltrated into the cel-
lular tissue.
  Where the thrombus  has acquired  a considerable size, it may evidently
impede the passage of the head, and after the delivery, that of the  placenta
and lochia.
  Madame Lachapelle relates a very curious instance, in which a thrombus,
that had first commenced during the labor, underwent a rapid development
after the child's expulsion.  The tumor obstructed the vagina so much, that
it prevented the escape of the lochia, whence the latter accumulated in the
womb, and became, somewhat later, the source of a profuse hemorrhage.
Fortunately,  she continues, in the attempts to  introduce my hand  into the
uterus, for the purpose of extracting the clotted blood, I  ruptured the tumor
involuntarily, near the entrance of the vagina, Avhen a large  quantity of
coagulated blood  immediately escaped, its size diminished, and all the at-
tendant symptoms disappeared without any particular treatment.
  Finally, the pressure of the tumor on the neck of the bladder may cause
retention of the urine and fecal matters.
  When the thrombus appears early in pregnancy and has been emptied by
incision and the patient cured, it may reappear some time after and at the
same place.  A relapse of the kind is reported by Montgomery.  The tu-
mor, AAhich shoA^ed itself in the left labium in the seventh month of gesta-

  1 For ie details of this case, see the Gazette Medico-Chirurgicale (February 28,1846). 
             TUMORS  OF  THE  VULVA  AND VAGINA.          691

 [ion, caused so much  pain as to induce the author to puncture and empty
 it on the ISth of  June.  He Avas sent for again  on  the 13th  of July, and
 discovered a much larger tumor than the preceding,  and Avas again obliged
 to puncture it in order to relieve the patient.   It  did not return until  the
 24th of August, at Avhich time the young woman Avas delivered.
  The diagnosis of these tumors is, in general,  quite easy;  for  their sudden
 appearance, their rapid development,  their  hardness when the blood is
 simply infiltrated, and fluctuation av hen  it is  collected in an abscess;  the
 violent pains they give rise to, and  the bluish discoloration of the skin, are
 ahvays sufficient to detect them.   Nevertheless, they have sometimes been
 confounded Avith  certain other tumefactions,  such  as the  simple varicose
 ones, an inversion of the vagina, the descent or inversion of the Avomb, and
 with the vaginal herriiae  formed either by the intestine, the omentum, or the
 bladder;  but  as Ave shall have occasion hereafter to treat of each of these
 tumors, and their peculiar signs, it seems useless to enter here into their dif-
 ferential diagnosis.
  The prognosis is usually unfavorable;  thus,  " in sixty-two cases brought
 to my knoAvledge,"  says M. Deneux, " the mother died in tAventy-tAvo of
 them, either during the gestation, or else during or after delivery; and with
 the exception of a  single instance, all  the children  of these tAventy-tAvo
 females Avere likeAvisc lost."   The profuse hemorrhage is the most frequent
 cause of the patient's death, though  the latter may also be occasioned by
 the gangrene and suppuration which often follow  the primary  symptoms.
  [The gravity of the prognosis,  as asserted by Deneux, is confirmed by M. Blot in
 his thesis for the Concours  (Paris, 1853).  In making  out a statement of 19 cases
 published since 1830,  the  latter author finds that five  of them were fatal.  All the
 children of the mothers who died were still-born.]
  These tumors may terminate either by resolution,  suppuration, rupture,
 or gangrene; but  as the progress of the disease exhibits nothing peculiar in
 any of those cases, Ave shall merely  mention them  in passing.
  The  treatment of  thrombus  necessarily varies  according to its size, and
 the sufferings  thereby occasioned  to the female,  as  also to the  period at
 which it is manifested.   If the patient be in labor when the tumor is devel-
 oped, and  the latter be large enough to seriously impede the passage of the
 head, the  effused  liquid  should evidently be evacuated by a free  incision,
 made on the most dependent part of the SAvelling,  the extent of which must
 be proportioned to its volume.  If this operation is performed  some time
 before the head engages in the excavation, it Avould be advisable, after hav-
 ing emptied the sac, to make use of the tampon in order to prevent  hemor-
 rhage ; but if, on the contrary,  the tumor is only opened when the head is
 fully engaged, the application  of the tampon may  be dispensed Avith, for the
 child's  head Avill sufficiently compress the divided vessels to prevent a fur-
 ther discharge of blood.   In the latter case, it Avould be requisite to attend
 to the precautions described beloAV, after the delivery.
  The question  is  not, hoAvever, so easily decided Avhen the thrombus ap-
pears during pregnancy  or after delivery, and  authors are  far from being
unanimous as respects the course to be pursued.  To give greater precision
to out th rapeutic  recommendation, Ave shall distinguish the cases in Avhich 
692
DYSTOCIA.
it is necessary, 1, to incise immediately; 2, to incise at a lat jr period; and,
3, to omit incision altogether.
  1.  When it is necessary to Incise immediately. — The tumor is sometimes
so large as to fill a great part of the excavation, and  seems capable of ob-
structing the discharge of the lochia.  Careful examination then shows the
skin or the mucous membrane covering its internal surface, to be so greatlv
thinned by  distention and to present so deep a violet hue that gangrene or
spontaneous  rupture seems likely to occur at any moment.  On the other
hand, the quantity of fluid effused, and the disorder which it necessarily
produces in the cellular tissue in which it has formed a large cavity, renders
its  absorption very improbable ; the evident fluctuation  discoverable over
the greater  part of the tumor induces the reasonable belief that it does not
contain a large clot, and that there is nothing, therefore, to prevent a con-
tinuance of the internal discharge.   The patient experiences  acute pain,
and, lastly,  her increasing weakness, the feebleness of pulse, pallor of the
skin, &c, lead to the opinion that the disorder is  not  limited to the tumor
of the excavation, but that in all probability the blood is making its way to
the upper part of  the abdomen.  Under these  circumstances, it would cer-
tainly be nothing short of folly to depend upon the efforts of nature alone,
and immediate incision appears to us indispensable.
  2. Postponement of Incision.—If, however, the  tumor is  small, being no
larger, for example, than an egg;  if the walls are of considerable thickness
and of a natural color; if it is but slightly painful, and does not appear to
increase  in  size;  if, from the  coagulation of the effused  fluid, fluctuation
becomes more and more obscure; if, in a word, there is every reason to hope
that the internal hemorrhage is not only arrested, but its recurrence rendered
impossible through the  compression of the ruptured vessels by the coagulum,
I have no hesitation in believing  that everything should be done to assist
resolution, and, consequently, that the instrument should not be used, unless
rendered necessary by certain accidents, which may occur under the circum-
stances.
  This method, I  am aware, has both its advantages and disadvantages;
still I regard  the former as  of greater importance than  the  latter.  As
advantages, I  would mention:  1, the possibility of absorption, which we
certainly  have occasion frequently to observe as  taking place Avith much
larger effusion ;  2, the rarity of consecutive hemorrhages.   This latter point
Ave shall discuss hereafter.
  The partisans of immediate  incision reproach expectation with exposing
the  tumor to suppuration and gangrene, besides thinking that a late inci-
sion does not  ahvays protect  against hemorrhage.   Let us examine  the
worth of these objections.
  The attempt to bring about resolution does not dispense with the necessity
of a careful oversight of the case :  now,  before becoming affected Avith gan-
grene, the walls of the  tumor present to the attentive eye of the surgeon
certain changes Avhich  forewarn him of the danger.   On the other hand,
when the  blood, which, extravasated in  the tissues, acts as a foreign body,
and excites  around it first an irritation and  then  an intense inflammation,
suppuration does  not take  place  without having been preceded  by heat, 
TUMORS  OF THE  VULVA AND  VAGINA.          693
redness, greater or less tension of the tumor, and more or less pain to the
patient:  now avc  can hardly expect the physician to be so negligent as to
allow all the phenomena of a suppurative inflammation to pass undiscoA'ered.
Therefore, as soon as the tumor, so far from progressing toward . complete
resolution,  presents some of these  preliminary symptoms,  it Avill  be time
enough to  have  recourse to the operation.  But would  it not have  been
better to have  practised it at once ?  Certainly not;  for  independently of
the chances of obtaining resolution, you have now the  advantage of perform-
ing incision under circumstances the best calculated to prevent consecutive
hemorrhage.
  Indeed, it seems to me undeniable, that, Avhen the hemorrhage has ceased
for several  days, and the  greater part of the blood is converted into a solid
clot, which, either by direct compression, or by extending into the opening
of the ruptured vessel, shall have obliterated the latter, the cavity may be
incised  Avithout probability of hemorrhage.   I am  acquainted with  the
observations relied on by M. Deneux and others, as shoAving that secondary
hemorrhage is not an impossible occurrence; but, in my opinion,  they are
far from being  conclusive against the opinion which I hold.
  If hemorrhage is  ever to be feared as  a consequence of opening san-
guineous tumors  of the vulva  and vagina,  I certainly maintain  that  it is
especially so when practised immediately; for, as the rupture of the varicose
veins is then recent,  there  is nothing to prevent the blood from flowing
externally: the determination of blood to the  parts,  which may have con-
tributed to  the  production of the rupture, still exists, and during pregnancy,
the obstruction to the return of the circulating fluid by the large venous
trunks, in consequence of the pressure of the uterus, highly developed as it
is, and situated above the superior strait, is remarkably well calculated to
produce venous hemorrhage.  I am well aware that the  tampon  may be
applied, as also that the partisans of immediate incision rely chiefly  upon it;
but whoever has used the tampon, knoAvs Avhat suffering it occasions when it
has to be left in its place  for several days,  and hoAv  difficult it is,  notwith-
standing all the means proposed for the purpose, to maintain a free discharge
of the lochia.
  It appears to me that M. Velpeau, Avho treats the fears of some  authors
on the subject of hemorrhage as chimerical, has had reference rather to cases
of thrombus frequently  Avitnessed by him in non-pregnant  Avomen, than to
those which appear in the puerperal state; for, according to him, there is no
vessel in,  this region  large enough to become a source of anxiety.  This last
proposition  I esteem  erroneous, if it  be intended to apply to  pregnant
females;  it is well known that the arteries and  veins of the vagina share in
the  development of the  entire  generative apparatus,  and all practitioners
have felt the varicose veins  projecting  beneath  the vaginal mucous mem-
brane during pregnancy, and also  the  pulsations of  large arteries.   The
latter sensation  is  so evident as to have been styled, by Osiander, the vaginal
pulse.
  Finally, it may be said that, by deferring the incision of the tumor, we
inmr  the risk  of  an extension of the effusion, and a separation of the peri-
toneum over a large surface, all of Avhich would have  been avoided  by  pro 
694
DYSTOCIA.
 viding  a free  exit  externally.  This, doubtless, is possible;  but when avo
 come to reflect upon the conditions by which we Avould limit the  expectant
 method, and the attempts to obtain resolution, it will be  seen that Ave are
 protected from any such  danger.  Besides, if it is necessary to  apply the
 tampon after immediate  incision,  may not this have the same  effect  by
 obstructing the discharge of blood outAvardly?  Unfortunately,  this  is no
 hypothesis, for it is  supported by one of M. Deneux's OAvn  observations.
   At Avhatever  period the incision is practised, it is best not to insist  upon
 the removal of  all  the clots;  but, at the first  dressing, to respect all that
 seem to adhere to the surrounding parts ; for Avhile their immediate detach-
 ment Avould risk a return of the hemorrhage, they Avould come aAvay gradu-
 ally at the subsequent dressings.   If necessary, their separation might be
 assisted by  daily injections.
   Another  question has  reference  to  the part of the tumor to be operated
 upon.   Most authors agree to make the incision external, that is, through
 the integuments ;  for they find that the dressing is  thereby rendered easier,
 that it  does not require the introduction into the vagina of foreign bodies,
 which might obstruct the discharge of the lochia, and that the wound is not
 subject to irritation from  the uterine fluids.  I would add that the cicatrix
 would be less dragged upon in future labors, and, therefore, less exposed to
 rupture when the external  parts are  greatly distended by the fcetal head,
 I  therefore adopt  the external incision but  upon one  condition, namely,
 that it shall be possible, which is not ahvays the case ; for when the tumor
 is situated in the greater or lesser labia, it presents two surfaces, one mucous
 and  the other  cutaneous,  and unless  there exists  a very thin and altered
 point,1 which of itself deprives  the surgeon of the poAver of choosing, it
 may be incised either outAvards or imvards.    But the  thrombus is not
 always situated  so  low down;  in such cases, and I  would recall the one the
 details of which I  have already related, the tumor being altogether within
 the excavation, and limited outAvardly  by the  bony Avails of the  pelvis,
 presents none other than  a mucous surface to the instrument.  Therefore,
 should incision be deemed  necessary, it can then only be practised  upon the
 wall of the  vagina.
   I make this remark, because it forms, in my opinion, an additional reason
 for recommending late incisions.  A large wound in the walls of the vagina
 is  not, under ordinary circumstances, a serious affair;  but  in the  case of a
 neAvly  delivered female it would  be  attended with great inconvenience;
 for, not to  speak of the serious consequences Avhich  might result from the
 introduction of the uterine  fluids into the cavity, it is evident that a dressing
 which should be at once sufficiently protective and suitable, and at the same
 time permit the free discharge  of  the lochia, would  be of very difficult
 performance.
   When incision is decided upon, it should be practised freely; for a  simple
 puncture would allow only the fluid blood to discharge, Avhilst clots of con-
siderable  size would certainly  be left  in the cavity.   A too small incision

  1 It. were useless to  state that if the integuments upon  any point of the  tumor are
exceedingly thin, or affected with gangrene, the incision should be through the affected
parts. 
TUMORS  OF  THE  VULVA  AND VAGINA.          695
would have the same inconvenience, in part;  therefore, the opening should
be large, and made upon the part  most favorable to the discharge of the
fluids.  Though the incision be very extensive at the moment it is practised,
on account of the great  distention of the integuments, it diminishes much
by the retraction of the walls of the tumor after its contents are discharged.
It Avill, besides, have the  very great advantage of facilitating the extraction
of the clots.
  After the incision and  the partial evacuation of the  clots, it is very com-
mon for inflammation to be set up in the cellular tissue in which the effusion
had taken place.  This  inflammation is to be opposed by the appropriate
means; but, like M. Deneux, we should  place in  the  first rank attentions
to cleanliness, frequent  Avashings, and injections, at  first  emollient,  and
afterwards containing  a small amount  of chlorine, to  be  throAvn gently
within the cavity.
   3. The  Omission of Incision altogether.—It is evident that whenever the
means employed to assist nature in effecting resolution seem to affect favor-
ably the  size of the  tumor, and its consistency, by which we mean its be-
coming more compact and solid, their  employment  should be continued, and
cutting instruments abstained from.

   § 3. Various other Tumors.
   The other tumors met Avith on the  external parts of generation, are  can-
cers, phlegmons, cysts in the  thickness of the labia externa, together with
various excrescences and syphilitic vegetations.  But Avhatever may be the
nature of  these tumors, the  course  of the practitioner is ahvays the same;
that is, to do  nothing, so long as, by their size and  character, they do not
oppose the dilatation of the vulva; but, in the contrary case, to puncture
the cysts,  to  open the abscesses, and  to  extirpate the vegetations of degen-
erated parts.   As to the modus operandi in these cases, it is too simple  to
require a  particular description.   The possible  occurrence of serious hem-
orrhage ought not however, to be  lost sight of.  (See Avhat is said on the
subject, p. 519.)
   Prompt action is not  requisite in cases of polypus, for, unless it be very
large, it  will  seldom offer  an insurmountable  obstacle to the expulsory
efforts of the Avomb ; because, when adherent to  the vagina, these abnormal
growths are often pressed beyond the vulva.   But if their size should be
deemed too great to permit delivery, the  tumor might be removed.
   In  a case where  M. Gensoul Avas obliged  to apply the forceps, he seized
the head and the fibrous body, Avhose pedicle adhered  to the upper part of
the vagina, at  the same time, and brought them  away together.  The polv
pus weighed tAventy-tAvo ounces after it Avas extracted. 
696
DYSTOCIA.
                        CHAPTER  VII.

             OBSTACLES  AT THE  NECK OF THE UTERUS.

  The difficulties which  may be encountered at the neck of the uterus are
due to the following causes, viz.: adhesion of the lips, complete obliteration
of the cervix, rigidity of the orifice, spasmodic contraction of the orifice,
various tumors, and scirrhous or other degeneration of tissue.

  § 1. Agglutination  of the External  Uterine Orifice.
  This is a very rare  complication,  and but few examples of it are reported
in the books ; though  perhaps, as M. Naegele remarks, from Avhom  I extract
the following details, this rarity is OAving to the fact, that the various degrees
of agglutination have escaped  the  notice of the  physician; the powers of
nature alone triumphing over the accident in most cases.
  Its existence may be suspected when the inferior uterine segment descends
low down in the excavation at the commencement of the labor, and presents
no trace of an  orifice; or when the latter  presents as a fold or a holloAv,
which is slightly depressed at its centre, and very often  not corresponding
to the pelvic axis.   The middle of this little  depression is usually occupied
by a  filamentous web, some fleshy  tissue, and a  cellular network, in the
centre of which a small narroAV opening is  found; sometimes the lips are
held  together by a consistent  mucus.   As the contractions become  more
energetic, the lower segment of the womb is forced into the excavation, and
becomes so thin that, at the first exploration, the  finger appears to be sepa-
rated from  the head  by the membranes alone; but, notwithstanding the
strength of the pains, the uterine orifice is not only tightly closed, but even
seems to ascend somewhat, and to be carried  towards one side.  The orifice
may open spontaneously under the pressure of the energetic contractions;
but if it resists, and  the  accoucheur does not early recognize the source of
the difficulty, a rupture of the Avomb, or a paralysis of it, Avhich is not less
dangerous, might result in consequence.
  The question arises, what  is the nature of this agglutination ? It has
probably followed an  inflammation  of the cervix uteri, and  the upper part
of the vagina.; since the pseudo-membranous or fibrous tissue that composes
it, is similar, says  Naegele, to that  substance which serves as  the bond of
union between the placenta and womb, or that uniting the pleura pul-
monalis to the  pleura costalis, or  the  intestines with each other  and Avith
the abdominal wall, Avhen an  inflammation of these parts terminates  by
adhesion.   In a case Avhere a woman died during  labor, the adhesion of the
neck  Avas found, at the post-mortem examination,  to be so resistant that it
could neither be  lacerated nor broken by  any moderate force, and the
membrane that blocked it up Avas of an aponeurotic character.
   The precise period at  Avhich its formation commences cannot be deter-
mined.   In  a Avoman  Avho  presented  this peculiarity  during labor, the
orifice was patulous six Aveeks before her delivery.
   The agglutination of the orifice has been remedied in most cases Avithout
xnuclj difficulty, the membrane having beer  easily ruptured  either by the 
           OBSTACLES  AT  THE  NECK  OF   THE  UTERUS.       697

 finger or some blunt instrument, and the operation has generally been fol-
 lowed by the loss of only a feAV drops of blood.  The  index-finger should
 be preferred to everything else, for if this  is not sufficient to break down
 the obstacle, we can expect but little aid from an instrument.  It is really
 difficult to understand how this agglutination, which almost always yields
 to the pressure of the finger, can  resist the impetus of the strong contrac-
 tions of the womb.

   [I haA'e met with two cases of adhesion of the external orifice.  In the first one,
 which occurred at the Hospital of the Clinic, I detected the condition of things
 whilst practising the  touch during pregnancy.  I was,  therefore, prepared when
 labor came on.  At first, there was considerable resistance, but  when the pains
 became very powerful, the adhesions yielded spontaneously, and delivery  was
 accomplished naturally. . The second case was one of a first labor, to which I was
 called in consultation by a physician in the city. The patient had been  in pain for
 three days without any progress being made.  I became satisfied, after several very
 careful examinations, that there was no opening upon the lower segment of the Avomb,
 though 1 thought I could detect the place of the external orifice by the existence of
 a very slight depression there.  "When a pain came on, I  endeavored to destroy the
 adhesions by strong pressure with rapid rotation of my finger.  After a few fruit-
 less attempts, I succeeded; the opening dilated rapidly, and delivery took place in
 a regular manner.]

   § 2. Complete  Obliteration  of the  Cervix  Uteri.
   At the  present day it is  an  ascertained  fact that the neck of the womb
 may  be entirely  obliterated at the time  of labor, and by  adhesions  too
 strong to  be broken doAvn  by the  finger.   But  it  is  an exceedingly  rare
 occurrence, and the accoucheur must not permit  himself to be deceived by
 a great obliquity of the cervix, rendering the orifice of difficult access, nor
 by an agglutination of the  lips of the os tincae,  since  it is possible  for an
 overlapping of the two latter to be mistaken for an absolute obliteration of
 the orifice.   " Several times," says Duges, " we have found the anterior lip
 covered and embraced by the posterior one, which thus masked the opening,
 so that the finger could only penetrate  it in a very oblique direction ; though,
 when effected, this introduction afforded a  means  of rectifying  the  error
 promptly, and of reducing the parts to a more favorable state."

  [There can be no doubt that real obliteration of the cervix does sometimes occur.
 It differs from simple agglutination  of the external orifice only  in the greater
 strength of the adhesion, which requires  an operation to overcome it.  As regards
 the nature of the affection, therefore, the distinction is of  slight importance.
  The best work Ave  have on obliteration of the neck of  the uterus was  published
 bv M. Depaul in 18G0.  In  it are reported three cases of his own, in addition to
 those which had already been made public.
  The external orifice is the  one  usually obliterated, though the internal one is
 pnmetimes affected in the same way.  The diseased action producing it  sometimes
 begins after fecundation, though it seems probable  that  it oftener existed before
 it, having already considerably contracted the opening:  under  these  circum-
stances, the  intervention of  pregnancy gave  rise  to conditions favorable to  the
completion of the closure.   An  attentive  study  of cases leads  M. Depaul to the
conclusion that these complete obliterations may have  their origin in violence done
to the neck of the uterus in the first labor, especially when it was long, painful. 
698
DYSTOCIA.
and required the use of instruments.   All  inflammations and other alterations  of
the cervix may be followed by obliteration; therefore it is that primiparae are not
exempted, though less exposed to it than those who have borne children.
  When the neck is obliterated, labor begins regularly, and the pains continue for
several hours  or  days, becoming at last less  frequent  or ceasing entirely.  The
vagina is often hot and dry, and the lower segment of the uterus, rendered thin bj
pressure, descends very low into the pelvis, but it is impossible to discover an open-
ing upon it.   To be sure of this, however, requires great skill in touching; the
vagina should be explored throughout its whole extent, even to its insertion upon
the uterus,  for without this, a mere obliquity of the orifice might be  mistaken for
an obliteration.   This error has often  been  committed, and cannot be  too carefully
guarded against.
  Vaginal  hysterotomy is the only available treatment.  "Whenever  it is possible
to do so, the incision should be made upon the point of obliteration, which may
often be recognized by a small depression  corresponding to the thinned cicatricial
tissue.
  The mode of operating is very simple.  " In one case," says M. Depaul, " I used
successfully a pair of long scissors.   I prefer, hoAvever, a common bistoury, lung
enough for the purpose, and either rounded or pointed, and protected  by wrapping
in linen to  Avithin half an inch of its extremity.   The blade should be conducted
along the fingers of the  left hand, previously introduced and applied to the  part
upon which the opening is to be  effected.  The cut should be made transversely,
and about  half an inch only in length, the tissues being divided layer by layer''
(Depaul.)
  Another  method is to seize the parts to be divided with a pair of toothed forceps.
Then  the  fold which is caused  to project  by drawing upon  the  forceps may be
readily cut with  straight scissors, without the least fear of wounding the  child.
The first stage of the operation is ended when the ovum is reached.  The second
stage  consists  in  making several other incisions with a blunt-pointed  bistoury and
curved scissors ; after Avhich the labor is allowed  to proceed  as usual.

  § 3.  Rigidity of the Cervix.
  Rigidity of  the cervix, also termed  anatomical or mechanical rigidity,  is far less
common than spasm  of the neck of the uterus, often  described  as  spasmodic
rigidity.   In anatomical rigidity, which we are  now discussing, the  fibres of the
cervix seem endowed Avith  an extraordinary power of resistance, which  cannot be
explained by any alteration of tissue.  It is a sort of passive resistance which the
neck opposes to the process of dilatation.   Its tissue seems dense and like a piece
of leather soaked in grease.  The labor continues without dilatation of the orifice,
which  retains a  certain  thickness, against which  the contractions strive in vain
until the woman  is exhausted with her fruitless efforts.  This anatomical condition
of the orifice  must not  be confounded with a neck which continues  thick, simply
because the contractions are insufficient, badly directed, or lost against a mechanical
obstacle which prevents the engagement of the foetus.]

   Under certain circumstances, the fibres of the uterine neck seem to possess
an extraordinary degree of resistance ;  and although they have none of the
characters Ave are about  to indicate as  appertaining to an inflammatory or
spasmodic contraction, yet their dilatation  is  not effected.   According to
DeAvees, this resistance of the cervix uteri  is particularly apt  to  be met with
in very young girls, or in middle-aged Avomen in their first labors, and also
in those cases in which parturition takes place prematurely.
   There  is  one  symptom that would lead us to suspect rigidity of the os 
           OBSTACLES  AT  THE NECK  OF  THE  UTERUS.       699

.iter:, even before an examination ; we allude to AAThat is ordinarily termed
the pains in the loins.  These have ahvays appeared tc Madame Lachapelle
to be a consequence of the rigidity of the external 01 fice, either  from its
experiencing a kind of cramp, or that, because of its having to sustain the
whole force of the uterine contraction  in consequence  of  its firmness, it
suffers more than when soft and yielding.
   Prolonged baths, employed  from the beginning of the labor, and  bleeding
from the arm, if not contraindicated by the general condition of the patient,
are the only measures Avhich need be used under the circumstances.
   However, as  this extreme sIoaviicss appears from the beginning of  the
labor, that is to say, at a period in which the membranes are still intact, the
life of the foetus is by no means endangered thereby, and its only effect is to
fatigue the mother greatly.  Therefore, unless some dangerous complication
should supervene, there is nothing to do but recommend patience.  Still, if
the labor  should be  extremely prolonged, and  by its duration seem likely
to endanger the life of the mother, it Avould be right to make a feAV  incisions
upon the lateral parts of the cervix.

   § 4. Spasmodic Contractions  of the Neck.
   Again, it may happen, that after having attained a considerable degree
of dilatation,  the cervix  becomes affected  Avith spasmodic contraction,
whereby its subsequent expansion is  retarded, or suspended altogether for
several hours.   The orifice then presents a thin, cutting edge, and is Avarmer,
drier, and more sensitive to pressure of the finger;  in short, is much more
irritable than usual.
   This condition, which has been designated as spasmodic contraction of the
external orifice, may be confounded Avith the simple rigidity just spoken of,
and with the natural retraction of the neck, when the presenting part of the
child does not engage in its opening  immediately after  the  rupture of  the
membranes.  In the latter case, hoAvever, the thick, soft, and easily dilatable
edges of the orifice  Avill ahvays  enable us to avoid error.   In the former
case, the diagnosis is often more difficult if all the phenomena of the labor
have not  been  Avatched,  and the extreme sensibility of  the  neck,  Avhich is
not generally met Avith in rigidity, will be the only evidence  that Ave have a
case of spasmodic contraction to deal Avith.1
   This state of spasm does not generally last for a great  Avhile;  but so long
as it exists, the  dilatation is  extremely sIoav, and sometimes hardly takes
place at all.  Usually, however, the efforts of the body of the womb  over-
come the  resistance  at last, and the head of the foetus clears the orifice;
but in some cases it happens that, being no longer supported, the  neck re-
tracts immediately, and grasps the  neck of the foetus more or less  forcibly,
so that a neAV dilatation is  required to alloAV  the shoulders  to pass; nor is
this second dilatation as easy as might be expected.
   This spasm of the external orifice may be met Avith in strong and plethoric

  1 Rigidity is a passive force, by which the fibres of the orifice resist the  dilatation
they have to undergo.  Spasmodic contraction is an active  force, by which  the fibres
contract and diminish the size of the opening previously exhibited by the mouth of the
womb. 
700
DYSTOCIA.
 women, but also in lymphatic, nervous, and very irritable individuals, of a
 pale and relaxed fibre.   In the former case, general bleeding  is one of the
 first measures to be had recourse to, but in the latter it might prove hurtful.
 Under both circumstances, however, recourse may be had with advantage
 to emollient injections, fumigations, baths, and the administration of lauda-
 num by clysters, or, preferably, the application of belladonna to the uterine
 neck itself.   Chaussier, who has particularly recommended the use of this
 latter remedy, was in the habit of using an  ointment prepared by mixing
 and triturating one  drachm of the extract or juice of belladonna  with  an
 ounce of lard.   But as  the application of  this ointment is quite difficult,
 Professor P.  Dubois prefers the ordinary dry extract.  He places a little
 pellet of it, about the size of a pea, on  the nail of the index-finger, which
 latter is then carried up  to the cervix, where, in the course of a few minutes,
 the heat and  moisture of the parts soften the extract, which is then readily
 smeared over the external and internal surfaces of the neck.
   The belladonna,  so highly lauded  by some accoucheurs,  is  by others
 thought to  be useless.  It seems to me  that this difference of opinion has
 arisen from confounding simple rigidity with spasmodic contraction.  Though
 without action in the former case, I think it very useful in the latter.
   If all these measures prove unsuccessful, or if an  accident,  which endan-
 gers the life of the mother or child, should demand a prompt termination
 of the labor, the accoucheur will have to  choose between a forcible introduc-
 tion of the  hand and multiple incisions upon the neck.  (See Difficulties of
 Pelvic Version.)

   [Incision of  the neck, or vaginal hysterotomy, is certainly the  preferable opera-
 tion.   To perform it, a blunt-pointed bistoury is laid upon the forefinger  and con-
 ducted to the  orifice,  which it cuts by a  conjoined sawing motion and pressure.
 The larger part of the blade is previously wound with  a piece of linen bandage in
 order to protect  the vagina.   The multiple incisions  in  this case  yield  all their
 advantages, and render consecutive laceration far less probable than would a-single
 incision.  Very rarely will it be necessary to make them more than half an inch
 long, whilst they may be often less than this ; for it is the almost universal practice
 to be content with cuts of from three  to four-sixteenths of an  inch  in depth only,
 around the circumference of the orifice.  The lateral parts of the neck should  bo
 chosen for the  incisions; though, if necessary, they may be  made  upon the anterior
 lip, and lastly, upon the posterior one.
  In the vast  majority of cases the operation is a very simple one, though  some
 difficulty may be encountered in the use of an ordinary blunt-pointed bistoury.  In
 this case, a curved blunt-pointed bistoury, Avith a concave  edge, is preferably em-
 ployed.
  For my own  part, I choose almost always a pair of angular scissors, with blades
 shaped like a raven's bill.   It is directed upon the finger,  opened when the orifice
 is reached, and after one blade is  inserted  between the  ovum and the orifice the
 incision is made.]

  But it is  not the external orifice  alone which may retard  the delivery of
 the foetus by retracting on its neck, for very often the internal one, or rather
that portion of the uterine walls which corresponded to it in the non-gravid
state, letracts forcibly on the neck  of  the child, even before the head has
cleared the  external  orifice; so that the latter, being retained in the portion 
           OBSTACLES  AT THE  NECK  OF  THE  UTERUS.       701

of tne organ  that appertains to the neck after delivery, can  advance no
further.  This internal contraction only takes place Avhere the waters have
escaped for some  time, and it evidently  results, as Dewees has remarked,
from the double tendency of the Avomb  to regain its primitive form, and  to
accommodate itself to  the shape of the  parts contained Avithin its cavity.
  There is every reason to suspect that  the delay in the progress of the head
is dependent on this cause,  when, notwithstanding  the energy of the pains
and the absence of all other sources of dystocia, it is found to make no ad-
vance at all, or, even if it approaches the vulvar orifice during the contrac-
tion, it  returns  to  its  primitive position  immediately afterwards.   Besides
which, if the finger is  slipped above the head, the latter will  be found  free
in the excavation;  but one  of the orifices (the internal one, most usually,)
will be strongly retracted around the neck.
  Bleeding, general bathing, and  laudanum injections may be employed
usefully under these circumstances  also, though it sometimes happens  that
the contraction of the internal orifice persists notAvithstanding.  Under these
circumstances, should version be judged necessary, the  most serious difficulty
may be anticipated in  passing the hand through the retracted part; and if
the application of the forceps be deemed requisite, as it Avould be if the head
were already engaged,  but delayed by  the retraction of the internal orifice,
this latter circumstance, by arresting the  shoulders, Avould render the deliv-
ery impossible.  It is  then  Ave must have  recourse to the measures so much
vaunted, and so often employed by DeAvees with success, namely: to bleed-
ing in the arm, pushed ad deliquium animi.  But, in order to avoid drawing
too great a quantity of blood, the patient  should be directed to stand up,  if
possible, and, as soon as fainting occurs, she is  to be  replaced  on the bed;
when, according to the American accoucheur, the relaxation in the retracted
orifice, produced by the syncope, will be such that the pelvic version, or the
extraction of the head by the forceps,  can ahvays  be  performed.   Finally,
in those cases Avhere the Avoman's general  condition does not permit a resort
to blood-letting, Ave  may employ  the  opiates  in a  full dose, either by the
mouth or by injection,  Avith great advantage.  The inhalation of chloroform
may also prove very useful.
  The reader Avill  also understand that, in a natural  labor by the pelvis,
the retraction of one of these orifices may likewise arrest the head.  Under
such circumstances, if the  source of difficulty  is confined to the external
one, numerous incisions might be made in the ring of  the os uteri; but if
it is at the internal orifice, Devvees' plan  should certainly be followed.  It
is likeAvise important to ascertain at once whether the  child is still  living;
for  though it be difficult to admit that a strangulation  of the foetus  can
occur from direct pressure, yet it is not  the less true that the umbilical cord,
from being  nearly  ahvays compressed  in these unfortunate cases, exposes
the child  to a  speedy  death; and if  the infant is already lost, Ave may
employ, beneficially, either belladonna,  or the opiates  internally, according
to the orifice retracted.
  In cases of this kind, the  use of anaesthetics might prove serviceable, by
producing relaxation of the partial spasm of the uterine fibres.  M. Dubois
has  administered them  with  advantage,  as is shoAvn by an example given in 
702
DYSTOCIA.
the excellent thesis published by Dr. Tissier on the subject.   (Paris Theses,
1860.)  In all cases, chloroform should be tried before  having recourse to
bleeding to syncope.

  § 5. Obliquity of  the Orifice.
  In consequence of the usual direction of the  uterus, the  neck is  slightly
turned  dowmvard and backAvard.  The posterior obliquity may,  in some
cases, be much greater, whilst in others the orifice may be directed stronglj
forAvard, or toAvard one of the sides of the pelvis.  When treating hereafter
of malpositions of the body of the Avomb, Ave shall have occasion to speak
of the effect of retroversions and lateral obliquities  upon the direction  of
the neck.  We would  treat at present of the posterior obliquity of the
orifice, which is by far the most frequent.
  The posterior obliquity of the neck may be due to an extreme antever-
sion of the  body of the organ, though it  may  also be  very Avell marked,
even Avhen the fundus  of the womb projects no  farther forward than usual.
This deviation of the orifice may also take place during  labor; but it  may
also exist in the latter stages of pregnancy.
  In  the former case, the obliquity is due to the fact that the dilatation of
the orifice is effected  more at  the  expense of  the  posterior than  of  the
anterior lip, and, consequently, the  plane  of this  opening  Avould naturally
be  found, in most cases, behind  the long axis of the organ.  Wherefore,
this irregular dilatation may, independently of any deviation in the fundus,
produce such an obliquity of the neck, that the plane of its orifice, instead
of being horizontal, has very nearly  a  vertical direction; that is, the open-
ing looks directly tOAvards the  anterior  face  of  the sacrum, its  anterior
margin has become inferior, and its  posterior one  is  noAV  the superior.
When existing before  the commencement of labor, its mode of production
is altogether different.  We  knoAV  that in vertex presentations the head
of the foetus engages in the excavation in the  latter months, pressing the
lower part of the  uterus before it.   Now, in the  normal  direction of this
organ, it is evident that the head must press more especially upon the por-
tion anterior to the orifice, Avhich anterior portion  it must carry before it.
Hence, it is plain  the  external orifice of the neck  must  necessarily be situ-
ated altogether posterior to the projection formed by the head in the lesser
pelvis.
  But Avhatever may  be the manner and  time of its production, its effect
upon  the progress of  the labor is ahvays the  same.  Consequently, Avhen
the child's head is urged oh by the uterine contractions,  it  presses the ante-
rior inferior wall of the uterus before  it, and thereby evidently retards the
delivery.  In fact, the dilatation of the neck must  necessarily be very slow
and imperfect; besides,  the expulsive efforts are spent against the anterior
part of the cervix, Avhich part, corresponding to the void in the pelvis, and
being distended by the head, is sometimes forced doAvn nearly to the vulva,
and threatened Avith a rupture.   Most  generally, there is time for rectifying
this unfavorable  situation of  the cervix; nevertheless, the patient  must
remain in bed as much as possible; for it  is very apparent  that, in the erect
position, the body  of the womb constantly augments this posterior obliquity 
            OBSTACLES AT THE  NECK  OF  THE UTERUS.        703

in the neck by being carried fonvards.   The termination of the labor may
also  be facilitated by  placing the  orifice in its natural  position with the
finger; this is done, during the interval, by hooking the anterior lip, and
carefully bringing it to the centre of the vagina, and then sustaining it in
this position until a neAV contraction comes on; when  the head is forcibly
pressed doAvn and engages in the  opening, and  no longer  permits  the lip to
regain its abnormal position.   The  labor is sometimes speedily terminated
after this little manoeuvre.
  It occasionally happens that the cervix uteri is well  dilated, though not
as yet sufficiently so to permit  the parietal protuberances to traverse it;
and this condition of things lasts for a considerable period, notAvithstanding
the long and acute sufferings of the patient.  In  such cases, the engage-
ment of the head may  be singularly facilitated by making a slight pressure
on all the periphery of the orifice  with the extremity of the index-finger,
carried rapidly around it.
  Again, the dilatation may often be completed and the  head be down in
the excavation, but notwithstanding the expulsory efforts  of the Avomb, it
is retained there by the anterior lip of the neck, Avhich is pressed before it;
the head cannot overcome the resistance thus made by the band formed by
the anterior lip, and several hours may elapse Avithout  any advance in the
progress of the labor.  When this happens, the folloAving course  should be
adopted in order  to promote a prompt engagement at the inferior strait:
taking advantage of an interval,  the accoucheur hooks the anterior lip with
his finger, and dniAvs it tOAvards the symphysis pubis, Avhere  it is retained
until the pain  comes  on;  then  the extremity of the  finger,  placed  under
this portion of the neck, pushes it above the descending  part of  the head,
until it gets beyond the occipital  boss ; Avhen the occiput is found  to engage
almost immediately in  the pubic arch, and the labor terminates tAvo or three
hours sooner than it Avould have done Avithout this  little manipulation.  It
is occasionally necessary  to repeat these attempts several times; but as
they are attended Avith no inconvenience Avhen properly performed, they
may be renewed without fear.   We will add, that the most favorable period
for  this purpose  is that when the head, after having reached  the  pelvic
floor, is on the point of clearing the inferior strait, provided the  pains are
energetic, and the cervix  sufficiently dilated to permit the passage,  if the
axis of its orifice were  parallel to the axis of the head.

  § 6.  Saviclling  and Elongation  of the Anterior Lip.
  It is not at all unusual to find the head descending in the excavation long
before the complete dilatation of the os uteri, whereby the  anterior lip is
necessarily compressed betAveen the former and the  symphysis pubis.   As a
general rule, this  compression, and the consequent  pain, disappear on the
irompt termination of  the labor; but if the latter be prolonged,  and espe-
cially if the pelvis scarcely reaches its normal dimensions, the compression
is very severe, a considerable tumefaction will result in that part of the an-
terior lip found below the  constricted point.   Duclos, of Toulouse, has met
with three instances of this kind, tAvo of Avhich Avere in the  same woman;
M. Nicgcle has published another, Dr. Lever tAvo more,  and M. Danyau one, 
704
DYSTOCIA.
making seven in all.  M. Blot mentions a case in which the tumor formed
by the anterior lip Avas an inch and a quarter thick, and forced doAvn to the
vulva.  The labor had to be terminated by the forceps.
  The following case is one of those reported by Duclos: A woman, thirty-
four years of age, who was in  labor with her fifth child, Avas suddenly at-
tacked, after twenty-four  hours of moderate pains, by acute sufferings, which
called forth loud cries ; an elongated body appeared betAveen the lips of the
vulva, and its apparition was accompanied by a slight hemorrhage, pallor
and feebleness.  On his  arrival, he found a cylindrical tumor projecting
four fingers' breadth beyond the parts; it was tAvo inches broad near the
vulva, and was irregular, resistant, and of a Avine-like color.  After a careful
examination, he ascertained that it was formed by the elongated and tume-
fied anterior lip  of the cervix.   He first thought of applying the forceps on
the child's head, but afterwards concluded to aid its delivery by draAving on
the occiput, and  operating on  the forehead by means of the index-fingei
previously introduced into the rectum.  In  the cases  observed  by Naegele
and  Danyau, as also in one of the women reported by Lever, the labor ter-
minated  spontaneously.   There is, therefore, nothing  to be done in most
instances; though if the  tumor be  of large size, very tense and black, and
apparently threatened with gangrene, the example of the English surgeon
just named might be folloAved; that is, to make a number of punctures, for
the purpose of evacuating the infiltrated liquids and diminishing its volume.
  On the whole, then, I may remark, with  M. Danyau, that this species of
tumefaction can scarcely be considered as a mechanical obstacle to the de-
livery ; and that the unusual length  of the labor must rather be attributed
to the extreme pain it occasions, and to the disorder and irregularity of the
uterine contraction caused thereby.
  The cases recently mentioned  by M. Montgomery  under the name of
thrombus of the  lips of  the cervix, and  which will soon be described (see
page 705), are evidently instances of this  affection.  The observations of
the Irish accoucheur appear to us similar to those  just mentioned.  As re-
gards the prognosis, however, it is important to distinguish  simple infiltra-
tion from a true effusion.
  M. Montgomery thinks that this condition of things might be mistaken
for a case of insertion of the placenta upon the  neck, the tissue of the infil-
trated lip bearing considerable  resemblance to  the placental tissue.  Still,
as he observes, it may ahvays be readily ascertained that the tumor is not
only applied to the internal surface  of the womb,-but that it is also situated
in the substance of the latter.  The finger can never be made to penetrate
betAveen the tumor and the internal surface of the  uterus.

  § 7. Abscesses in the  Lips of  the Cervix  Uteri.
  Genuine abscesses are occasionally developed in the substance of  the lips
of the os  tincae, Avhich, independently of the unfavorable influence they may
have over the gestation, must necessarily disturb the regular progress of the
labor; because,  Avhere they invade a considerable  portion of the neck, its
dilatation is thereby rendered  very sIoav and very painful; besides Avhich,
their size may be so great as to retard the passage  of the head.  The reader 
           OBSTACLES  AT  THE NECK  OF  THE  UTERUS.       705

 will find in Bonet (Sepulchretum, vol. ii., lib. iii., sec. 38, Obs. 2) the history
 of a Avoman avIio died without having been  delivered,  after five or six days
 of suffering, in  whom a large abscess, filled with putrid pus, and occupying
 the neck of the womb, Avas found at the post-mortem examination.
   If the  presence of fluctuation should establish the  diagnosis, the proper
 course would evidently be to incise the tumor.

   § 8. Sanguineous Tumors or Thrombus of the  Lips of the Neck
 of the  Uterus.
  We have already seen that the anterior lip of the cervix sometimes be-
 comes considerably swollen during labor, and that the swelling may some-
 times  be  occasioned by an infiltration of blood.   This infiltration, which
 may become a mechanical obstacle to the expulsion of the head, is certainly
 the first degree of a much  more serious accident;  for the blood, Avhich is
 merely infiltrated at the outset, may, by separating the meshes of the tissues
 of the neck, collect in  a cavity, which, by  opening afterward  in the same
 way as the thrombus of the vulva, may give rise to mortal  hemorrhage.  A
 case of this kind Avas communicated to the Obstetrical Society of Dublin by
 Dr. Johnson, and its charaoier Avas so remarkable  as to justify  our giving a
 short analysis of it.
  A woman, who had already given birth to six children, Avas delivered for
 the seventh time, after four hours of  easy labor.  The child presented by
 the breech.  The after-birth came aAvay Avithout difficulty, and the patient
 was perfectly Avell for the first three days; about the fifth day, hoAvever, she
 was seized suddenly, and Avithout any apparent cause, Avith profuse flooding.
  The uterus was thoroughly contracted, and yet, notwithstanding the em-
 ployment of the most appropriate  means,  she died in about an  hour and a
 half.   All the  abdominal and thoracic  organs were found, at  the autopsy,
 to be perfectly  healthy.   The uterus Avas Avell contracted, but upon  the left
 side of its  neck, at about an inch from its orifice,  there Avas discovered a
 rupture,  with  irregular and blackened  edges.   This  opening, Avhich was
 large enough to permit the easy  introduction of tAvo fingers, conducted  into
 a cavity formed in  the substance of the neck, large enough to contain  a
 small orange.   Five or six  open vessels, of  a  size  sufficient to admit the
 introduction of a small bougie,  Avere observed  upon the internal surface of
 the cavity, and  were proved  by insufflation to communicate  Avith the uterine
 sinuses.  " A careful examination of the specimen," says Mr. Montgomery,
 "convinced  me that it Avas a case of thrombus, Avhose  external envelope
 formed a thin  layer of the uterine tissue,  became  gradually thinner, and
 finally ruptured.  The fluid and coagulated  blood escaped through the  rup-
 ture, and the hemorrhage continued."   (Dublin Quarterly Journal, 1851).
  The  thrombus  is, in  all probability, developed during labor, under the
 folloAving  circumstances.   When the  neck  is  half dilated and the Avaters
 discharged, the  anterior lip  is found to  SAvell, thicken, project, and descend
 beneath the presenting part,  usually the head, to the disengagement of Avhich
it sometimes presents an insurmountable obstacle.   An  infiltration of blood,
which  may become  converted into a sanguineous collection, is soon formed
in the substance of the lip.   The cavity increases in size, until its walls rup-
      45 
706
DYSTOCIA.
fcure and give rise to hemorrhage.  The discharge may then take place dur-
ing the labor itself, though far more frequently it does  not appear until some
time after delivery.   In the latter case, it is more likely to prove dangerous,
as the complete retraction of the uterus makes it difficult for the accoucheur
to divine the true cause.
  The introduction  of a tampon into the vagina is certainly the most useful
measure that can be employed.

  § 9. Fibrous Tumors and Polypi of the Cervix.
  Besides the  indurations, the cedematous  swellings, and the cancerous de-
generations affecting the cervix uteri, which  will be described in the following
paragraphs, there are certain tumors, which, though filling up  the excava-
tion, really have their origin or seat in the proper tissue of the neck; others,
that arise from the body of the womb,  to which they still adhere by a long
pedicle,  are found hanging doAvn into and obstructing  the cervix.
  A. Fibrous Tumors of the Cervix  Uteri. — These tumors may be developed
in the neck as well as in the tissue of the uterine walls.  In a case described
by Madame Lachapelle, the pelvic excavation was almost entirely occupied
by a tumor that seemed inclosed in the lateral and posterior portions of the
neck; it Avas as large, she states, as  the head of a foetus at term, and would
have been the more likely to deceive an inattentive person,  from the fact of
its presenting a depression similar to a fontanelle.  The child was very small,
and had been dead for a long time;  so  that, notwithstanding the size of the
swelling, it was enabled to flatten  it doyvn and pass through the  narroAV
passage  that still remained free.   Madame  Boivin and M.  Duges  found,
when making a post-mortem examination of a woman who died of peritonitis,
after a very painful though natural  labor,  a fibrous body about the size of
the fist  in the substance of the neck ; the child  had  a fractured cranium,
and Avas still-born.  In another case of the kind, Ramsbotham Avas obliged
to resort to embryotomy ; but the Avoman recovered.
   M. Danyau reported to the Academy (1851) a case  in which he was much
more fortunate, for  he succeeded in  enucleating a tumor of considerable size
Avhich had been developed  in the posterior lip of the cervix.   Encouraged
by the idea that, although he might not be able to remove it altogether, he
might, at least, extirpate a portion large enough to give passage to the foetus,
he determined to operate, and was successful in bringing it away completely.
The appearance of  the tumor was precisely that of a fibrous  tumor of the
uterus;  it weighed  about twenty ounces, and  its greatest diameter was six
inches.   When enucleated completely, the tumor was dravvn down, but could
not be extracted until  after it Avas divided  into two parts.
   I  Avas called, in  February, 1853, to take  charge of a young Avoman at
term in her third pregnancy, and whose waters had  been discharged four
days previously.
   Upon practising the touch, I was astonished to find the excavation filled
by a tumor apparently of the size of a full-grown foetal head.  At first I
was unable to discover the  orifice of the womb, and it was only by carrying
the finger very high up in front and to the left, that  I succeeded in intro-
ducing  the ind< x into something like the finger of a glove, Avhich appeared 
           OBSTACLES AT THE  NECK  OF THE UTERUS.        707

to me to be the cervix retaining its full length.  Penetrating still deeper, I
at last reached the internal orifice, above which I distinguished the fcetal
head.
  What, noAV, was the nature of the great tumor Avhich had thus turned the
neck aside, and prevented  the effacement  that  it  should have undergone
during the last feAV Aveeks of gestation ?   Where, also, Avas it situated ?
  My first hope was, that it Avould prove to be merely an exaggerated ante-
rior  obliquity of the neck, and I asked myself, Avhether what sometimes
happens to the anterior lip, had not occurred in the present instance to the
posterior one, and whether  the latter, forcibly depressed by the foetal head,
did not alone form the tumor Avhich filled  the excavation.   But the tumor
had a peculiar consistence and apparent fluctuation, by no means resembling
the hardness  of the head, besides' Avhich, the  hypothesis did not explain the
persistence of, and the increased length of the neck.  A fresh examination
induced me to conclude that a solid tumor  had become developed in the
substance of  the neck.
   The Avaters had continued to discharge for the past four days Avithout any
pain, and I resolved to Avait.   The next day, the condition of things remain-
ing the same, I requested M. Dubois to examine the patient.
   A long investigation induced M. Dubois to suppose that a cyst containing
fluid had formed  in one of the lips of the orifice, and therefore he recom-
mended Avaiting, and finally puncture, if the tumor  should appear to present
an insurmountable obstacle, after labor had continued for a certain time.
   At first I did not coincide with this diagnosis, but it also seemed to me
Avisest to Avait for the pains.  The latter appeared decidedly on the evening
of the next  day, five days after the membranes Avere ruptured ; they con-
tinued all night Avithout effecting any change either in the tumor, or in the
situation or length of the neck.  To clear up the diagnosis, I introduced the
entire hand  into the excavation, and grasping the  Avhole tumor, I declared
 joyfully to my friend, M.  Parchappe, that I had  been deceived, that  M.
 Dubois Avas right, and that, most happily,  Ave had to deal  with a cyst.
   With  a long trocar, of at least an eighth of an inch in diameter, I made a
 puncture, but to  my great surprise  nothing  escaped.  I endeavored to re-
 move obstructions from the  tube, if there were any, but in vain ; nothing
 appeared.
   My sensations Avere so decided, and so convinced Avas I that I had to deal
 with a cyst, that  I had  no hesitation  in puncturing anew;  but the  same
 result folloAA-ed, and I Avas obliged to relinquish the idea.
   M. Dubois being absent, I requested my professional brother and friend,
 M. Danyau,  to assist  me with  his  advice.   I related to him all  that had
 passed, and  insisted  especially upon the  result of my two  punctures, but
 notwithstanding all this, M. Danyau, after examining the patient, Avas con-
 vinced of the existence of  a cyst.   He made tAvo  successive punctures, but
not a drop of fluid escaped.   There Avas no avoiding the conclusion ;  it Avas
not a cyst.
   What, then, was to be done?  We could no longer hear the pulsations of
the fcetal heart.  After proving our incapacity of making an  exact diagnosis
of the nature of the tumor, we thought that its soft and apparently fungous 
708                           DYSTOCIA.
character would enable us to incise it throughout its extent, and thus ci eate
a passage to the foetus, which we then might extract.  The tumor Avas there-
fore divided into tyvo lateral parts, and Ave were able to reach the head.
  The forceps were at first applied Avith much difficulty, but notAvithstanding
the diminution that the tumor had undergone, it obstructed the entire exca-
vation, and rendered the  extraction of the head impossible.   Craniotomy
and the application of the cephalotribe forceps were equally unsuccessful.
  Blood floAved freely from the incised tumor, the patient Avas pale and
prostrated, and the uterine contractions became weaker and Aveaker.  But a
single feeble  hope remained,  namely,  pelvic version.   It Avas performed
immediately, and  the trunk of the foetus, bringing with it the entire tumor
externally, enabled us at last to extract the child.
  The operation had lasted two hours, and the unfortunate lady Avas ex-
hausted.  Before extracting the placenta, ergot was administered, the uterus
rubbed, and  the after-birth Avas  expelled almost spontaneously.  Notwith-
standing all our precautions, and the use of all  kinds of tonics and stimu-
lants,'some blood still escaped from the womb,  which in a patient  already
exhausted by the  hemorrhage from the operation, was sufficient to cause a
fatal termination.   She died about half an hour after her delivery.
  The autopsy showed that the tumor,  which Avas larger  than the head of a
child at term, had  formed in the anterior lip of  the cervix.  By its Aveight,
which Avas considerable,  it had during  life so twisted the  neck around,  as to
bring the posterior lip in front, which explains the situation of the orifice, as
the seat of the tumor accounts  for the persistence of the length  of the neck,
notAvithstanding the progress of gestation.
  The tumor was constituted of a soft and spongy tissue, resembling rarefied
placental tissue, the meshes of which  circumscribed numerous cavities, in
which no fluid was to be found.  No abnormal element could be discovered
by  the most careful examination, no newly-formed pathological product;  it
was simply an enormous hypertrophy of the tissue of the neck.  Such Avas
the opinion of several professors who examined  the  specimen at the School
of Medicine.
  There is every reason to believe that  this tumor was developed during the
last pregnancy, for, eighteen months before this last delivery, I  attended her
on account of a miscarriage, and did not at that time detect any anomaly
either of  structure or form affecting the neck.

  [The preceding example shows how  difficult the diagnosis may be in such  cases.
To aA'oid error, it ought to be borne in mind that fibrous tumors of the uterus often
become softened during  pregnancy to such a degree as wonderfully to  resemble
those containing liquid.   I have already  met with several examples of this kind.
The softening should be seriously considered as regards  the prognosis, as it  facili-
tates  the  flattening of the tumor.  Thanks to it, the foetus  has sometimes been
known to engage in the  pelvis  by the  side of a tumor which at first seemed  as
though it would render delivery impossible.  I witnessed one  of these unlooked-for
terminations in connection with  Dr. Franquet, a patient of whom had a tumor  of
the neck and lower segment of the uterus  descending into the cavity of the  pelvis
and occupying one half of its area.  In the case of this Avoman, it might very well
have  become  a question whether  the Caesarean  operation should  be performed.
She was, nevertheless, delivered at term of a living child which presented by th«
breech.] 
OBSTACLES  AT THE  NECK OF  THE UTERUS.       709
   These examples  show Avhat  may be  feared or hoped  for in such  cases.
 Thus, we should Avait when the tumor is very small and so situated  as to
 correspond with one of the large diameters of the pelvis, or extirpate  it, if
 the bistoury can reach it Avithout danger, which seldom happens; on the
 other hand, where its size no longer permits us to attempt the  extraction of
 a  living infant, to resort to embryotomy;  and, if  the excavation  is  com-
 pletely obstructed, to open a passage for the child by the Caesarean operation.
   b. Polypi, or fibrous  pediculated tumors, Avhether  attached to the  neck
 or body of the Avomb, obstruct delivery only at the cervix.  On this  account
 both are treated of in connection.   They are not so serious as  the preceding
 tumors, inasmuch as they can generally be extirpated, although their size
 would seem to render them an insurmountable obstacle to delivery.
   As a  general rule their diagnosis is readily made out, though several sin-
 gularerrors on this head are recorded  by authors;  for example, Dr. Merri-
 man relates a case in Avhich an experienced physician  mistook  a polypus for
 the head of  a child; and  Smellie  furnishes tAvo similar instances; conse-
 quently, avc must not trust to a superficial examination.
   The influence of uterine polypi over the progress of labor will be modified
 by a number of circumstances;  thus, when the  tumor is small, it  may be
 compressed  against one of the walls of the excavation by the child's head,
 and the latter then passes before it; or, where the  pedicle is very long, the
 fibrous mass  is pushed by the head entirely out  of the vulva,  and therefore
 only retards  the  fcetal  expulsion in a  slight degree.  This  occurred  in a
 case reported by Dr. F. H. Ramsbotham; who says, " I Avas summoned to a
 woman in labor, and found a tumor of  the size of a goose's egg hanging in
 the vagina.   (Fig. 109.)
  " I had no difficulty in determining it to be a  polypus, whose pedicle was
 attached to the  internal wall of the  organ above  the neck.  Dilatation took
 place rapidly, and the membranes ruptured ; then, in less than an hour, the
 head, urged on by powerful contractions, forced the  body of the polypus
 outside of the vulva and became disengaged."   ( Obstetric. Med. and Surg.,
 p.  237.)
  After having consulted Avith his father, Avhether it       Fl°-109-
 was advisable to remove the polypus  at once,  the
 question Avas  determined in the negative.
  In many cases, therefore, we may trust to the re-
 sources of the organism, remembering at the same
 time, that too great  a delay is not without danger
 both to the mother and child ;  and,  where the ineffi-
 ciency of the uterine  contractions  has been fully
 uscertained, a division of the pedicle  appears to us
 to be the only resource.  If the subsequent extrac-
 tion of the tumor is rendered very difficult by its
 volume, it might be cut up into several pieces, as I
 have seen done on two occasions, or be firmly grasped
with a small serrated forceps.  Pelvic version, which    This figure,  taken  from
is recommended by some authors, could be performed   j^JtaSn8J°£polyp™
in  those cases  only in whicl  the length of the   described by him.
 
710
DYSTOCIA.
pedicle gives great mobility to the tumor, and allows it to be pushed above the
superior strait.   It is unnecessary to add that, if the existence of this turaoi
in the canal be ascertained during the latter months of  gestation, it should
be excised immediately, if it be of sufficient size to render the parturition
difficult or tedious.

   § 10. Fungous, or Cauliflower Tumors, &c
   These tumors, which resemble a caulifloAver in their appearance, may arise
from either lip of the womb; and then by acquiring a considerable size, they
mask the orifice and  render it nearly inaccessible.  As they often give rise to
hemorrhage, and as the spongy tissue that constitutes them has some analogy
with the placental structure, they  have occasionally been mistaken for a
placenta praevia.  Both Madame Lachapelle and Denman relate errors of this
character ; and I witnessed the following still  more singular  case.  The in-
ternes of  the  Lourcine Hospital sent for M. Nelaton, Avho Avas surgeon to
the establishment, to turn in  a supposed case of hand presentation.  M.
Nelaton desired me to accompany him; and, on our arrival, Ave ascertained
that these  young gentlemen had mistaken an  enormous caulifloAver excres-
cence, that sprung from the  anterior lip of the cervix uteri, for the hand;
its pedicle was  at least an inch and a half long, and its  base  presented five
or six little vegetations that had been mistaken for  the fingers.
   It frequently happens that  these tumors are small enough to admit of the
child's spontaneous  delivery; indeed, such Avas  the fact in the case  just
mentioned; but there are  many others where the accoucheur is less fortu-
nate.  Take, for  instance, the seven cases reported by  Puchelt;  in one of
which it was necessary to  make  incisions upon another part of the hard
and scirrhous  neck,  so as to secure the introduction of the hand, and  in a
second,  to  remove the tumor,  that Avas attached to the anterior lip  and
occupied all the vagina, by the scissors;  gastrotomy was resorted to in  a
third, on account of  a rupture of the Avomb, and not even the child  was
saved; in another, the extraction of the child Avas impossible, notwithstand-
ing the perforation of the  cranium, and  the Avoman  died before delivery.
Only a single mother survived.

   § 11.  Encysted Tumors.
  Adhering to the cervix uteri, or to the vaginal walls, they may also exist in
the excavation.  As  a general rule, they are rounded, well defined, movable,
elastic, yielding a little under  a moderate pressure, and sometimes fluctu-
ating ;  the mucous membrane covering them remains unaltered.  A small
puncture, in the Avay of exploration, will  always dissipate any doubts con-
cerning their true nature, especially if containing a liquid ; and where they
inclose a solid, cheesy, or fatty matter, some  portions of it will adhere to
the canula.
   An attempt should be made to push the tumor above  the  superior strait,
before the  head  becomes engaged; and the membranes must be ruptured
early, so  as to  determine the  engagement of the foetus.  In the opposite
case, it will be  requisite to evacuate the liquid by a simple puncture, or
even to make an incision large enough to allow the contents to be Dressed out 
OBSTACLES AT  THE NECK  OF  THE  UTERUS.       711
   § 12.  Induration, with  Hypertrophy of the Cervix  Uteri.
   This affection is more frequently observed in the anterior than the poste-
 rior lip, though it may affect  both ; but in no case has the volume of the indu-
 rated part been great enough to impede, mechanically, the expulsion of the
 child; but the alteration very often retards the dilatation, and sometimes
 even renders it impossible.  Venesection and tepid bathing may be resorted
 to Avith advantage.  Certain English practitioners highly extol the use of
 tartar emetic, given in nauseating doses, but I  have not had an opportunity
 of testing  its efficacy.   If these means  prove ineffectual, or if some more
 grave complication requires  the prompt termination of the labor, Ave might
 have recourse to  repeated incisions made on the neck of the womb.

   § 13.  Of  the Cancerous Neck.
   Like all the organs of the economy, the  cervix uteri may be affected
 with scirrhus, or  may form an encephaloid tumor; and Avhen this does take
 place  the  prognosis is very  unfavorable, both for the mother and child.
 For example, of  twenty-seven females reported by Puchelt, five died during
 the labor, nine shortly after delivery,  and but  ten  recovered ; the fate of
 the other three is  not stated.  However, if the disease is  still in its  first
 stage; if the patient's general condition is not seriously altered ; and es-
 pecially  if the malady has made but little  progress, or the tumor is small,
 the danger is not so  imminent, and the expulsion of the child may then
 take place regularly.   But even  Avhere the  delivery is effected  sponta-
 neously,  its influence over the subsequent progress of the tumor  is  not the
 less disastrous ; for the pressure to Avhich the diseased part is exposed seems,
 in most cases, to  hasten its development;  and, Avhether the labor  be termi-
 nated  naturally or  by the resources of art, its  progress aftenvards is much
 more rapid.   The child, likewise, is very often lost  in the cases under  con-
 sideration ; thus, of the tAventy-seven Avomen  above cited, fifteen were de-
 livered of a  still-born  child, and ten  only of a living  infant; nothing  is
 said 6f the fate of the other  tAvo.
   The indications  for  treatment, when  the cervix uteri is affected with
 cancer, will  necessarily vary, according to the seat and size of the tumor;
 for, if it is not very voluminous, or if it is located on the posterior lip, or
 the pelvis be of large  dimensions, there is every reason for hoping  that the
 efforts of nature  Avill prove adequate to the dilatation, and the expulsion of
 the foetus.
   I have seen the former process effected at the expense of the sound ante-
 rior lip, where the  other Avas invaded by a cancer throughout, Avhich also
 extended to  the  posterior vaginal Avail.1  Wherefore, there is  no occasion

  1 This case appears to me too remarkable not to be  reported, at least in a conder.sed
 form.
  A female aged forty-five years, who had previously had several children, came to
 the "Clinique" about  the  commencement of the last month of her gestation; when,
 by resorting to the touch, it was  ascertained that the posterior vaginal wall was occu-
 pied throughout by an elongated tumor,  which was curved in a serpentine form,  and
 extended from  the  posterior lip of the cervix, to within a finger's breadth of the
vulva.   The lip was nearly an inch thick in all its transverse extent (which latter  ivas 
712
DYSTOCIA.
for immediate action;  although it must not be forgotten that, if the  degen-
eration of these parts is more extensive,  the powers of nature  alone are
nearly always inadequate to the accomplishment of the delivery.
   Some authors have recommended  copious bleedings; but sanguineous
emissions, though advantageous in cases of rigidity, or of simple induration
of the neck, would here  only enfeeble  the patient Avithout producing any
change in the condition of the orifice; and  the only available resource of
our  art is still in the  repeated incisions on the periphery of the  cancerous
mass;  because turning, and the application of the forceps, Avhich have been
advised by certain  accoucheurs, are  evidently only  practicable where  the
bistoury may  have  previously facilitated  the  entrance into  the womb.
Without  this  precaution, one or more fissures dividing the lobes of the
scirrhus would naturally result from the introduction of the hand  or instru-
ment, which, at the moment  of the head's passage, would  extend still fur-
ther, and  encroach  perhaps  on the body of  the womb.   Or, if the fissures
should not  form, the neck, by not dilating, would create an obstacle to the
delivery, and the patient Avould  be exposed  to a rupture  of the organ, to
convulsions, and to all the consequences that attend labors rendered difficult
by mechanical impediments; unless, indeed, there happened  to be  a rupture
of the subvaginal  portion of  the Avomb itself, and the child's passage was
effected through this accidental orifice.
  Lastly, in those cases where the  application of  the forceps is still impos-
sible, even after the incisions have been made, a grave question is offered
for our solution.  Supposing the child is still  living, we have only to choose
between  its mutilation  and the  Caesarean operation.   Though  this  last
operation be  serious under all  circumstances, it nevertheless seems prefer-
able here  to the first, because it affords a considerable chance of saving the
child ; and  the mother's life is already so greatly compromised by the dis-
ease with  which she is affected, that we should not, in my estimation, hesi-
tate  to sacrifice all to the safety of her infant.

more considerable than usual), and it had contracted adhesions with the vagina by its
posterior face.  The tumor presented nearly the same thickness in all parts; its ante-
rior surface was irregular and nodulated, as  was also  the posterior lip of the cervix
uteri: but its hinder surface adhered to, or  rather was confounded  with, the recto-
vaginal septum.  When this woman arrived  at full term, the labor began, and  the
dilatation was effected very slowly, though  completely, at the expense of the anterior
lip.  The tumor whose volume seemed to offer an insurmountable obstacle to the de-
livery, only rendered the second stage of the travail a  little more tedious than usual;
for, being pressed back by the child's head, it became nearly transverse in the exca-
vation, and formed on the perineum a  pad, or a kind of crescent, the convexity of
which looked downward, but its  concavity was  directed upwards, and arrested the
head; finally, under the influence of the powerful  contractions, the head  pished the
tumor still  more backwards, by forcibly depressing the perineum, and then passed in
front of it, and soon cleared the external parts. 
OBSTACLES  PRESENTED  BY  THE  UTERUS.         713
                        CHAPTER  VIII.

        obstacles dependent  on  the  body of the womb.
   § 1. Of Uterine  Obliquity.
   When studying the phenomena of gestation, Ave enumerated the various
 causes that forced the uterus to depart more or less from the direction of the
 pelvic axis;  and we demonstrated that, under the influence of those causes,
 the Avomb very often  inclines forwards and  to the right  during the latter
 months of pregnancy.  It is not, therefore, of this right antero-lateral incli-
 nation Ave are about to speak, in treating here of uterine obliquity as a  case
 of dystocia,;  because, where it is slight, and Avhere it may be considered as
 a normal result of the development of the womb, it  affords no obstacle to
 the parturition;  but when the obliquity is more extensive, it may impede the
 spontaneous expulsion of the child, and will, therefore, claim our attention.
   Deventer, and most of the writers on this subject since  his  day, have de-
 scribed four  varieties of it,  namely, the  anterior, the posterior, the right
 lateral, and the left lateral obliquity.  But the modern accoucheurs, such
 as Baudelocque, Gardien, Desormeaux, and P. Dubois, believe that a  pos-
 terior obliquity cannot take place ; for the prominence of the sacrum and of
 the lumbar vertebrae, they say,  prevents the  uterus from being carried
 backwards ; however, from the facts reported by Deventer, Levret, Merriman,
 Duges, and Velpeau, Ave feel Avarrauted in still retaining these four varieties.
   1. Of the Anterior  Obliquity.— As a natural result of the resistance  pre-
 sented by  the posterior abdominal plane, the Avomb inclines forward, Avhere
 it only encounters  the abdominal muscles, Avhich  form a soft and an exten-
 sible wall.  When this obliquity is inconsiderable, the physician has only
 to remain  a simple spectator of the efforts of nature;  but when it exists in
 a higher degree, it becomes a source of annoyance and pain during the latter
 months of gestation that demands attention ; and it also gives rise to difficul-
 ties in the course of the labor that  should either be prevented or corrected.
   An unusual inclination  of the  plane  of the  superior  strait, or a well-
 marked laxity of the  abdominal Avails, favors the obliquity; and where  this
 laxity is carried to an  extreme, the ventral muscles gradually relax  and
 yield, theAvomb inclines more and more fonvards and doAvnwards, its fundus
 gets above the pubis, and then falls anteriorly, like an inverted sack, on  the
 thighs.  This displacement has been designated as the ventre en besace,  and
 by the Latin authors it is described under the name of the venter propendulus.
 This displacement gives rise to acute pains in the groins, in the fore part of
 the thighs and loins, Avhen the abdomen is not supported by a  proper band-
 age during pregnancy; and, at the time of labor, the cervix uteri is carried
 so far back against the anterior face of the sacrum, that it dilates with  the
 greatest difficulty; and if the membranes be prematurely ruptured, or if the
 pelvis is unusually large, it nearly always happens that  the  child's head
 presses the anterior inferior part of the uterine Avail before it; which part
 appears at the vulva Avhile its orifice is directed  considerably  upAvards and
 backAvards.  But if the pelvis be small, this engagement of the head does
uot take place, and the anterior uterine Avail  is then forcibly compressed 
714
DYSTOCIA.
between it and some portion of the superior strait.   The enormous distention
in the former case, and the pressure on the  lower part of the uterus in the
latter, expose this portion of the organ to laceration or gangrene.  Under
such circumstances, the abdominal  exploration and the vaginal touch can
alone explain the cause of the difficulties and pains which the patient ex-
periences.  The obliquity in the body is readily recognized by the external
examination ; and if the head be engaged  in the excavation, the  finger intro-
duced into the vagina Avill find a voluminous, smooth, and  rounded tumor,
filling up the whole cavity of  the lesser pelvis, and upon which no opening
similar to that of the cervix uteri can be detected ; but Avhen carried further
upAvard and  backAvard towards the sacro-vertebral  angle, it wall reach
(though at times  with  great difficulty) the anterior border of  the cervix ;
but,  most generally, it will be  impossible  to  recognize  the  po'steiiior lip.
This circumstance has  several times been  mistaken for imperforation of the
womb, or a complete  obliteration of the neck, and, as a  consequence, the
vaginal Caesarean operation has occasionally been performed, where nothing
more than an obliquity of the uterus was  to be remedied.   If the head has
not yet engaged, the tumor will not occupy the excavation, but the same
difficulty  will  still  be  experienced  in finding the cervix.  Both  of these
modes  of exploration  should  be employed; for Ave  have  already learned
(p. 702) that the  cervix may be oblique, while the body retains its natural
position ;  and  it is evident that, under such  circumstances, a resort to the
touch alone might lead us to suspect an obliquity that did not really exist;
and, on the other hand, the internal exploration Avould guard  against the
errors that the deformed appearance of the woman's abdomen might possibly
make us  commit; for  it  alone  can enable us to  distinguish the obliquity
from that deformity already alluded to, under the name of anteflexion, in
which the Avomb  is shaped  like a  retort.  In the former  case, the cervix
will be detected high up towards the posterior plane of the pelvis; in the
latter, on the contrary, it will correspond to the  centre of the  excavation,
notwithstanding the great fomvard inclination of the body of the Avomb.
   2. Of the Posterior Obliquity.—This variety of obliquity (which is denied,
as above stated, by most modern authors)  must be attributed to an excessive
resistance on the part  of the abdominal walls, Avhich prevents the uterus
from following the direction of the  axis of the superior strait, when it rises
out of the pelvis; that  is, from inclining forwards, and therefore it is almost
exclusively met with in women bearing their first child.
   The direction of the  uterine axis  is not  to be judged of in reference to the
axis of the body, but to that  of the superior strait.  Noav, it is undeniable
that the womb, in some cases, instead of  being  directed from above doAvn-
ward and from before backward,  has  its long axis  directed from behind
forward, and sometimes even in a direction parallel to  the plane of the supe-
rior strait, so that, Avhile its fundus  reposes on the posterior inferior plane of
the abdomen, its  neck  is situated above the pubis.

   [Deviation of  the orifice toward  the  pubis  undoubtedly takes  place in a certain
number of cases.  We admit willingly, however, that  instead of regarding it aa
due to obliquity of the uterus, it  were better explained as produced by an irregulai
development of the organ, whose posterior half was extremely depressed, the ante-
rior portion having resisted.] 
            OBSTACLES  PRESENTED  B\   THE  UTERUS.         715

  I cannot better describe the signs appertaining to this particular obliquity
than  by relating a few examples of it;  and these  citations will have the
further advantage of verifying the fact, and of establishing its possibility.
  I have tAvice  had, says Merriman, from whom I extract  the following
case,  an opportunity of observing this singular and unusual position of the
uterus, in which the os uteri is carried so far above the symphysis pubis that
it is inaccessible  to the finger, and the posterior part of the pelvis so com-
pletely filled  by  the  body of the womb that it  is impossible to touch the
sacrum.  A  case of the kind has been published  by Dr. S. H. Jackson ; but
it  occurred in a woman who had not reached full term.   In the first of my
cases, the woman Avas at  term, and the labor continued for several  days;
but the uterus  regained  its ordinary position after severe efforts, and the
labor terminated spontaneously: the child Avas still-born, but the mother re-
covered.  The other was  published  a long time ago, in  a dissertation on
retroversion of the Avomb, which has been sharply criticised by  Dr. DeAvees.
The  following is an abstract:  " Mrs. F----was taken Avith symptoms of
labor, on Monday, June  16, 1806, at which time a discharge of the liquor
amnii Avas perceived, and severe  and apparently strong pains  recurred  at
distant intervals.   In the course of the day, the patient Avas examined per
vaginam, when there appeared to be a singular condition of the part.  The
whole of the back part of the pelvis Avas filled up by a globular tumor, Avhich
prevented the finger  from passing in the direction of the coccyx  and sacrum,
but it Avas  obliged, in  tracing the tumor, to  take a direction  towards the
ossa pubis, above the crest of Avhich it could be passed ; but neither here nor
anywhere else could  the os uteri be felt.
   " By introducing the finger into the rectum, it appeared that the tumor
was uterine, and that some bulky part of the foetus was contained Avithin it;
but Avhether the  nates or  the head, could not be  clearly distinguished.
   " On Tuesday, the 17th, the discharge of liquor amnii continued ;  the pains
were frequent and excruciating, and the tumor was pressed doAvn closer upon
the perineum.  A rigor, terminating  in convulsions, and folloAved by fever
and  delirium, took place  this day;  but  a prompt bleeding and evacuating
the boAvels relieved these symptoms.
   "Wednesday,  18th, and Thursday, 19th, no material  alteration Avas ob-
served.  The pains continued regular and distinctly marked  through these
days, but Avere much less severe and distressing than at first.
   " Friday,  20th, another very careful examination of the parts Avas made.
The uterine  tumor presented the same shape and bulk, quite obstructing the
passage towards  the sacrum, for  even the coccyx could not  be felt, except
the finger was introduced into  the rectum ;  Avhen the finger in the vagina
was carried fonvard, in the  only direction in Avhich it could pass, namely,
anteriorly, it reached above the pubes, but still the os uteri could not be felt;
yet, on withdraAving the finger from above the  symphysis pubis, there was
now, for the first time, perceived upon  it the  true appearance of a shoAV,
which furnished  a convincing proof tha.t the os uteri Avas situated in that
direction, and encouraged us to hope that an alteration in the state of the
uterus Avas at hand.
   "Our hopes Avere not vain; for, on the next  day, Saturday, 21st, a con- 
T16                           DYSTOCIA.
 siderable alteration was discovered in the pains, and in the situation Df the
 globular tumor, which occupied the pelvis.  The pains' were more powerful
 and effective, and the tumor, Avhich  had  been contiguous to and pressing
 upon the perineum, was found to have a little receded, while a flattened
 mass (Avhich proved to be the head of the  child in a state of complete putre-
 faction, with the bones separated, and the brain almost dissolved) was forced
 down from above the pelvis, between the ossa pubis and the uterine tumor.
   "After a few hours of active pains, the tumor ascended above the brim of
 the pelvis, and was no longer to be felt; but noAV the os  uteri was  easily dis-
 tinguishable, though still very high.
   "It was judged right to make an opening into the head, and about a pint
 of grumous blood and brains was evacuated; this alloAved an opportunity of
 grasping  the  scalp, and by means of this so much assistance Avas afforded
 in extracting the child, that the labor Avas terminated in a fe\v more pains.
   " The patient perfectly recovered, and lived many years afterwards in good
 health, but. never had another child."   (Synopsis.)
   " In a Avoman," says M. Velpeau, " who came to be confined at my amphi-
 theatre, in the month of May, 1828, the  fundus of the uterus was rather
 inclined  backAvards than forwards.  The head of the foetus  formed above
 the strait a considerable projection, which descended in front of the symphy-
 sis pubis  nearly to the vulva.   Besides, the walls of the abdomen  were so
 thin that the head, fontanelles, and sutures  could readily be detected through
 them: the occiput Ayas to the right, and  the  face to the left.   The  right
 parietal bone  rested against the anterior face  of  the symphysis pubis, and
 the left remained in front. The  os  uteri, Avhich Avas on a level with the
 superior strait, seemed to be scooped  out  of the substance of the posterior
 wall of the Avomb, which made it much longer behind than before.   In order
 to reach  the  orifice, and penetrate towards the  head  of the child, I was
 obliged to bend my finger, so as to make it pass almost horizontally above
 the pubis.   After seven days of' pain and  pretty strong  contractions, the os
 uteri, although very soft and very dilatable, Avas scarcely opened at all. M.
 Desormeaux agreed with me, that by means of position, and the  assistance
 of the hand properly combined, I ought  to try  to carry the  head to the
 centre of the superior strait,  by making it slide from below upAvards, and from
 before backwards over  the  pubis.   I  began to execute this manoeuvre at
 half-past  eight o'clock, and continued it, alternating with  several of the
 students, until nine o'clock.  From  this time  there Avas no longer a tumor
 in front of the symphysis, and the labor progressed so rapidly that in less
 than an hour the child Avas born, and the placenta itself expelled."   (Meigs's
 Translation, p. 404.)
   Dr. Billi, Professor at Milan, reports a case (Ann. de Chir., 1845, p. 113;
 in Avhich the retroversion Avas so complete, that  the orifice was  situated five
 fingers' breadth above the pubis, Avhilst the posterior part of the excavation
 Avas occupied  by the head of the foetus.  The  fundus of the uterus, in the
shape of a hard and rounded tumor, was  situated betAveen the vagina and
the rectum,  Avhich it compressed violently.
   1 might also add  similar examples from  Duges ; but these tAvo  are prob-
ably quite sufficient to render Avhat is meant by the posterior obliquity of the
womb fully understood. 
OBSTACLES  PRESENTED  BY  THE  UTERUS.         717
   By summing  up the symptoms so Avell  described by Merriman, we shall
 have: 1, a very considerable elevation of the os uteri, AA'hich is carried high
 upAvard  and fonvard above the symphysis  pubis; 2, a tardy dilatation of
 the cervix ; 3, the tumor, constituted by some part of the foetus (the shoulder,
 probably) pressing before it the  posterior inferior portion of the Avomb that
 envelops it, is strongly  engaged in the excavation,  and occupies all the
 cavity of the lesser pelvis;1 and, 4, the head situated above the symphysis
 pubis.   By collecting  in the same way the principal characters of M. Vel
 peau's case, Ave shall find a remarkable elevation of the presenting  part; a
 very unusual elevation of the cervix  uteri,  the orifice of which, being turned
 directly  forward, is placed  above-the symphysis, and  is scarcely accessible
 to the finger;  and, lastly, a considerable tumor formed  by the child's head,
 just in front of the anterior face of the symphysis.  And we may add, that
 such a tumor had previously been described by Duges,  in several of his obser-
 vations.1'
   The posterior obliquity of the womb is rarely so disastrous in its conse-
 quences  as Merriman's  case  proved to be; for most generally the strong
 contractions of the organ, the energetic efforts of the  patient  herself, and a
 sufficient amplitude of the pelvis, succeed in overcoming  its unfavorable
 influence, Avithout extraneous aid ;  and, besides,  it often happens that, at the
 time the membranes are ruptured, the head descends into the  excavation
 along Avith the discharged waters.  But on the other hand, as in the instance
 of the author  just quoted, the deviation of the  foetus, and of its  presenting
 part, goes on increasing,  and then it  may require version.
  [We haA'e stated that all difficulty in  accounting for  the way in which posterior
 obliquity takes  place  is removed by regarding it as  a  result of irregular develop-
 ment of the uterus, the excessive dilatation of  whose posterior segment pushes the
 i-ervix  forward.  That Prof. Depaul accepts this view  is  shown  by the following
 e;ise.  A  lady from the country, who had already borne children, was at the period
 of lier confinement; pains  had  been experienced for several days, but the  labor
 had made no progress.  When M. Depaul was called he found no appreciable  incli-
 nation of the uterus.  On making  an examination, the finger encountered quite  a
 large tumor occupying a part of the cavity of  the pelvis, more especially the pos-
 terior portion.   The neck was thrust forward and lodged behind the symphysis
 pubis.  It had  the form of a transverse fissure, with  two projecting lips, and its
 cavity was not blended Avith that of the  body of the uterus. On passing the finger
  1 It is highly probable that the engagement of the shoulder in the excavation is owing
 to the putrefaction of the foetus.  Merriman has not noted the prominence formed above
 the symphysis pubis by the head ; the absence of this projection, which was so remark-
 able in M. Velpeau's case, was certainly due to  an engagement of the shoulder, and
 the head was probably throAvn back on the opposite one, so that a spontaneous cephalic
 version took place.
  2 It has been remarked, in many cases,  that the child's head presented, after birth,
 a red longitudinal  mark between one of the  parietal protuberances and  the sagittal
 suture.  This long, narrow track seems to  be owing to the contusion made  on the  scalp
by the upper border of the  pubis.  In a  case of this kind, reported by  Paisley, the
midwife could not detect the child's head until after the discharge  of the waters.  The
head would not descend, and the woman died of  exhaustion;  and, at. the autopsy, the
frontal and  parietal bones of the right side were found applied against the pubis,
which bad made  a depression there of one or two inches in extent. 
718
DYSTOCIA.
between these lips  it was found that the internal surface of the anterior ore pre
sented a concavity looking backAvard.   The posterior one was swollen at its uppei
extremity, and had, on a level with the internal orifice, a transverse, rounded pro-
jection, a little convex in front.  The  swelling seemed to be about the size of a
finger, extremely hard and tense, like a contracted tendon.  M. Depaul succeeded
in hooking his finger around this part, and thus became satisfied that it was formed
by the posterior half of the internal orifice, whose fibres had become hypertrophied
and contracted.  He also found that the uterine caA'ity, in consequence of an abnor-
mal development posteriorly, formed a sort of bag, which hung far below the neck, and
in Avhich a part of the breech was engaged. Incisions of only three or four sixteenths
of an inch in depth were made to the right  and left on the internal orifice, when
the neck immediately opened, allowing the operator's hand to pass readily into the
uterus and seize the pelvic extremity.   A very large foetus, in process of decompo-
sition, was easily extracted, and the patient recovered rapidly.
  What was the difficulty in this singular case ?  Both MM. Devilliers and Depaul
regard it as an extreme development of the posterior portion of the inferior segment
of the uterus,  in connection Avith  another peculiarity not always met with,  viz.,
hypertrophy and tension of a portion of the circular fibres situated at the internal
orifice.  (Bulletin de VAcad6mie de Medecine, 1865.)]

  3. Lateral Obliquities.—For  the  reasons formerly given (page 702), the
right lateral obliquity is far more frequent than the  left; indeed, but very
few examples of the latter are ever met with.   These variations in the direc-
tion of the uterus are  rarely of such a nature as to  constitute a serious
obstacle to parturition;  they act more particularly in modifying, and some-
times even  in  altogether changing,  the  presenting part of the foetus.   Let
us suppose, for instance, says  Duges, that the womb  be oblique enough to
carry the child's head toAvards the border of one of the iliac fossae, as I have
seen in two cases;  but it can hardly remain at  this point, for it will either
be pressed back into the excavation, or else it will slip further forward  and
outAvard, and the  child, by thus becoming more and more oblique, will ulti-
mately present one or the other shoulder at the superior strait.
  4. Treatment of Uterine Obliquity. — In a  large majority of cases  the
obliquity of the Avomb, whatever may be its variety, presents no special indi-
cations for treatment; it constitutes a source of delay in the progress of the
parturition, but it scarcely  ever becomes  a serious cause of dystocia.  Con-
sequently in these, as in all other slow labors, the first duty of the practitioner
is to wait.   In some very rare instances, Avhere it happens that an excessive
degree of obliquity is  not  rectified under the  influence  of  the  poAvers of
nature, the intervention of  art becomes necessary; and the indications then
presented are, — to restore the  Avomb to its normal position, to sustain it
there, and to remedy any accidents that may happen.
  The measures Avhereby the first two indications  may  be  fulfilled, are per-
fect rest on the back, when the obliquity is anterior, or on the side opposite
to the one occupied by the fundus uteri, when it is lateral, and the employ-
ment of the hands to support and maintain the deviated organ, or of a large
bandage properly applied, to produce  the same effect.  The patient  should
be advised not to bear down until after  the displacement is remedied.  If these
means are not sufficient, it will be necessary, while thus operating externally
on the body, to act at the same time on the neck; for that purpose intro- 
HERNIA  OF  THE  WOMB.
719
ducing tAvo fingers into the uterine orifice, and taking advantage of an interval
betAveen the pains to draw it gently towards the centre of the pelvis, Avhilst
the other hand is employed in pressing the fundus of the organ in the oppo-
site direction.
  These measures generally succeed, and their use should be continued  as
long as the double interest of the mother and child will permit; but if they
prove unsuccessful,  and the reduction  of  the obliquity  and the delivery
becomes  impossible, our only resource is to  open an artificial  passage, by
making an incision into that portion of the uterine wall which projects into
the vagina (the vaginal Caesarean  operation). Still  this  ought to  be con-
sidered  an ultimate  resource, and  one  not to be  resorted to until after the
impossibility of introducing the hand into the  uterus to  effect  the pelvic
version has been fully ascertained.
  In the posterior obliquity, the Avoman ought to  remain seated  or standing,
or,  if possible, even reclining a little forward. If the head forms a projec-
tion above and in front of the  pubis, as in  the case of Velpeau, and those
reported by Duges, the hand should support the hypogastrium, and, by
perseverance, it will succeed in pressing back the head to the centre of the
excavation.   This manoeuvre will  be  rendered more easy by the  vertical
position, by Avalking, or, if necessary, by the yvoman's resting on her hands
and knees, so  that the fundus of the womb will hang forward, as  it were.
A kind of see-saAv movement then takes place,  Avhich,  by depressing the
part of the child that occupies the fundus, elevates that near  the neck.
Finally, should all these plans fail, the pelvic version must be resorted to.

  § 2.  Of Hernia  of the Womb.
  Most of the cases of hernia  of the Avomb may be referred  to what we
have described under the  name of anterior obliquities of this organ.   These
are true eventrations;1 and it is exceedingly rare  for the uterus,  by escaping
through one of the natural  openings of the abdomen, such as the inguinal
or the crural rings, to constitute a hernia,  properly so called.  Some Avell-
established examples of it, hoAvever, are  found in the  books; for instance,
Simon, in his Memoir on the Caesarean operation, and Sabatier, in his work
on the displacements of the Avomb and vagina, both of AA'hich are found  in
the valuable collection  of the Academie  de Chirurgie, have related  several
very curious instances of the kind.
  In most cases, the displacement of the Avomb had existed prior to the
fecundation, and  the organ  thus situated Avithout the abdominal inclosure,
continued to be developed until full term.  In some others, Avhich are more
difficult to admit, this organ having attained a  certain degree of develop-
ment, gradually dilated one  of the  crural or inguinal rings, and constituted
an external hernia.   These latter have been admitted by Desormeaux, but
they are rejected  by M. Moreau, avIio  considers them as  genuine eventra-
tions, and AA-e are disposed to adopt the latter view, at least so far as  regards
the  case reported by  Ruysch.  Sometimes, hoAvever, the existence of an old
  1 A term applied to the hernias following any accidental opening in the abdominal
walls; as also the falling of  the belly,  resulting  from  an extreme relaxation of the
anterior ventral walls.—Translator. 
720
DYSTOCIA.
hernia has occasionally seemed to favor the development of a hernia of the
uterus.1
  The characters of this latter, during the gestation and labor, are too well
marked to require a detailed account of the signs of recognition.   But, at
the time of the parturition, the inefficiency of the efforts of nature  should
be fully tested by a prolonged  delay,  before resorting  to the  Caesarean
operation, which  is' the  only resource recommended  by very many accou-
cheurs ; for, in some cases, the labor has been knoAvn to terminate sponta-
neously.  In a case related  by Ruysch, a midwife, by raising the  tumor,
succeeded  in returning the foetus into the abdomen, and  the  delivery was
effected as usual.

  § 3. Of Prolapsus  Uteri.
  It is possible for a prolapsus of the womb to exist in a non-pregnant woman,
and yet the latter may conceive, as is fully proved by the folloAving observa-
tion of Marrigues, reported by Chopart.  " A female, who Avas affected with
a prolapsus, had  been impregnated  by the direct and  immediate introduc-
tion  of  the fecundating principle into  the  uterus, through its  gradually
dilated orifice."   The conception having once taken place, the  uterus may
go  on developing until term, and  at the time of labor  may present  an
enormous tumor hanging between the thighs ; or this falling may only occur
during the gestation; and again it may suddenly come on  in the course of
the parturition, Avhere the patient is abandoned to herself, or is  attended by
inexperienced persons,  who  allow her to remain standing or Avalking for a
long  time, or who permit  her to make  strong bearing-down efforts, with a
view of hastening her delivery before the os uteri is sufficiently dilated.2

  1 One Ramus, aged twenty-four years, and having borne six children, had a right
inguinal enterocele, which appeared  some time before her marriage.  At the third
month of a seventh pregnancy she was attacked by an annoying, dragging sensation
oh the left side of the hypogastrium.  The tumor hitherto observed in the latter region
disappeared, and she discharged blood by the vagina.  By placing her hand  over the
inguinal hernia, she discovered  there a hard and strange body, that was painful on
pressure, and which she several times attempted to push back again, without success.
Several weeks afterwards she felt some movements at that point, and sent for a physi-
cian,  who detected at the lower and right  portion of the abdomen  a  tumor, that
descended on the thigh of this side, covering the pubis, and even extending across as
far as the left thigh;  this tumor was twenty-six inches in circumference at the middle,
and twenty-four inches at its junction with the abdomen. Several attempts at reduction
were made without effect.  The pains came on at the eighth  month, and hysterotomy
was then performed, but the reduction was still impossible after the delivery, and the
uterus was left on the exterior.  Both the mother and child were saved.  (Ledisma de
 Salamanca;  Gaz. de Med.,  715, 1840.)
   2 According to M. Moreau, the patients are particularly exposed to this kind of dis-
 placement in the five or  six weeks following  the delivery.   The uterus, which  had
 been distended by the product of conception, still infiltrated  by fluids,  hypertrophied
 in a measure, has a much larger size and a far more considerable weight than usual,
 the ligaments that were stretched have  regained as yet neither their consistence nor
 habitual strength.   Now if, on the one hand, there is more weight in the organ to be
 sustained, and, on the other, greater weakness of the ligaments which should sustain
 it,  it is very apparent that a  cause which, in the ordinary conditions of life, would be
 insufficient to bring about a displacement, will produce it under the circumstances 
i
            TUMORS  OF THE BODY  OF  THE  UTERUS          721

  The prolapsus may prove a source of serious difficulty in the progress of
the parturition, for experience has shown that this accident may not only be
productive of long  delays, but  likewise  of real  danger; perhaps, it may
even render the  spontaneous expulsion  of the  foetus altogether  impossible,
either (as has  long since been  remarked)  because  the Avomb, which has
descended to the lowest part of the  abdomen, and possibly even beyond the
abdominal inclosure, is  removed, as it were, from the influence  of the con-
tractions of the  abdominal muscles ; or because, being Avedged in between
the surface of the child's body and the Avails of the pelvis, it has  lost a
great part of its energy in consequence of the long-continued pressure.
  The difficulties to be overcome will also vary according to whether the
prolapsus be recent or of long standing ; for, in the latter case, the prolonged
contact  of the organ Avith the  internal face of the thighs, and Avith the dress,
may have  produced  a  state of induration of the cervix  Avhich opposes its
steady dilatation; indeed  this has often been impossible, and the physician
has been obliged  to incise it to  overcome the resistance offered  by the in-
durated parts.   On the contrary, Avhere the  accident has recently occurred,
or, still  better, if it is only manifested during the labor, the dilatation of the
os uteri is sometimes effected spontaneously ; and  the duty of the accoucheur
is then limited to facilitating  it by the use of the appropriate means.
  The special indications presented by a falling of the Avomb, when it  occurs
during pregnancy, have already  been treated of.  (Page 528.)
  All attempts  at reduction Avould be dangerous during the labor;  and,
consequently,  the accoucheur must  then be  satisfied  Avith hastening the
dilatation of the  os  uteri as much as possible,  and  Avith  preventing the
lacerations it Avould suffer, by suitable incisions, in cases of induration.
  The delivery of the placenta likeAvise demands much circumspection, since
it is evident that Ave cannot trust its expulsion to nature, and still less can
we draAV on the cord in the usual manner;  hence,  the after-birth must be
artificially separated.  Immediately  after its  delivery the  uterus  retracts,
and then its reduction is often quite easy.

  [# 4. Tumors of  the Body or the  Uterus.
  Puchelt mentions ten cases of cancerous degeneration of  the body of the uterus,
the neck being healthy.   In one case, the entire body of the organ was diseased.
As these tumors rarely present any mechanical obstruction  to the expulsion of the
child, we will merely observe that they interfere with the contractions of the uterus
and predispose to its rupture.
  Fibrous tumors are by far the most common.   They are distinguished according
to their  situation as sub-mucous, interstitial, and  sub-peritoneal.  All these may
interfere with delivery by disturbing the regularity of the  contractions of the
uterus, but chiefly by obstructing mechanically  the expulsion of the foetus.
  The fibrous masses, whether  pediculated or  not, which grow upon the segment
of the uterus, may be assimilated to the same  kind of tumors and polypi of the
neck.  We have, therefore, nothing to  add to what has been already said in regard
to them.  (See  Fibrous Tumors of the Keek, page 706.)
  Fibrous tumors of the  upper  segment are grave in proportion to the length of
just indicated.  For  these  reasons, therefore, we cannot too strongly urge the patients
to keep in the horizontal position during the early part of their lying-in, and to avoid
all kinds of violent exertions for the  first six weeks following their delivery.
      4G 
722
DYSTOCIA.
their  pedicles.  When non-pediculated and situated  in  the  fundus, they have no
tendency to engage in the cavity of the pelvis below the head of the foetus; whilst
those  with long pedicles attached at the fundus, may form serious obstacles should
their  lower extremity become engaged below the head.  In the latter case, the only
thinjr to be done is to divide the pedicle and remove the tumor.
  All sub-mucous fibrous tumors are liable to cause hemorrhage during the delivery
of the after-birth, because their  size  interferes with the contraction of the uterus.
An unusually severe  hemorrhage may also result from  a direct insertion of the
placenta upon the portion of mucous membrane  covering the tumor.   It will be
readily seen how this unfortunate disposition of the parts might facilitate the loss
of blood from  the open orifices of the utero-placental vessels, which remain unclosed
because the tumor obstructs  the contraction  of the muscular fibres.
  The peculiar changes which occur  at the  internal surface of  the  uterus after
delivery, often have a singular effect  upon the continuance of  sub-mucous fibrous
tumors.  There are cases which prove  that the uterine mucous membrane may un-
dergo ulceration, and the tumor  thus exposed become enucleated, so to speak, and
expelled into the vagina.   I  have myself seen two cases of this sort of spontaneous
cure.
  Sub-peritoneal fibrous  tumors  are  generally less grave than  the sub-mucous
variety, yet they may prove a very serious obstacle should they happen  to occupy
a part of the cavity of the pelvis.  I reported in my thesis for the  Concours1 a case
furnished me  by M. H. Blot, and of which the following is a summary.    A woman

                                       Fig. 110.
                         Fig. 110. Section of the fibrous tumor.
  S. Synphysis pubis.  V. Bladder, t. Small fibrous tumor.  ('. Another small fibrous tumor.  T. Principal
tuu'.or. c. Central cavity of the tumor, r. Rectum.  /. Utero-rectal cul-de-sac.  p. Pedicle of the tumor
where it is attached to the posterior surface of the uterus.

from Argenteuil was brought to the hospital of the Clinique after fruitless attempts
had been made to deliver her.   It was a shoulder presentation  and the  left  hand
and a loop of the cord hung  from the vulva.  The turning Avas very difficult and
the head was momentarily arrested at the superior strait which it cleared suddenly.
The patient died of  metro-peritonitis, and  the autopsy revealed the  presence of
three fibrous tumors.  One of them was  attached to the  middle of the posterior
1 Tarnier, Cases in ivhich it is necessary io extract the Foetus.  Paris,  18'jO. 
TUMORS  OF  THE OVARY.
\
723
(surface of the uterus by a pedicle of over two inches in length, which soon enlaro-ed
to a volume  greater than  that of the head of a foetus at term.  It filled the utero-
rectal cul-de-sac, projected above the superior strait and reached the fundus of the
uterus.   At  numerous points it was adherent to the recto-uterine cul-de-sac.  An
antero-posterior section having been made, it was found that the centre of the tumor
was broken down into a pulpy mass of a grayish color.  (See Fig. 110.)]
                         CHAPTER IX.

 W TUMORS  APPERTAINING TO THE ADJACENT PARTS AND CELLULAR
              TISSUE OF THE CAVITY  OF THE PELVIS.

   Tjiksi; tumors  are various in character  and may appertain either to the
 ovary, Fallopian  tube, bladder, intestine, or cellular tissue of the pelvis.

   § 1.  Tumors of  the  Ovary.
   This organ may be affected Avith a number of diseases, nearly all of Avhich
 have the effect of singularly augmenting  its volume; thus cysts, distended
 with solid  or liquid matters, are frequently observed there, and  abscesses
 have also been met with; or this body itself may become hypertrophied, or
 be affected  with scirrhous or encephaloid cancer.   But Ave shall not treat of
 these latter affections, further than to examine the influence they may have
 over the puerperal, functions.  In this respect,  it is highly important to
 ascertain the exact  seat of the tumor; for sometimes  the  diseased ovary
 remains in  the abdominal cavity above the superior strait;  and, again, it is
 very often  displaced, and falls into  the pelvic excavation.  In the former
 case it may, doubtless,  obstruct  the development of the uterus by its bulk,
 and thus bring on a  premature labor; or it may produce an obliquity of the
 womb by pressing the latter to the opposite side, and thus prove a source of
 dystocia; but it particularly claims the attention of the accoucheur when
 situated in  the lesser pelvis; for it may then so obstruct  the passages, that a
 natural delivery of  the child becomes Avholly impossible.
  The tumors, constituted by the displaced ovary, nearly ahvays fall  doAvn
 into the cul-de-sac, formed by the peritoneum, it being  reflected from  the
 posterior surface of the uterus to the anterior one of the rectum.  In a single
 case only, reported by Jackson, has it been found behind the rectum, Avhich
 latter was then pressed forward.  This singular anomaly merits attention.
  The ovarian tumors vary greatly, both in their volume and form —from
 the size of a small orange up to that of a child's head ; sometimes they only
 occupy a part of the  excavation, Avhile at others, they fill  it up so completely
 that the finger can  scarcely be introduced betAveen  them  and  the  pelvic
 walls.  It is important in practice to ascertain  these differences of sizo ami
 location, and equally so to detect the nature of the tumor, and the kind of
 material that forms it.   In some cases of ovarian dropsy, the fluctuation hs
bo evident that no possible doubt can exist  concerning  its character, but in
others, this  sensation is not so clearly recognized; though here the smooth
and p dished surface of the tumor, and its rounded form, compared Avith  the 
724
DYSTOCIA.
irregularities, and the nodules exhibited by cancerous degenerations of thia
organ, will facilitate  the  diagnosis.  The  density of the fluid  tumor, its
elastic resistance and fluctuation, are singularly modified during the con-
traction ;  because, being then strongly compressed by the child's head, the
sac, that was at first  soft and yielding, becomes hard, tense, and resistant;
consequently, it is advisable to examine both during and after the pain, for
the differences then presented will likewise aid  in making out the diagnosis.
The exploration should be made both  by the vagina and rectum, since this
is the best method of distinguishing  the enlargements of the ovary from
those belonging to the uterus or the vagina.  This double exploration only
admits of their being confounded with the tumors existing in  the recto-
vaginal septum ; but this error would be of little consequence, since the tAvo
cases present the same indications for treatment.
   The presence of  such tumors is always a very unfavorable complication
of the labor; but the prognosis will necessarily vary with their volume, seat,
nature, and mobility, as also according to the period at which the physician
is summoned.  Thus, in thirty-one cases  recorded  by Puchelt, fifteen Avere
fatal to the mother and twenty-three to the child.  Twenty-one children and
one woman died during the labor.
   As regards the treatment, the same  course is not always  to be pursued
in the cases  under consideration.   There is evidently nothing to be  done
where the size and locality of the tumor afford a Avell-grounded  hope of a
spontaneous delivery; but when it is  movable, and the  head has not yet
engaged, it is recommended to  attempt to press up the  former  above the
abdoVninal strait; and, should the tumor still have a  tendency to fall back,
after having been carried up, it  ought to be supported, while the feet are
sought after, or an application of the forceps is resorted to.
   But in  some grave cases, the engagement of the head, or the adhesions of
the tumor, render a return of  the latter impossible; here it is particularly
important to be certain of its nature; and if the signs  above indicated have
not proved sufficient to settle the diagnosis, a puncture should be made in
it, AAdiich  would determine  the question  of its fluidity or solidity.   If it
proves to be an ovarian dropsy, it is to be evacuated by a trocar  somewhat
larger than the one used for the exploratory puncture;  but if the cyst be
multilocular,  or if it  contain  a  cheesy matter  that cannot escape through
the canula of the trocar, a free incision will evidently  be requisite.
   By allowing the fluid to escape, the  incision  would have the  double
advantage of facilitating the labor  when the  tumor  is very large, and of
preA-enting consecutive inflammation of the cyst, when  the latter, though
too small absolutely to prevent the expulsion of  the foetus, is  yet large
enough to delay it greatly.   Under the latter circumstances, indeed, the
compression it undergoes during labor  may excite in it a violent  inflamma-
tion, and,  in some cases, even produce a rupture.  As a consequence of this
rupture, the fluid may be discharged  externally through a perforation of
the vagina, or be effused into the cavity of the  peritoneum.
  The incision or the puncture is usually made by the vagina, as the evacu-
ation  of its contents is more easily effected through this  canal.   Some per-
sons, ho wever, fearing lest an incision made through the vaginal wall might 
TUMORS  OF  THE  RECTUM.
725
. become enlarged at the moment  of the passage of the head, have recom-
 mended the  introduction of  the instrument through the  rectum;  and
 although this mode of operating ought, in  general, to be rejected, it should
 certainly be followed in those cases in which the tumor is located betAveen
 the posterior part of the rectum and the anterior surface of the sacrum.
   Again, the  tumor is solid, it cannot be pushed up, and the size is so great
 as to render an extraction of the foetus altogether  impossible.  The case  is
 then  most  serious, and we have only to choose betAveen an  extirpation of
 the tumor, or  a resort to embryotomy, or to the Caesarean operation.   Under
 such  circumstances, if it Avere possible to ascertain that the abnormal groAvth
 had  not contracted intimate  adhesions to the  neighboring  parts,  I would
 willingly adopt  the vieAvs  of Merriman, who recommends its extirpation ;
 but if this latter be deemed impracticable, a mutilation of the child might
 be resorted to, Avhen there is room  enough betAveen the tumor and the pelvic
 wall  to afford a passage  to the foetus grasped by the embryotomy  forceps;
 otherwise, the Csesarean operation seems to be the only resource.
   The folloAving summary, which  will  serve to illustrate the danger of the
 operations just recommended, is extracted  from M. Puchelt's statistics: In
 five cases, Avhere the delivery was  abandoned to the  resources of  the organ-
 ism, four of the mothers died, and but two children were born living.  The
 simple  pushing  up of  the tumor was  only followed by the  safety of both
 individuals in a single instance, Avhile in another case the infant was still-
 born.   Version Avas performed twice, after having previously  pushed up the
 tumor, but this  double operation was only once successful for the  Avoman;
 the child,  though born  living,  died immediately afterwards; but in  the
 other, both mother and  child perished.  A simple  puncture of  the tumor
 was attended Avith success in one case, though in tAvo others it did not obvi-
 ate the necessity for embryotomy, and both women  died.  The incision of
 the mass, which  Avas  practised in three instances, was  favorable  to both
 individuals in a single case only, while in the other tAvo the  children per-
 ished ; in the fourth, version was effected after the incision, but both mother
 and child were lost; the  same result attended the application of the forceps
 in one case; a perforation of the cranium was  found necessary in six, and
 only three of the women recovered; and, finally, both parties survived in
 those instances Avhere the blunt hook could  be employed.

   § 2. Tumors appertaining to the Fallopian Tube.
   As the tumors of the tube are much  more rare than  those of the ovary,
 they seldom constitute a mechanical  obstacle to the delivery.   In fact, only
 one case of the kind is on record,  that related by Chambry of Boulaye, in
 the old Journal de  Medecine,  Chirurgie, et Pharmacie.   It appeared as a
 round, hard, irregular, and partly osseous tumor, the true seat of which Avas
 subsequently ascertained  by the post-mortem examination.  If a similar case
should De met with, it Avould offer the same  indications for treatment as the
ovarian tumors.
  § 3. Tumors of  the  Rectum.
  a.  Fecal matters may accumulate and  harden in the rectum, and give
rise to unpleasant symptoms, which  sometimes simulate a regular  disease 
726
DYSTOCIA.
»f the intestine; and if such an accumulation takes place  toAvards the end
of pregnancy, it  may render delivery difficult, or  even impossible,  by
obstructing  the passages the  foetus  has to traverse.   In several  of the
reported cases, injections could not be made,  and  laxatives given by the
mouth proved ineffectual.  For  instance, Guillemot  says, " We are con
strained, before delivering her, to  extract  all the  excrements Avhich  dis-
tended the said large bowel;" and Lauverjat  likeAvise  remarks, " I intro-
duced my finger into the vagina, and pressed on the matters, Avith the view
of diminishing their solidity ; I then gave two injections, Avhich soon emptied
the intestine ; the pains, which had been completely suspended for six hours,
reappeared,  and the  labor Avas terminated  in less  than fifteen minutes."
Under like  circumstances, I  knoAV  of nothing better than  to  folloAv the
example of these practitioners.
   A curious case, in many respects, is reported by Fournier, who says: " I
was sent for by three surgical students, Avho had been ineffectually attempt-
ing to deliver  a woman for five days.   Having ascertained, on my arrival,
that  she  was costive, and had not had a passage for a week, I immediately
directed  an injection.  The student charged  Avith this duty  endeavored in
vain to find  the anus; and, on going to  his aid, I  discovered  that it Avas
imperforate, and that no vestige whatever  of an  orifice remained ; but,
instead, a line similar to the raphe extended  from  the coccyx to the vulva.
I introduced my finger into the vagina, where I found the  rectum floating,
and as it was filled with excrement, compressing the womb, the canula was
introduced there, and the injection penetrated into the intestine, from Avhence
a prodigious quantity of cherry-stones, mixed up with fecal  matters, came
away at once; and after this evacuation, I terminated the labor."  (Diet.
Sci. Med., torn. iv.  p. 155.  Cas. rares.)
   B.  Scirrhus. — Dr. Lever relates having met with  a case Avhere the labor
was  rendered difficult by the presence of a cancerous tumor situated three
inches above the  anus.  But such tumors rarely acquire  a large size, and
the application of the forceps would nearly always prove sufficient to over-
come the obstacle.

   § 4. Tumors of the  Bladder.
   The tumors in the pelvic cavity, dependent on the bladder, may be caused
either by a procidentia vesicae, a cancer of this organ, or a urinary calculus.
In addition to which, we have elseAvhere spoken of the unfavorable influence
that  an excessive distention of the bladder might have over the puerperal
functions.
   A.   Procidentia Vesicoz (Falling of the Bladder).—Under this title, certain
authors have described  an inconsiderable displacement of the bladder, but
which does not the less constitute a true hernia of the organ; and we shall,
therefore, refer our remarks on this subject to the article in which hernial
tumors are treated of in detail.
   B.   Cancer of the Bladder. — Puchelt extracts one case of this disease from
Oberteufer, and Dr. Lever reports another; both of Avhich would seem to
prove that the vesical walls, Avhen attacked  by cancer, may form a tumor
in the excavation large enough to obstruct the course of parturition.   As to 
TUMORS  OF THE  BLADDER.
727
its treatment, this tumor evidently presents the same indications as all the
ether solid ones before described.
  c Urinary Calculi. — Instances of a stone in the bladder descending into'
the excavation, and  thereby obstructing the free passage of the head, are
not very unusual.  The  numerous cases of this kind on record prove that
they are always situated below the head, or else are placed  betAveen it and
the symphysis pubis.   In a single instance only, reported by Lauverjat, the
calculus was above the pelvis, though, as M. Velpeau remarks,  it is difficult
to understand how it could then arrest the expulsion of the foetus.
  Calculi vary very much in their size, and the same is true of their shape,
which fact modifies  the prognosis.   The diagnosis is  not ahvays  an  easy
matter,  though if  the tumor felt behind the symphysis  pubis  is hard, cir-
cumscribed, and gives rise to pain when pressed upon  by the  finger or the
child's head, if it  is situated Avithout the vagina, and if it is  firmly  fixed
during the contraction, but is movable during the relaxation of the womb
there is  every reason to suspect the existence of a calculus ; Avhich suspicions
Avould naturally lead us to the use of the catheter, whereby the  foreign  body
can nearly always be detected.
   Treatment. — An attempt should be made to press up the stone above the
superior strait, before or even during  the labor, and prior to the engagement
of the head ;  or, if the latter is still movable — although it may be  engaged
— it should be raised up from the strait, and  the calculus be pushed above
it.  But, unfortunately, it  is not always possible to do this, either because
the head has descended too far to be pressed back (the stone  being below
it), or because this latter is forcibly Avedged in between it and  the symphy-
sis.  In  such  cases,  an extraction of the calculus seems to  be  the  only
resource; however, this need not  be attempted at once, for  some of the
reported facts would seem to prove that its spontaneous expulsion may take
place, even Avhere its great size  might preclude all hope of such an event,
as occurred in the folloAving case  reported by Smellie.   The Avife of a  coal-
porter, who  had long been suffering from the presence of a  stone in the
bladder,  became pregnant.  The  midAvife, summoned at the time of labor,
was  surprised to find a hard resistant body lying before the head ; but as
the means of the patient did not admit of her sending for  a  physician  in
consultation, the midAvife could only keep up the spirits of her  patient dur-
ing the long and painful parturition.   At last, she felt  something coming
aAvay, which proved  to be a stone about the size and shape of a goose's giz-
zard, and Avhich  Aveighed from five to six ounces.  Immediately after  its
escape, the child Avas expelled, and  the woman recovered in due time, but
she aftenvards suffered from incontinence of urine.  Some surgeons  have
been encouraged, probably by facts of this kind, to attempt an extraction
of the calculus through the previously dilated  urethra;  but this operation
requires too much time to admit of being performed during the progress  of
parturition.   If there  should be no  hope of succeeding by the forceps or
pelvic version, on account of its  large size, it would be  necessary to resort
to the operation of vaginal lithotomy, and incise the urethra directly on the
itone through the anterior vaginal Avail. 
728
DYSTOCIA.
  § 5. Of Hernial Tumors.
  A considerable portion of the intestine, omentum, or bladder, may become
engaged  in one of the  culs-de-sac formed  by the peritoneum,  in  being  re-
flected from the  bladder to the womb, and  from the latter to the rectum,
and thus constitute a true vaginal hernia.  But Avhen the parts that are dis-
placed and engaged between the rectum and the vagina descend still more,
and cause a prominence in the perineum, the term perineal hernia is applied.
  Under the title of vaginolabial hernia, a tumor has been  described which
is situated in the substance  of the labia, or in the lowest and most projecting
part of the fold which  it forms with the skin.
  A. Intestinal or  Omental  Hernia.—The seat of a vaginal enterocele, or
epiplocele, is sometimes between the vagina and bladder, but oftener betAveen
the rectum and posterior wall of the vulvo-uterine canal, and always on one
side of it, in consequence of the vaginal adhesions both behind and in front.
The misplaced organ forms a tumor there which is very variable in its size,
and which either presents the clammy softness of epiplocele, or the elasticity
or rumbling of an enterocele.  Though easily recognized, these tumors have,
in some  instances, given rise to serious mistakes, which might have proved
disastrous to the patient.   I was summoned, says Levret, to a case of this
kind, where the question was actually discussed, Avhether a  large portion of
the tumor should be removed or not;  but  I demonstrated, in a satisfactory
manner, that some part of the intestine had slipped down into the substance
of the septum, through  the bottom of the cul-de-sac that is found between
the neck of the womb .and the upper part of the rectum.  (Levret, Abus des
regies.)
  The prognosis is unfavorable, not only from the obstacle  thereby created
to the expulsion of the child, but also from the pressure of the head on  the
hernial  sac ; because an inflammation, that  is always serious, and  which
might sometimes even terminate in gangrene, may result in consequence.
All authors have, therefore, recommended the  reduction of the  hernia as
soon as possible.
  To accomplish  this,  it is better to place  the woman on her knees and
elbows, so as to facilitate the return of the intestine and the engagement of
the head ; this position Avas followed by  the happiest results in the case
above reported.   In another instance, Stubbs, by compressing the hernial
tumor, succeeded in reducing it, and the head then engaged.  In my esti-
mation, the  taxis  should be preferred  to Levret's method, taking care to
sustain the head at the same  time  with  the other hand, if the hernia be
voluminous.  Where the reduction is impossible, it is necessary to terminate
the labor as soon as possible by the aid of the forceps, or by turning.
  B.  Vulvar or Perineal Hernia. — We may  be  allowed to speak in this
place of vulvar or perineal hernias, which, although they  do not present a
mechanical  obstacle to  parturition,  may give  rise to special indications
during  pregnancy  and  labor.  These  tumors,  which  are  situated in  the
lowest and most  posterior  part of the greater labia, may be formed by  the
escape of a loop of intestine, and  sometimes  a portion  of  the bladder.
They have been oftener  observed during  pregnancy than at any  other
period, and  may ultimately acquire a very considerable  size.  Papus men- 
HERNIAL  TUMORS.
729
tiors hiving dissected one which had the form of a large bottle, hanging to
the right of the anus, and descending as far as the leg.  In one of the cases
observed by Smellie, the  tumor, Avhich  toAvard the end of gestation was
as large as the fist, became strangulated and gangrenous.
  The seat of the tumor, Avhich is ahvays situated in the lower part of the
greater labia, betAveen the edge of the anus and the tuberosity of the ischium,
the ease Avith which it is reduced in  the horizontal position, and its sudden
reappearance when  the patient rises or makes the least exertion, serve to
indicate its nature.   Enterocele may be distinguished from cystocele by the
gurgling Avhich accompanies the reduction of the former.   The latter often
diminishes in size after  urinating or using the catheter, and desires to uri-
nate are produced by pressing upon the tumor.
   It is  evident that the exertions of labor have a tendency to increase the
size of the hernia  greatly, and even to produce strangulation.  It should be
kept reduced by pressure properly applied.
   c.  Vesical Hernia, or Cystocele.—It sometimes happens during labor that
the fundus of the bladder descends beloAV the head, and constitutes a tumor
of variable size at the anterior superior part of the vagina; the descent
being probably  caused by the  pressure  made by
the child's head or the inferior part of the Avomb,          fiq.ih.
on the fundus of this organ.  The  patient has a
feeling of weight  or fulness  in  the  pelvis, and a
dragging sensation  about the umbilicus; she has
a constant desire  to urinate, without the poAver of
emptying her bladder, though, sometimes,  each
uterine  contraction is followed  by the emission of
a small  quantity  of  urine; besides Avhich, a more
or less  oval tumor, that  is smooth,  soft, and fluc-
tuating  betAveen  the pains,  but hard and tense
while the}'' last, is detected  by the touch at the
upper front part of the  vagina;  and above  this
the head can often  be  distinguished ; indeed, the   ^s1™1 cystoceie, taken from
n            -i   ■••  i  i •  i  i            ii         Bamsbotham.
ringer may easily slip behind the tumor, and reach
the  cervix uteri; but it cannot pass betAveen the  former and  the  pubic
symphysis.
   The  tumor  formed by a cystocele is occasionally quite large.   Madame
Lachapelle says :  " The first thing that attracted our attention Avas a pedicu-
lated tumor, about the size  of an egg, which  projected a  little from the
vulva, and seemed  to be attached to the right anterior wall of the vagina
near its middle.   The  pedicle Avas about an inch and a half in  thickness,
and  the tumor contained a liquid,  all  of Avhich could be pressed  back
through  the pedicle; an  opening Avith a thick margin was  then detected,
which appeared  to  communicate with the bladder.   In fact, according to
the Avoman's account, the tumor augmented in  size  in the erect position,
though  it  often disappeared after the emission of urine, and ahvays Avhen
using the cold bath.  The uterine  pains increased the size of the hernia,
and  the head  in  descending  compressed, and rendered it very tense;  after
having  emptied the bladder, I reduced  it, and recommended the students
 
730                           DYSTOCIA.
to support it Avith tAvo fingers during  each contiaction of the  ,vomb.  The
head soon cleared the passage, sustaining the hernia  itself, and the labor
terminated favorably."
   The tumor is nearly always seated at the anterior part of the vagina;  bur
in a case  reported by Sandiford, it was located between this canal and the
rectum.
   There is one variety of tumor, formed in the pelvic cavity, which is the
more Avorthy of  attention, as its  true  nature might be misunderstood
from its singular situation.   It depends on a  lateral displacement of the
bladder, and M. Christian assigns to it the folloAving characters, namely, a
remarkable fulness on one side of the pelvis, more especially during the
uterine contractions, Avhich give to the tumor an evident elasticity and ten-
sion ; it is generally circumscribed, though its base is someAvhat spread out,
and extends along the side of  the pelvis  as far as the sacrum ; its volume
varies, of course, with the quantity of fluid contained in  the  sac, occasion-
ally equalling one-third of the transverse diameter of the pelvis.
   The tumefaction completely  disappears after the use  of the catheter;
and, by directing the concavity  of the instrument doAvmvards,  its point can
be felt through the Avails,  and  can readily be moved from  before backwards
in a horizontal  direction.  As the tumor  is covered by the vagina, and its
base  is diffuse, there is no danger of mistaking  it for the bag of waters,
since it does not prevent the finger from reaching the uterine orifice.   Cys-
tocele may sometimes be  removed  by pressure, and almost always by the
catheter;  its size will vary Avith the  extent of displacement, and Avith the
quantity of urine contained in it.
   Cases of this kind merit serious attention, for they may be confounded
with  other tumors;  and  such  an  error of diagnosis might lead to  the
performance  of a useless and perhaps dangerous operation. Dr. Merriman
(Synopsis, page 202) speaks of a surgeon, Avho, supposing he  had  to treat
a case of  hydrocephalic  head, thrust a sharp instrument into  the bladder:
and  a similar mistake, according to Hamilton, was committed by another
practitioner,  Avho  imagined he Avas opening the bag of waters.
  In all these obscure cases, a resort to  the catheter  is  the  best possible
means of diagnosis; nevertheless, it must be observed, that, for this  meas-
ure to be  conclusive, it should be done in such  a  manner as to plunge  the
beak of the instrument into the liquid contained in the cavity of the tumor;
that is, after the  instrument has once entered, it should be turned over, so
as to make its concavity look  doAvnwards and backwards.  As a remedy,
this  is the only one requisite, and  the  instrument ought to be left in the
bladder until after the head is engaged.
  Unfortunately,  its introduction is not always an easy matter, particularly
where the  head has been  wedged in the pelvis for a long  time; under such
circumstances, an  attempt should be  made to  press up the former during
the intervals; but if this. is impracticable, and there  is  reason to fear a
rupture of the bladder from its overdistention, I know of no other resource
than to pur-oture the organ with a very delicate trocar. 
TUMORS  OF  THE  PELVIS.
731
  § 6.  Of Tumors developed in the Cellular Tissue of the Pelvis.
  We have yet to treat of the fatty, the fibrous, and  the cancerous masses,
and of the abscesses, or encysted  tumors, that may be developed in the cel-
lular tissue of the lesser pelvis, nearly all of Avhich are situated in the sub-
stance of the recto-vaginal septum, though  they are  occasionally found on
the sides of the vagina.  In one instance, reported by Ed. Meier, the deliv-
ery Avas rendered  impossible by the  existence of a cyst, about the size of a
child's head, between the uterus and the  bladder.  The steatomatous and
cancerous tumors are usually found in contact Avith the osseous or ligamen-
tous Avails of the pelvis, to Avhich  they seem  to appertain.  (See page 076.)
  It must be  apparent that there is an identity of nature and seat between
the tumors of the cellular tissue and those of the ovary; the reducibility of
the one, Avhen non-adherent, and  the irreducibility of the others, constitute
the only marked  difference betAveen the two.  Consequently, the diagnosis
is not easily made out after the engagement'of the head, or when the ovarian
tumor is retained in place by old  adhesions ; but, fortunately, that would be
an error of little  importance, since  both present the same indications for
treatment.  It is  more easy to distinguish the tumors of the cellular tissue
from those appertaining to the organs before spoken of, and Ave refer to the
signs already given, as characteristic of each of them.
  The  reader will understand  that  the prognosis  varies  according to  the
size, nature, density, and seat of the tumors.   When small, compressible,
and situated in the direction of one of the long pelvic  diameters, it will most
frequently permit a spontaneous termination of the labor; and this may also
take place, if, notwithstanding its hardness and size, it still retains a certain
degree  of mobility.  Even  in those  cases where it is impossible to push it
above the superior strait, we may still hope  that, being forcibly compressed
by the  child's head, it will permit the latter  to pass.  During my sojourn at
the Clinique, I saAv a woman, in Avhom the child's  head Avas arrested at the
superior strait for a  long time, by a  tumor, which Avas probably fibrous in
its character, and was situated in  front of and on a level with the sacroiliac
symphysis.  An application of the forceps  had been seriously  thought of,
but the tumor, located in the recto-vaginal septum, was gradually forced
doAvn by the head, under the influence of strong contractions, as far  as  the
floor of the pelvis, Avhere it Avas  pressed backAvard, at  the  same  time dis-
tending the  perineum, and the labor terminated  by the  birth of a living
child.
  In many cases, the volume and  permanence of these tumors do not permit
us to anticipate so happy a result, and it will then be necessary to interpose.
The indications to be fulfilled will vary according to the particular case:
that is, Avhere an abscess or an encysted tumor is detected, it is to be  punc-
tured, so as to evacuate the liquid, or it is to  be incised Avhen the contents
cannot  be removed by a simple puncture ;  but where the tumor is solid, is
easily accessible, and has contracted no intimate adhesions with the vagina
or rectum, it ought to be extirpated.   Tavo  modes of operating have been
recommended for  this purpose ;  in the one, the vaginal Avail only is incised,
while in the other the tumor is reached  by making an opening in the peri-
neum.  The success  obtained by Drew and Burns pleads  in favor of  the 
732
DYSTOCIA.
latter procedure.   In the worst cases, where  the situation of the tumor, oi
the numerous and firm adhesions which it has formed, render its extirpation
impracticable, our only resources are in the obstetrical  manipulations, pro-
perly so called;  namely, the application of the forceps, or tractions on the
feet, if the tumor is not very large, and the Caesarean operation, or embry-
otomy, if  the excavation  be so obstructed that the extraction of a living
child is impossible.
                          CHAPTER  X.

          RUPTURE OF THE UTERUS AND OF THE VAGINA.

                           ARTICLE I.
                       RUPTURE OF THE UTERUS.
   Rupture of the womb is one of the  most dangerous accidents that can
happen to a female in the puerperal state.  Exceedingly rare during the early
months of gestation, it is somewhat more frequent in  the latter half of
pregnancy; but it is during the second stage of the labor, especially, that
it most frequently takes place.
   Rupture of the uterus has seldom been  observed in women bearing  their
first child.  Thus, in seventy-five cases,  reported by Churchill, nine occurred
in primiparae, fourteen in women in their second pregnancy, thirteen in their
third, and thirty-seven in their fourth or succeeding  ones.
   The woman's age does not seem to have any marked  influence over the
production of this accident.  Nevertheless,  the organic  alterations which
constitute a predisposition are more unusual in early life than in advanced
age.
   As the male child is ordinarily somewhat larger than the female, this,
according to Dr. Clarke, would be  a predisposing  circumstance; thus, in
tAventy cases of rupture, mentioned  by  Dr. M. Keever, fifteen  were male
children; and of thirty-four cases by Collins, twenty-three of the children
were boys.
   The rupture may be seated  either in  the body  or neck of the organ.
When it affects  the cervix, it is highly important to ascertain Avhether it
only involves the sub-vaginal portion, or  whether it invades that part situated
above the insertion of the vagina; because the former is attended with very
little danger, and  occurs very frequently;  indeed, it takes place at nearly
every labor, just at the instant when the head is clearing the orifice, and it
is scarcely ever  followed  by any unpleasant symptoms.   The last, on the
contrary, presents the same dangers, and has similar consequences with the
ruptures of the body.   Therefore, we need  only mention here the  lacerations
that are limited to the orifice, and which do not extend  beyond the vaginal
insertion; and all that Ave are about to  say concerning the uterine ruptures
refers exclusively to those in the body of the Avomb and in the supra-vaginal
portions of the neck.   These  latter are the more frequent, and  they are
located  somewhat oftener on the posterior than on the anterior face. 
         RUPTURE OF THE  UTERUS AND OF THE  VAG1NTA.     733

   § 1. Causes.
   Rupture of the uterus always supposes a distention of the organ, and this
 distention is most frequently dependent on pregnancy.   The uterine walls
 become  softened, in consequence  of the modifications they undergo; their
 thickness is  a little diminished at certain points, and  they become more
 supple, more elastic, and therefore better calculated to  support  a slow and
 gradual pressure; for OAving to this suppleness, they can yield without rup-
 turing, though their distention renders them less fitted to sustain a sudden
 and forcible shock.  By this distention, and the increase in volume to Avhich
 it gives rise, the uterus is forced to ascend above the superior  strait; and
 thenceforth it is no longer protected by the osseous Avails of the pelvis, and,
 consequently,  is more  exposed to external violence, from Avhich  it was
 shielded during the non-gravid state.  Coming, from its situation, in imme-
 diate contact with the abdominal  parietes without  the  intervention of any
 other body, it  is subjected to the unequal pressure AA'hich the rapid and
 irregular contraction of the  abdominal  muscles during  any violent efforts
 may make upon it.
   Pregnancy, and  the  modifications thereby impressed on  the  uterus,  are
 therefore the  essential  predispositions  to  rupture of the uterus; but, inde-
 pendently of these conditions, Avhich exist in all  gravid Avomen, there is  a
 number of other circumstances Avhich have a more immediate influence over
 the production of this accident; and Avhich authors have  designated under
 the titles of the predisposing and the determining  causes.
   1. Predisposing Causes. — Under this head Ave  must  include  everything
 that can augment the distention or diminish the resistance of the  uterine
 Avails, as, for instance :
   A. A great abundance of the amniotic liquid; the presence of  several
 children, cv.c.
   B. The extreme thinness of the uterine Avails, which is met with in certain
 women, and Avhich  cannot be accounted for.

   [Thinning of the walls of the uterus is most common in Avomen who have had
 many children, and consequently predisposes them to spontaneous rupture.  Turn-
 ing, in such women, is more dangerous than in primiparae, because the thin walls
 of the womb are more readily lacerated.]

   C. An enfeeblcment of the uterine parietes, dependent on causes Avhich have
 operated at a more or less remote period, such as falls, bloAvs, &c.; the con-
 tused Avails inflame, become  softened, and ulcerate; sometimes the rupture
 comes on during the same pregnancy, at others, several gestations may suc-
 ceed it Avithout any accident, and yet a rupture take place at a subsequent
 one.
   The  enfeeblement may likewise result  from  di\rers softenings; such as
those designated by M. Dezeimeris  as the atrophied, the apoplectiform, the
inflammatory, and the gangrenous ramollissements, and  those produced  by
organic alterations.  We must add another circumstance, Avhich is, in truth,
very unusual, but Avhose influence has been fully demonstrated  by  several
well-attested  instances,  namely,  those  Avomen  Avho have undergone the
Cesarean operation, and who have had the rare fortune to escape the grave 
734
DYSTOCIA.
dangers that attend it, seem more disposed than others to uterine rupture in
the folloAving  pregnancy:  thus, Dr. Kayser has brought forward six case*
in his excellent thesis, in which the patients, Avho had  before been operated
upon safely, have been compelled  to  submit to gastrotomy, in consequence
of a rupture of the Avomb ; three of these Avomen died.
   D. All the organic alterations, and  all the degenerations of tissue of which
the uterus may be  the seat, such as the scirrhous, fibrous, or encephaloid
tumors.   The softening and ulceration  of these morbid  masses  may render
that portion of the walls they occupy thinner and Aveaker; oftener, on  the
contrary,  they augment the thickness and even the consistence of the uterine
tissue, but still act as predisposing causes of ruptures,  at least during partu-
rition, in the following Avay : the point  thus affected not contracting, whilst
all the others are in action, the resistance made by it  Avould be wholly pas-
sive; and hence, whatever be its strength, it cannot  hold  out  against  the
contractions of all  the rest of the organ, the action of Avhich, being  aided
by that of the abdominal walls, weighs with all its force, as it were, on that
portion which does not participate in the general action; and if  we suppose
that any  obstacle Avhatever prevents  the ready engagement  of the foetus, the
uterine effort, Avhich is incapable of overcoming the resistance it encounters
in clearing the  superior strait, is felt  at the point Avhich does not contract,
and consequently this latter  becomes ruptured.  And it is by a similar
mechanism that the irregular or partial contractions may produce a  rupture,
by leaving some one  point of the  uterine Avails in a state of inertia, whilst
all the others are contracting.
   During the labor, Ave must add everything that may render the parturition
difficult,  or require unusual  and long-repeated contractions on the part of
the organ.  In  this  respect, all narrowing of the pelvis, every  tumor that
obstructs the excavation, all resistances offered by the cervix uteri, Avhether
dependent on an agglutination of the  lips, a degeneration  of its tissue, or a
state of spasm, or a considerable obliquity of the body, and  the malpositions,
 as well as the malformations of the foetus, may become causes of rupture of
 the uterus.
   The ruptures of the uterus Avhich  take place during labor almost ahvays
 occur after the rupture of the membranes.   Still, James Hamilton reports
 a case in which the membranes were found  entire at the autopsy.
   2. Determining  Causes.—A number of causes may serve to produce a
 rupture under  the  influence  of some  one of these predispositions; all of
 which, however, can  be  classified under tAvo principal heads,  namely, the
 external  or traumatic, and the internal causes.
    3. External or Traumatic Causes. — It is not Avithout some hesitation that
 I venture to say a few words here about the traumatic  lesions to which the
 womb is  exposed as a cause of rupture; for  it is well knoAvn that, at every
 period of life, this organ  is liable to  be injured by  a projectile thrown by
 gunpowder, by any murderous instrument, or by the horn of an infuriated
 animal.   But it must be remembered  that the increased  size of the organ,
 during gestation, exposes it then more than ever to  this variety of lesions;
 though the consequences and the indications for treatment are, in other re-
 spects, nearly the same.   Again  Ave must add that perforations  and lacera-
 tions of the uterus often result from  ill-directed obstetrical  manipulations. 
        RUPTURE OF THE UTERUS  AND  OF  THE VAGINA.     735

  The Avomb is also  greatly exposed to  compression or violent contusion of
its walls, Avhen it is developed by the product of conception.  This compres-
sion  may be mediate, that is to  say, dependent on  exterior causes, such as
falls or blows on the abdomen, the  pressure of this region by the  backing
up of a coach against a wall, or the passage of its wheels over the belly ; or
it may be immediate, that is, due to the violent contraction  of the abdominal
muscles.  The effects of  mediate compression are generally of little conse-
quence,  owing to the mobility of the uterus, the suppleness of its Avails, and
the point d'appui Avhich the latter find in the surrounding parts.   Never-
theless, they sometimes are  folloAved  by diastrous  consequences: thus  it is
stated, in the old Journal de Medecine,  that a Avoman had  a rupture of the
womb at the seventh month  of her gestation, in consequence of having been
pressed  betAveen a Avail and- a carriage.  As before  stated, the contusion of
the ventral  parietes  seldom produces an immediate rupture; but the bruise
and consecutive inflammation of the uterine  structure may determine an
ulceration, and then a perforation at some future period.
   The ruptures by immediate compression, or those which result from  the
violent contraction of the abdominal muscles, seldom occur Avithout the pre-
existence of some one of the  alterations of the uterine Avails, considered above
as  predisposing causes.   They generally folloAv a fit of coughing,  sneezing,
or vomiting, or take place during a paroxysm of anger; but they may like-
wise be occasioned by the patient's attempts to raise some burden, and by
 the forcible bending of the  body backward, which latter cannot occur Avith-
 out the recti muscles of  the abdomen becoming closely approximated to the
 vertebral column during the forward curvature of the trunk; in  all these
 movements the Avomb is forcibly compressed betAveen the abdominal muscles,
 which contract vigorously, and the posterior plane of the abdominal cavity.
 A rupture has been knoAvn  to occur at  all stages of gestation, from the ear-
 liest months up to full term, under the influence of some one of these causes.
   4. Internal Causes. — Authors have incorrectly considered the enormous
 distention of the uterus during pregnancy as being capable of producing  a
 rupture; for,  although this  distention is a predisposing cause, yet however
 great it may be, it cannot of itself give rise to such an accident Avithout the
 previous existence of an organic alteration.  The same is true of the violent
 and convulsive movements  of the foetus, Avhose impetus is  too inconsiderable
 to occasion a  rupture; and  besides, the Avomb is fully protected' against its
 influence by the amniotic liquid and the suppleness of the  Avails.
   During  labor, the uterine contraction is the  most frequent  determining
 cause;  and though the Avails  of the organ Avere altogether passive in the
 course of gestation, they here  play the  principal part in  the production of
 the rupture.
   After the membranes are ruptured  and  the Avaters entirely discharged,
 the Avails of the uterus are applied directly upon the fcetal ovoid.   Now, in the
 doubled-up condition of the various parts of the child, numerous projections
 and irregularities are presented, which make the resistance at its different
 points very unequal.   Consequently, some parts of the uterus are more or less
 stretched over the projecting parts, and, to use Madame Lachapelle's expres-
 sion, some of the  muscular  fasciculi act in a Avrong direction, whilst others,
 finding a firm support, contract Avith greater energy. 
736                          DYSTOCIA.

  The equilibrium of the forces is then, says M. Taurin, broken at several
points of the Avomb, and the organ contracts irregularly. The non-compressed,
healthy, and thicker parts contract with greater poAver, and draw upon the
parts in the vicinity; the latter, already distended by the foetal projections,
become still thinner, their resistance yields more and more, and  at last, in-
capable of longer resistance, they give way  under the more  powerful con-
tractions of the neighboring parts.
  Such would be the course of affairs,  more especially in an unfavorable
position of the foetus, — one of the shoulder, for example.
  We would add further, that when the labor is prolonged greatly, the pres-
sure of the foetal projections upon the walls  of  the uterus may cause their
inflammation, ulceration, or even gangrene, all of them circumstances likely
to facilitate rupture.
  Deformities of the pelvis, by presenting a mechanical obstacle to the pass-
age of the foetus, also constitute a predisposition to rupture; but even here,
the contraction  is  the determining cause.  In some other cases, the hard
and unequal projections presented by the irregularly contracted circumfer-
ence of the pelvis may produce a direct rupture of the lower segment  of the
uterus, or of the walls of the cervix.  Thus, we may readily  conceive that
a too great anterior projection of the sacro-vertebral angle, as also the pro-
minent ridge sometimes presented by the superior and posterior face  of the
symphysis pubis, might bruise,  or even  tear,  the part of the uterus which is
strongly compressed between it  and the head of the foetus.  M. Taurin men-
tions  a case in his thesis  in  Avhich M. P. Dubois attributed to this compres-
sion a rupture comprising a part of the vagina, the Avhole anterior surface
of the neck, and which extended  up the left side of the body of the uterus.
  The child's active movements are as foreign to the laceration that takes
place in parturition as to those  that  occur during  pregnancy.   For, accord-
ing to the observations of M. Duparcque, if this movement is effected during
the relaxation of the Avails, their suppleness and  extensibility enable them  to
yield to this force;  but if, on the contrary, it takes place while the contrac-
tion lasts, the resistance which they then present would require a far greater
impetus to overcome it  than  any that  can  result from  even a convulsive
movement  of the foetus.   The contraction is therefore the sole determining
cause; but, for it to produce a rupture,  its  action must be favored by  one of
the predisposing circumstances before  indicated, the  influence of yvhich  is
easily understood.
  These spontaneous ruptures  hardly ever take place except in labors  at
term, and appear impossible in  abortions at four or five  months.  A case
which removes the smallest doubt as to the possibility of such an accident
within the first six months of gestation, has, hoAvever, been communicated  to
M. Danyau by M. Castelneau.   A Avoman died almost suddenly in  conse-
quence of a profuse hemorrhage, and it Avas found that the neck of the  uterus
and the vagina Avere ruptured, the former  through its entire length and the
latter at its upper part.   The accident occurred, in all probability, during
contractions Avhich expelled the ovum very rapidly ; for although no portion
of it remained in the uterus, the organ presented  every appearance of one
which had  attained the usual development at five months of gestation. 
          RUPTURE OF THE  UTERUS  AND  [)F  THE VAGINA.     737

   However, h  must  not be  forgotten  that  rupture jf the Avomb has often
 occurred during parturition,  from the imprudent manipulations made with
 a vieAV of terminating the labor.   For hoAv often has an application of the
 forceps, a resort to version, or a difficult extraction of the placenta performed
 by inexperienced hands,—hoAv often have all of them been followed by the
 early death of the patient, and a laceration of the organ been  detected at the
 autopsical examination!  In fact, cases of this kind  are mentioned by nearly
 all authors; and  Madame Legrand, the midwife-in-chief  of La Maternite,
 informed me that several women are brought to the hospital every year to
 lie, the victims of such attempts made  in  the city.   I have seen a uterus,
 the loAver two-thirds of whose body on the right side had been torn away by
 the embryotomy forceps; and, in another case, I found at the post-mortem
 examination a perforation in  the right superior part of the body of the Avomb.
 produced by the attempts which a practitioner had made to separate a firmly
 adherent placenta.   Facts of this  nature cannot be repeated too often, for
 they are calculated  to render young physicians, who intend to practise mid-
 wifery, more cautious;  and to convince• them that,  to have attended two or
 three Avomen  in labor is not  all that is needed to render  them capable of
 performing the  most difficult operations of our art.

   [I repeat, therefore, that spontaneous rupture of  the  uterus is an event of rare
 occurrence, whilst lacerations produced by the manipulations required in turning,
 or the introduction of an instrument, are comparatively common.  I have met with
 but a single  case of  spontaneous rupture,  but,  unfortunately, have seen  quite a
 number of traumatic  lacerations  resulting from badly performed operations.  The
 most skilful operator,  Avithout any fault of his own,  may be the  involuntary cause
 of rupture and cannot be justly censured ;  yet it is  nevertheless true, that  almost
 all such occurrences are the immediate consequence of want of  skill or  the use of
 too great force in the  introduction of the hand or an instrument.]

   § 2. Symptoms.
   The signs of rupture of the  uterus are easily made out; for most frequently
 the laceration takes place suddenly after some violent effort that has neces-
 sitated a forcible contraction of the abdominal muscles.   It is  manifested
 by an exceedingly sharp pain just at the point Avhere the accident occurred,
 which  makes the patient scream out from the intensity of suffering.   This"
 acute, or, as  Desormeaux describes it,  agonizing and cramp-like1 pain,  is
 accompanied by a-sound of tearing  or cracking,  loud enough, in some cases.
 to be heard by the surrounding persons.   This pain soon changes to a sensa-
 tion of numbness, and  is followed almost  immediately by SAVOoning; the
 patient becomes pale, her pulse sinks, and she falls  into a state of syncope.
 These primary phenomena are the only ones that are manifested  Avhen the

  ' According to Dr. Roberton, when a rupture takes place in consequence of a con-
 traction of the pelvis, it is preceded by crampy pains and a sensibility to pressure at a
 circumscribed point of the hypogastrium.  This crampy pain is caused by a compres-
 sion of the  uterus between the child's head and the  promontory of the  sacrum, or some
 other prominent osseous part.  A pain  of this nature existed in a high degree in a
woman, in whom the anterior lip of the cervix uteri was considerably tumefied, and
was also situated much lower than the head;  Dr. Roberton succeeded in relieving it,
by pushing up the  tumefied lip during the interval between  the contractions.
      47 
738                           DYSTOCIA.

pregnancy is not far advanced, and when the uterus has not ascended high
enough to be easily accessible; or, else, when the ovum, having engaged in
the lips of the wound, plugs it up in such a way as to prevent any effusion
into the abdominal cavity.  A deceitful calm may thus succeed the storm,
and the symptoms be  only reneAved after several hours, or even days, Avhen
the uterus, by  contracting, shall  expel the parts it incloses into the abdomi-
nal cavity.  In  the opposite cases, and more especially in  the  advanced
stages of gestation, we can readily detect the softening and depression of the
hypogastric  Avails by an examination of the patient; for, instead  of feeling
the hard, globular tumor formed  by the womb in this region, we simply find
the yielding, depressible walls of  the abdomen, and still  loAver the more or
less reduced and  distorted  neck of the uterus.   The patient who, at  the
instant of rupture, or shortly after, experienced a gentle heat diffusing itself
through the abdomen, now feels  some strange  movements, or an unusual
weight at a  point where she never had  them before; and the accoucheur
himself detects the presence of the child in a spot where it should not be,
and he  can noAV distinguish its  movements and  the prominences it offers
much more  clearly than usual.   But these active motions of the foetus soon
cease to be apparent, though their final disappearance is ordinarily preceded
by an unusual  and almost convulsive agitation ; most generally, a little blood
escapes from the vulva, in consequence of the detachment of the placenta,
but this phenomenon may be wanting, especially in first pregnancies.  Where
the accident occurs during labor, the pains, that were hitherto strong and
energetic, disappear at once.
  The most  conclusive signs are furnished by the touch; thus, during gesta-
tion, the finger can detect a change in the  position of the womb, and  the
want of the volume which it generally has at the stage of pregnancy  the
woman  supposes  herself to have  arrived at.  Sometimes it can even feel a
part of the foetus situated  externally to the Avomb,  and depressing  the upper
part of the vagina.  During the labor it finds the bag of waters to become
suddenly collapsed, or no longer projecting  through  the os uteri, and  yet
without the  escape of any  liquid by the vagina.  The presenting part of the
child, which, a few moments before, was accessible to the finger, has now
gone up, and perhaps disappeared altogether; the cervix uteri has shrunk
up, and the  orifice is much less dilated than it was previously
  If an attempt be then made to  pass the hand into the uterine cavity, per-
haps it will  find this cavity Avholly obliterated by the retraction of the Avails;
or possibly it may encounter the  intestines there, or else only a part of  the
foetus, the rest having escaped into the belly.   The seat and extent of  the
laceration can thus be  determined, and, in some  instances, the hand may
even be made  to penetrate through into the abdomen.
  When all these  phenomena are met with, there can be no doubt in regard
to the nature of the accident, but  it is not ahvays possible to recognize them
so clearly; for if the child, instead of being displaced, remains in the cavity
of the womb after the rupture, it may happen that the  signs furnished by
the vaginal  touch, and the abdominal palpation, will be altogether Avanting.
In this case, the diagnosis is very difficult, and the cause of death is disclosed
•inly by the sutoosy.
! 
       RUPTURE  OF THE  UTERUS  AND  OF  THE  VAGINA.    739

  [Experience, or, if the expression  be preferred, personal acquaintance with the
incident, may enable one to suspect the occurrence of laceration  in  many of the
cases.  Suppose an accoucheur to be called to a case in which turning, or an appli-
cation of the forceps or cephalotribe, has been attemped ;  his first  thought Avill be
tn ascertain the fact that no rupt ire has been produced by the manipulations.   He
will,  therefore, learn  the number and nature  of the manoeuvres employed before
his arrival, and then proceed to examine the patient.   When rupture has occurred,
 he woman is almost always in a state of great  prostration, pale and  Avith altered
Features.  The breathing is accelerated and the pulse very quick.   Pressure on the
abdomen produces severe pain  on one of the sides of  the uterus, being that AA'hich
corresponds to the rupture.  Touching causes  the  discharge of a  little blood, the
appearance of which has, in our view, a certain  importance; for we have thought
that,  in such cases, it was brownish or syrupy in  appearance.   When rupture takes
place, the presenting part of the foetus often ascends  and  becomes  movable: eleva-
tion  and mobility of the presenting part ought, therefore, to be well considered,
especially Avhen they occur  at an advanced stage of the labor.  This explains Avhy
turning, so difficult in some cases on account of contraction of the  uterus, becomes
suddenly very easy after a rupture.  AVhilst practising the touch,  if the finger be
carried very  high, the laceration may sometimes be reached and the intestines felt
through it.   This remoA'es  all doubt in the matter; but it is often impossible to
reach the seat of the rupture, and then the  accoucheur must be guided by the signs
mentioned above  in forming his diagnosis, which he will verify after delivery by
introducing his hand into the uterus.]

  § 3.  Prognosis and Termination.
  The prognosis of uterine ruptures  is exceedingly unfavorable; for  they
nearly ahvays prove fatal to the child,  and expose the  mother to an almost
certain death.   Nevertheless, its gravity varies according to  the extent and
the seat of the lesion, and the consecutive phenomena  to Avhich this gives
rise.
  Some cases have been reported in which the great disorder, in the organ-
ism produced by the rupture, and the escape of the blood, Avaters, and foetus
into  the abdominal cavity, caused instantaneous death.  But, most generally,
some particular  phenomena, or symptoms, occasioned by the accidents  con-
secutive to the primary lesion, precede  the fatal termination; Avhich latter
may result either from hemorrhage, from the  inflammations and  suppura-
tions created by the prolonged sojourn  of a  foreign  body in the peritoneal
cavity, or from the operations necessary for its extraction.
  a.  Hemorrhage.— Flooding is  the most  frequent, and at the same  time
the most speedily fatal, of all these accidents.  Its source is evidently in the
torn  vessels of the Avomb, especially Avhen the rupture takes place at the
point of the insertion of  the placenta;  but Avhen this point remains intact,
it principally comes from the utero-placental vessels Avhich have been  torn
by the detachment of the  after-birth ; since the margins of the rupture, Avhen
this  occurs  at some distance from  the placenta, usually furnish but little
blood.   As  a general rule, only a small quantity of  it reaches the exterior;
while, on the contrary, it is effused abundantly into the belly along with the
amniotic Avaters  and the body of the child (Avhich  has passed in a great
measure  into the peritoneal cavity), and  the Avhole distends the abdomen
enormously.   Again, this effusion is equally profuse  in those cases in Avhich
the waters hpve escaped,  and the infant lies in the Avomb in such  a way as 
740
DYSTOCIA.
to prevent its issue.   The ruptured  margins being hindered from coming
together, the lacerated vessels continue to pour out their blood, until the
hypogastric walls oppose  a resistance to  the effusion, Avhich  is always too
late to prevent death ;  and the latter may thus take place Avithout being
preceded by any sign that would lead us to suspect the rupture.  Again, it
may happen, even when the delivery is effected immediately, that the con-
traction is not sufficiently energetic to obliterate the calibre of the vessels
entirely,  and the hemorrhage continues long  enough to destroy the patient.
  The effusion ordinarily  takes  place into the sac of the peritoneum ; but
when this serous tunic  is not implicated in the solution of continuity, the
blood infiltrates between it and the uterus, gains the duplicature of the broad
ligaments,  and may thus get into the cellular tissue of the pelvis aud loins.
In such cases, a layer of black  blood is found  interposed between the peri-
toneum and the womb, where, by becoming exactly modelled on the external
surface of the organ, it assumes  its form, and may thus by its livid color be
mistaken for a gangrenous state of this viscus.   (Duparcque.)
  Nevertheless, the uterus may  be ruptured, without being necessarily fol-
loAved by a profuse hemorrhage; as Avhere the laceration  takes place at a
point which is moderately provided with vessels, in the vicinity of the neck,
for example.  On the other hand, it may happen that, the ovum remaining
intact after the accident, the fissure becomes filled up  in a measure, either
by a portion of the membranes or placenta, or a part of the  child; or the
body of the infant may be partly driven into the abdomen, whilst the borders
of the laceration become so retracted around it that the salutary compression
thereby produced prevents a continuation of the hemorrhage.   Again, Avhen
the entire ovum passes rapidly through the fissure into the peritoneal cavity,
the uterus prevents  or  at least diminishes the bleeding by contracting at
once, Avhereby a powerful obstacle to the further discharge of blood is created.
  B.  Inflammation.— When the patient does not die from the loss of blood
that immediately follows  the rupture, a momentary calm succeeds, but the
presence of foreign bodies in  the cavity of the peritoneum gives rise to an
inflammation of this membrane, which is  the  more serious as they are the
larger; and even where the accoucheur has succeeded, by any mode what-
ever, in removing the foetus and after-birth, inflammation, though less to be
dreaded, may still result from  the operation or measures necessary  for this
extraction, and may speedily terminate in death.
  c Escape of an Intestine through, and its Strangulation in, the Fissure.—
A considerable  portion of intestine has been  knoAvn to pass through the
laceration  in the uterus, and to  become strangulated by the retraction of the
organ.   This accident, which would not be suspected, if the foetus Avere still
inclosed  in the Avomb, or if the latter had completely retracted, might, hoAV-
ever, be detected immediately after the delivery ; but should it escape detec-
tion, it would infallibly terminate in death, as occurred in the case reported
by Percy, and  reproduced by M. Deneux.  Consequently, whenever  there
is reason to suspect a rupture of the Avomb, it is necessary to carry the hand
lip into  the  interior of the organ  as soon as the delivery is effected, and
(following the plan of Rungius) to press back the intestines into the abdomen,
and then keep the hand in the uterine cavity until the organ is sufficiently
retracted, and the fissure diminished, to prevent a return of the hernia. 
       RUPTURE  OF  THE  UTERUS  AND  OF THE VAGINA.   741

  D. Recovery.— Some women have recovered from all these dangers ; a few
have even  undergone gastrotomy, and survived the  consecutive  accidents;
Avhile in others, the foetus and its appendages have escaped bodily into the
peritoneal  cavity, and have there given  rise to inflammatory  symptoms
which gradually passed off.  Salutary adhesions  Avere formed, as a  conse-
quence of the inflammation, Avhereby the foetus and its appendages were  in-
closed in a pseudo-membranous cyst that isolated them from the surround-
ing parts; the latter  became habituated  to  this neAV vicinage,  which has
continued for a variable period, and sometimes even throughout  life.  But
this cyst,  like those  which  surround  other extra-uterine products, may
become the  seat  of a  fresh  inflammatory action;  its  Avails  contract neAV
adhesions with neighboring  organs, and  \Are sometimes find ulcerations and
perforations  occurring, after the lapse of  many years, by  which  the  cavity
of the cyst is made to communicate with  that of the intestine or bladder,
and the last  pieces of  the skeleton are finally expelled through the urethra,
the rectum, or the vagina.1
   Where the child remains  in the uterine cavity, notwithstanding the rup-
 ture, and the contractions do not immediately expel it  by  the  natural pas-
 sages, the  same phenomena may be  subsequently manifested; that  is,  the
 inflamed and ulcerated  uterine tissue  contracts adhesions either with  the
 abdominal parietes or Avith those of some adjacent organ, and the foetal
 debris then escape through the ulcerated and perforated Avail, or  else  by  the
 natural openings of the excretory organs.   (Duparcque.)

   § 4. Pathological Anatomy.
   Every portion of the uterus may become the seat of rupture, though there
 are some parts which  are more liable to  be affected than others; such are
 the inferior  regions, the fundus, and  the  lateral portions  of the body, and
 the superior or supra-vaginal  parts  of  the  neck.   Moreover, the seat of
 laceration varies  according to the cause that has given  rise to it, as also to
 the period at which  it  takes  place; thus,  during  gestation, the body is
 ahvays ruptured,  but during labor, on the contrary, these  solutions of con-
 tinuity are met with about the  neck or inferior portion  of the body, which
 is, in general, thinner, and not so Avell  supported as the rest of the organ.
 Where the accident has resulted from some external  compression, the walls
 usually become lacerated toAvards the lateral parts;  when it has  resulted in
 consequence of a contusion, the  bruised  point is ordinarily the  one that
 aftenvards gives Avay :  and if the rupture  has been preceded by any organic
   1 For instances of recovery, see: Peu, Pratique des Accouchements, 341; Hamilton's
 Outlines of Midwifery; James Hamilton,  Select  Cases in Midwifery,  138;  Jos.  Clarke,
 Tram, of Association, vol. i. ; Douglas, Essays  on Ruptures of the Uterus, p. 7:  Labatt,
 Dublin Med. Essays, p. 343 ;  Frizell, Trans, of Association, vol.  ii. p. 15 ; Roos, Annals
 of Med., vol. iii. p. 377;  Kite, Mem. of Med. Society, vol. iv. p.  253; Powel, Med, Chir.
 Transact., vol. xii. p. 537; Birch, Ibid., xiii. p.  537;  Smith, Ibid., p. 373; Maclntyre
 et Brook, Med. Gazette, vol. vii. et Janvier, 1829 ; Hendrie, Amer. Jour, of Med. Science,
 vol. vi. p. 351; Davis, Obst. Med., vol. ii. p. 1070.
   MM. Keevar and  Collins have each reported  two cases; M. Duparcque quotes four
 from French authors.  Isiander states that he has  met with several cases of the kind.
 and M. Velpeau ment'oi 3 several others. 
742
DYSTOCIA.
alteration, the laceration takes place at the diseased point.  It may happen,
says M. Dubois, that the part of the uterus affected Avith chronic disease,
instead of being  weaker, is  really stronger and  more resisting than  the
healthy parts alongside, Avhich are the ones to give Avay.   (Taurin, These.)
The front and back Avails, being protected by the  anterior and  posterior
planes of the abdomen, would seem to be perfectly sheltered from such acci-
dents ; this, however, is not always the case, for instances have been reported
which prove  the  possibility of ruptures of this kind.  According to  Dr.
Roberton, Avhen the  laceration is  caused by a narroAvness of the pelvis, it
may occupy any portion of the womb, though more frequently, perhaps, it
involves its posterior inferior part; AA'hich  is explained, in his opinion, by
the pressure that the sacro-lumbar prominence makes on this region.  Some-
times, also, it takes place in the anterior inferior part, and is then due to the
osseous projections located on the internal face of the pubic symphysis.  The
anterior superior Avail is oftener injured by foreign bodies; indeed, it is the
almost exclusive seat of ruptures produced by wounds.
   Nothing can be  more uncertain than  the extent,  form, and direction of
the uterine ruptures;  since they vary in  size, from a little hole that is
scarcely capable of admitting the end  of the finger, up to a large fissure
extending over  tAvo-thirds of the fundus, or periphery of the neck, or, in-
deed, occupying nearly the Avhole  organ.   It may  have a longitudinal, a
transverse, or an oblique direction, or it may affect a circular form, as often
happens  about the neck;  or  it may run in a straight line, or in  a zigzag
course.  The  divided margins are  rarely observed  to present a clear and
regular section;  but, instead, they are most usually found unequal, hag-
gled as it were, contused, and ecchymosed to a more or  less considerable
extent.  If the rupture has resulted from some organic alteration, the ana-
tomical traces of  the  previous  disease are found  at the affected  point.
Lastly, if the patient has not died till several days after  the accident, the
autopsical examination will verify the presence of the  matters effused  into
the peritoneum, and the unequivocal  marks of a violent  inflammation of
this serous membrane;  besides which, the borders of the uterine fissure will
sometimes be red,  livid, and inflamed, and occasionally even gangrenous.
   The lacerations  of the womb do not ahvays implicate the whole thickness
of the organ, for the tunics, that enter into the  composition of its  Avails, do
not all  possess the same degree of elasticity ;  and  hence  it is possible for
them  to be ruptured separately.  Madame Lachapelle says, a fissure of  the
orifice propagated to the neck, and even to the body of the organ, has very
often divided the Avhole muscular layer, leaA'ing the serous membrane intact.
I have particularly observed, she continues, fissures of this kind on the sides
of the Avomb Avhich were covered by the duplicature of the broad ligament,
whereby the wound was prevented from extending into the abdomen.   M.
Duparcque furnishes a very similar  case; and  Dr.  Collins reports nine
others in which the peritoneum was not injured, though the muscular layer
of the neck Avas lacerated to a considerable extent.    I have likeAvise had an
opportunity of observing an identical  instance in the practice of Professor
Velpeau, in Avhich I Avas enabled  to verify the  truth of the remark made
by M. Cruveilhier; namely, that the  laxity in  the adhesicn of the perito- 
        RUPTURE OF  THE  UTERUS AND  OF  THE VAGINA.    743

 neum  to the cervix, and to the sides of the uterus, fully explains wh^ this
 membrane is so rarely involved in those cases  in Avhich a considerable rent
 has occurred in the neck, and Avhy the effusion of blood then takes place
 betAveen the  uterine tissue and the peritoneal serous membrane.   Cases have
 occurred  in  which the blood  collected in very  large amount, and  even the
 foetus  itself, completely expelled from the  uterine cavity, has been found  in
 the species of sac  formed by the detached serous membrane.
   In some more rare  cases, the muscular structure resists, and the peritoneal
 layer  alone  gives  Avay.  Where this  occurs,  the disease can  scarcely be
 recognized during life, for the phenomena that precede death are either those
 of a hemorrhage,  or of a violent peritonitis; but a large quantity of blood
 is ordinarily detected at the post-mortem examination, and, by searching for
 its source, one or more fissures of a variable extent are found in the uterine
 serous membrane.  To the case of this kind reported by Ramsbotham, we
 can now  add several others that have recently been published ;  one of the
 most curious of Avhich is that furnished by H.  Partridge (Arch, de Med., t.
 19), Avhere a great number of lacerations running transversely, Avere found
 at the post-mortem examination; these Avere more or less curved, and Avere
 variable in  depth, and they extended  from half an inch to tAvo inches in
 length.  A shred of peritoneum had been  completely detached and hung
 Avithin  the abdomen, thus laying  bare the naked fleshy tissue from Avhich
 it had  been  torn.

   § 5.  Treatment.
   The  measures that have been proposed for the treatment of ruptures of
 the Avomb, may be designated as the prophylactic and the curative.  The
 object  of the former is  to avert the influence of the causes that have been
 described as  predisposing to this accident; and we refer for an account of
 those Avhose  existence it is possible to foresee, such as the divers obstacles
 to delivery, to the  chapters on Dystocia ; and Avith regard to the others, as  it
 is usually impossible even to suspect their presence, Ave shall pass them over
 altogether.
   A rupture  of the uterus is only serious from the disastrous consequences
 which  follow it; therefore, the prophylactic measures must be directed, not
 against the  rupture itself, but  rather against  the consecutive accidents to
 which  it gh'es rise. The best mode of preventing them is to facilitate the
 retraction of  the organ  by immediately extracting the foetus and its appen-
 dages ;  for it  has  been  shown that it is the hemorrhage, and the inflam-
 matory symptoms  which follow the child's displacement and subsequent
 sojourn in the cavity of the abdomen, that are  to be particularly dreaded.
   Perhaps the indications for treatment presented under such circumstances
 will  be best  illustrated by supposing the  rupture to take place at three
 different periods of the puerperal state, namely . during the parturition „
during   the latter  months  of gestation;  and  during the  early  stages of
pregnancy.
   1. During  the Labor. — In this case the infant may either remain Avithin
the womb, or it may have been driven out of the uterine cavity.
  a. If the child remains in situ, its extraction, either by the pelvic version 
744
DYSTOCIA.
 or by the forceps, is of course the only admissible  operation.  When the
 forceps are used, it is very important, as M. Dubois remarks, that the child
 should  be fixed in its position  by the hand of an  assistant applied to the
 walls of the abdomen, in  order to prevent its ascending into the peritoneal
 cavity through the fissure.   The  introduction of the blades also demands
 especial care  when the neck is  ruptured transversely, in order to avoid
 passing them  into  the abdomen through the rupture.   But where any ob-
 stacle appertaining to the pelvis or the soft parts opposes its delivery by the
 natural passages, gastrotomy ought certainly to be performed if the infant
 is living and viable, and craniotomy when it is dead, or when it has suffered
 severely from  the slowness of.the labor.
  b. If one part of the child has passed into the abdominal cavity through
 the fissure, Avhile the  other portion of it is still inclosed Avithin the uterus,
 we must endeavor  to  deliver it through the  natural passages, by acting on
 the portion retained  in the Avomb, or Avhich has already engaged in the os
 uteri  or vagina.  But if  the  presenting  part is  high up,  and the hand or
 instruments cannot get a sufficient hold upon it, it will  be necessary to
 search through  the fissure after  the feet, and bring them doAvn into the
 vagina.  But  here another difficulty arises, for the escape of the Avaters and
 a part of the  foetus may  have  determined a contraction of the womb, and
 the lacerated  margins, participating in  this  retraction, may be  found so
 closely applied to the  child's body as to  render a passage of the hand im-
 possible ; under such circumstances, we might follow the example of certain
 accoucheurs, and open a passage by enlarging the Avound in the uterus with
 a cutting instrument, which would be far preferable to  the performance of
 the Caesarean operation.
  c. Supposing  the child has  passed  into the abdominal  cavity, and that
the organ has  not as yet retracted, that the os uteri is sufficiently dilated or
dilatable, and  the uterine fissure is still large enough to  permit the hand
and foetus  to  pass  through, Avhich conditions are  scarcely ever met  Avith
when  the rupture occurs  at the cervix, we ought, as in the preceding  case,
to go after  the feet even  into the  cavity of  the abdomen, and bring them
 back through  the lips of the wound, the neck of the uterus, and  the vagina,
and thus extract the  faetus  by the natural passages.   After this delivery,
the hand should again be introduced into the  uterine cavity, with the three-
fold object of  extracting the after-birth, of determining the contraction of
the organ, and of preventing  the strangulation of a loop  of intestine, if
any portion of the boAvel had engaged in the fissure.
  Should the  placenta have happened to fall into the peritoneal cavity, an
effort  should be  made to extract it without delay, by  a fresh introduction
 of the hand through the rupture.   An attempt should be made at the same
 time to  remove the  clots Avhich had formed in the abdomen.
  When such a manoeuvre is impossible, the only resource is in the Caesa-
 rean operation;  unless, being fearful of the disastrous consequences of this
operation, the  accoucheur should conclude to abandon the  foetus  in the
peritoneal cavity, and alloAV the mother  to  run  all  the dangers to which
 this determination  must nec-ssarily expose her.  If the child's death were
 positively ascertained, the  arrest of the hemorrhage might perhaps authorize 
         RUPTURE OF THE  UT-ERUS AND  OF  THE VAGINA.      74C

 this latter procedure, more especially if he should not see the patient until
 several hours  after the accident; but  it  would never  be excusable if the
 infant Avere living, and if he were not  satisfied that the  uterus, by being
 completely retracted, had obliterated the vessels Avhich furnished the blood;
 for otherwise, gastrotomy should be resorted to at once.
   2. During the Latter Months of Gestation. — Here, likeAvise, the extraction
 of the ovum is the Avisest course  to pursue; indeed, it  is imperiously indi-
 cated Avhen the child is living, and the pregnancy has advanced beyond the
 seventh month; and it may be accomplished by resorting either to gastrot-
 omy, to a forced dilatation of the os uteri, or to incisions  made directly on
 the neck of the Avomb.  The Caesarean operation will be preferred Avhenever
 the foetus is displaced (see  Casarean Operation); but if it is still resident
 in the uterine  cavity, Ave must endeavor  to dilate the  os uteri artificially,
 which Avill generally be feasible when the patient is near term, more especially
 if she  has previously borne several children ; and the  introduction of the
 hand might  likeAvise be facilitated by incising the periphery of the cervix.
 But these attempts ought to be made with  the greatest care, and should they
 offer any serious difficulties, and require too much time, we must renounce
 them at once, and open a passage through  the abdominal Avail.
   3. During the Early  Months of Gestation. — Most of our leading teachers
 advise us to abandon the patient in these cases to the resources of nature, to
 abstain from all operations, and to be content Avith combating the consecu-
 tive symptoms as they arise.  Three new indications are now presented, says
 M. Duparcque, namely: 1.  To  prevent  or arrest  the disorders of  innerva-
 tion, by raising  the  morale  of the Avoman, yvho is  instinctively struck with
 fears and  inquietudes, and  by administering the diffusible antispasmodics
 by the mouth, the skin, or the  respiratory passages; 2.  To combat or pre-
 vent the hemorrhage by abdominal compression, by refrigerants, compression
 of the  aorta, etc. ; and, 3. To prevent  or  combat  the inflammation Avhich
 ordinarily follows  the displacements of  the ovum, by the employment of
 local and general antiph logistics.

                           ARTICLE   II.
                       RUPTURE  OF THE  VAGINA.
  The Avails of the vagina may also be  lacerated during  the labor.  But,
 OAving to the differences that exist, according  to  the portion of the  canal
 these ruptures  may occupy, it has been customary to study separately the
 lacerations at its upper and  lower extremities,  and at its middle part.  In
general, the tAvo latter are of little consequence, or, at least, the dangers and
indications they present  belong rather to the province of the surgeon than
to that of the accoucheur; for, with the exception of thrombus of the vulva,
which may, as has been stated, require the  intervention of art during labor,
all the other lacerations are only unfavorable  to  the Avoinan, inasmuch as
they expose her to vesical or recto-vaginal  fistulas, which do  not claim our
attention here.   On the contrary, the lacerations  that occupy the  superior
extremity of the vulvo-nterine canal require a cursory notice, because they,
like  the ruptures  of the loAver  part of  the uterus, may become causes of 
746
DYSTOC^l.
dystocia.  The lacerations of the upper part of the vagina ma) /esi It either
from traction or from direct  pressure.  The  former may be OAving to the
uterine contraction, to the artificial pressing back of the uterus or present-
ing part  of the  child, and to  every act of the abdominal Avails, and every
movement of the trunk, calculated to elevate  the Avomb.  According to M.
Duparcque, the uterine contraction alone may produce a  transverse lacera-
tion of the vagina in the folloAving manner: the child's head being Avedged
in at the superior strait, or more or less  engaged in the excavation, and
unable to advance any further in consequence of the resistance it encounters,
and the womb still continuing to  contract, the latter withdraAvs itself, as it
were, from the child.  The margins of the orifice are gradually drawn up
toAvards the  fundus of the organ, whereby they get clear of the head in a
great measure,  and  sometimes  altogether.  Whence it  happens  that the
vagina becomes subjected to an active traction, proportioned to the energy
of the uterine pains; and consequently, as it offers only a passive resistance
to the distention and  compression it  undergoes, it is gradually enfeebled,
and ultimately gives way.
  The mode in which the efforts sometimes  made during version for the
purpose of pressing up the presenting part, or for penetrating through the
os uteri by main force, so as to carry the hand towards  the fundus of the
organ, act in the production of these lacerations, is easily understood.   And
this transverse rupture, having once commenced, may extend far enough to
separate  the uterus  almost entirely from the vagina.  Those fissures and
vaginal perforations which result from direct pressure, are ordinarily pro-
duced by an improper application of the forceps, or by the prolonged sojourn
of the  head  at the superior part of the excavation.
  The signs of this rupture, and the accidents  to which it gives rise, are very
similar to those of rupture of the uterus, excepting that they are less intense
and not so dangerous.  The pain is less acute at the time of its occurrence,
being sometimes even confounded with the labor-pain ; and the existence of
a laceration is only suspected, some time after, when searching for  the cause
of the  arrest of the labor. Here, likeAvise, the child may either  preserve
the place it  occupied, or  may pass partially  or wholly into the abdomen.
Most generally there is no displacement Avhen  the head had previously en-
gaged  in  the excavation,  and the rupture has taken place either at the
junction  of the vagina with the cervix or else  at some point above  the head.
Nevertheless, should the laceration be very extensive, the head may remain
fixed in the excavation, while the trunk is carried back into the abdominal
cavity  by the subsequent retreat of the Avomb, the orifice of Avhich, being no
longer  retained  by the vaginal connections, mounts up and retracts towards
the fundus of the organ, thus abandoning the foetus which it cannot expel.
It seldom happens that the whole child escapes into the abdomen, and, when
this does occur,, it always results from pushing up the head during the ill-
directed efforts to effect the delivery.   But, whether this  passage is partial
or complete, it ordinarily takes place in such a Avay that the pelvic extremity
engages first in the lacerated orifice.
  A considerable portion of intestine has sometimes been knoAvn  to escape
through a rupture of the vagina; it is evident that in such cases ieduction 
PUERPERAL  HEMORRHAGE.                 7-17
should be effected as soon  as  possible.   Although  it would seem that this
operation ought not to be attended Avith difficulty, it has occasionally proved
impossible.   Burns quotes from Dr. Kerver a case of rupture of the vagina
complicated Avith  the escape of a portion of intestine an  ell long.   It Avas
impossible  to  reduce  it, and gangrene ensued.  The faeces  passed by the
vagina; but, after some time, were discharged by the anus, and the patient
recovered.
  The prognosis is much less unfavorable than that of uterine ruptures ; be-
cause there is far less danger from the hemorrhage and consecutive inflam-
mations, and, besides, it is always possible to extract the foetus by the natural
passages.
  This extraction through the vagina is, therefore, the only indication Avhich
presents itself.   If the head is not displaced, apply the forceps; but if some
other part presents, the feet should be sought after through the rupture  in
the vagina,  Avhich  it may be necessary to enlarge if too small or too resist-
ing.  The Cesarean operation must not be performed, even should the foetus
have passed completely into the abdominal cavity, unless a contracted pelvis
should render it impossible to extract it through the natural passages.
                         CHAPTER  XI.

                    OF  PUERPERAL HEMORRHAGE.

   Hemorrhage is certainly one of the most frequent and at the same time
 most dangerous accidents that can occur to puerperal  Avomen, whether be-
 fore, during, or after parturition;  for it is most generally fatal to the child
 when it occurs at an early period of the pregnancy, and always subjects the
 mother to the greatest dangers, at whatever period it may come on.  Under
 the double aspect, therefore, of the mother's safety, and  the child's life, it
 constitutes a pathological phenomenon, which should interest every one in
 the highest degree; not only every physician who devotes himself  more
 especially to the practice of midAvifery, but likeAvise all who are engaged in
 the practice of medicine; for any one may be summoned in a time of pressing
 danger, and all may, by ill-directed or proper attentions, compromise or save
 the lives of two beings equally dear.  The importance of the subject, there-
 fore, Avill justify the detail into which Ave propose entering.
   Wc designate as puerperal hemorrhage (or the hemorrhage that occurs in the
 puerperal state)  every hemorrhagic accident that pregnant Avomen may be
 affected Avith, either during gestation or in the course of the labor and lying-
 in ; thus comprising, under this denomination, not only the losses of blood
 that have their source and seat in the genital organs, or in the foetus and its
appendages, but also all the effusions that may take  place into the tissue of
the principal viscera as a consequence of an exaggeration of the modifications
impressed on the general circulation  by pregnancy.   We have  already
treated of hemorrhage occasioned by the  rupture of a varicose vein,  (see
page 487,) also of that Avhich accompanies  abortion, (see Abortion.)   We 
748
DYSTOCIA.
have also devoted a long article  to hemorrhages of the vulva  and vagina,
(see Thrombus of the Vulva and Vagina, page 686.)   Hemorrhage attendant
upon delivery of the placenta, will  be studied in connection Avith the  other
difficulties which complicate its expulsion.  (See the last chapter on Dystocia.)
Here  we shall devote more  particular attention to the discharges which
occur during the last three months of pregnancy, or  during labor, and Avhich
have their  source in the vessels of the uterus, or foetus, or its  appendages.
As to the other hemorrhages, Avhatever be their origin, or the seat of effusion,
they present  the same indications for treatment  in the puerperal  state as at
any other period of life, and  consequently do  not claim our attention here.
For, during the labor, whether the hemorrhage takes place in  the lungs,
the stomach, or the brain, the only thing to be  done is to combat it by the
usual means, if the dilatation of  the os uteri is not  sufficiently advanced to
admit of an artificial termination of the  labor.   But  in the contrary case,
the accoucheur should apply  the  forceps at once, or resort  to version, and
thus relieve the patient as promptly as possible from the danger that threat-
ens her.
                            ARTICLE I.
              OF  THE CAUSES OF UTERINE HEMORRHAGE.
   The causes of uterine hemorrhage have been divided into the predisposing,
the determining, and the  special causes.

   § 1.  Of  the Predisposing Causes.
   We  must place in the front rank of the predisposing causes, all the disor-
ders in the general circulation that are induced  and kept up by pregnancy,
and which are manifested by palpitations of the heart, by obstructed  respi-
ration, varicose SAvellings of the veins of the lower  extremities, and by the
fulness and greater activity of the pulse; but, above all, it is important, in
order to  understand the mode of action of the  causes  described beloAV, to
bear in mind the changes that have occurred  in the structure of the Avomb
itself;  which changes have been studied in detail, when describing the ana-
tomical phenomena of gestation, but  which we again bring fonvard  'n a
summary Avay, for the better illustration of the subject under consideration.
   The mere fact of conception produces a state of orgasm in all the genital
organs, the uterus  particularly, Avhich determines  a considerable afflux to-
wards  these parts.  In some women,  of a  sanguineous temperament,  this
state of irritation is not confined to the hypertrophy of the mucous membrane,
but the development of its  vascular apparatus is attended or followed by an
exhalation of blood, and, in the course of a few  days, a uterine hemorrhage
takes place that seems to be  only a menstrual return, but Avhich, in reality,
interrupts a commencing pregnancy.   In certain cases, this fluxion is not
limited to the uterine vessels;  for, when  very considerable, it causes an
aneurismatic or a varicose swelling in the neighboring parts, such as the ves-
sels of the broad ligaments, which run to the  tube  or ovary.  These trunks
occasionally give way, and produce a mortal hemorrhage, as Ah  Leroy says
he found to be the  case in two Avomen  Avho died  a few days after  marriage.
   During the first month of  its  intra-uterine  life the ovum occupies only a 
PUERPERAL  HEMORRHAGE.
749
very small portion  of the  uterine caA'ity, all the rest being filled Avith the
pouch  formed by the epichorial  decidua and  parietal mucous membrane;
and hence, being free and floating, and having as yet  contracted but feeble
adhesions  with the Avails of the organ, the product of conception can only be
developed  by imbibing the  juices secreted  on the internal surface of the
womb ; (see Nutrition of the Foztus;) which secretion requires a much greater
activity in the circulation of the  uterus, and may  become a cause  of flood-
ing, under the influence of the least disorder.  SomeAvhat later, the  placenta
begins to  be developed, and with it  those numerous vessels Avhich, coming
from the internal surface of the uterus, and the external one of the chorion,
appear, so to speak, to run to meet each  other; then they interlace without
inosculating, and ultimately become  united, forming  a mass that is held
together by a species of flaky lymph, a product of  the uterine secretion.
  Now, avIio  does not see  in this process of vascular organization, in this
copious secretion that is constantly going on, and requiring so much activity
in the circulation of the organ, a  continual  predisposition to hemorrhage?
For, if any vivid moral impression, or any violent  physical commotion, dis-
turbs the harmony that presides over this neAV creation for a single instant,
by causing a derangement in the circulation, the just relations established
between the ovum and the Avomb are at once destroyed ; and the blood, being
forced  too  rapidly into these recently formed  vessels, overcomes the resist-
ance of their feeble Avails, and a flooding results in consequence.
  At a still more advanced  period of the  gestation, when the  placenta  is
organized, the production of hemorrhagic accidents is singularly favored by
tlu; doubic circulation of Avhich it is the seat, by the great development of
the uterine vascular apparatus, and  by  the peculiar structure of the utero-
placental vessels.   Quite recently, M. Jacquemier has carefully studied the
influence of each of these  circumstances, and  the  following summary will
serve to illustrate the results of his inquiries.
  When Ave examine the uterus of a pregnant woman in the  latter periods
of gestation, after having undergone its usual transformations, Ave are struck
with the development of its vascular system ; for the trunks of  the four
arteries that nourish the organ have increased in size, and their divisions or
ramifications in the texture of the womb are wonderfully multiplied.  The
vessels that existed before the impregnation  have  more than doubled  their
calibre, and a great number of others that did not  exist, or rather  were not
visible,  have successively formed, become  enlarged,  and attained a con-
siderable size. We have hitherto mentioned (see  art. Pregnancy) the ex-
traordinary development of the uterine  veins; and it  is only necessary to
recall here the feebleness of their Avails, which are composed of a single coat,
their adhesion to the uterine tissue, and the numerous divisions sent  by them
into the cavity of the organ,  which penetrate directly or indirectly into the
substance of the placenta itself.   It results from this  arrangement that, in
the arterial system of the womb, the blood passes from  trunks of a moderate
size into cavities very numerous  and  spacious  in proportion to the volume
of the  trunks ; which cavities are formed  by the numerous ramifications
given off  from the  latter  in the substance of the uterus;  while, in the
venous apparatus, a much greater disproportion exists between the trunks 
750
DYSTOCIA.
of the uterine and ovarian A^eins and  their branches, so that the blood
passes from very large cavities into narrower tubes.
  This arrangement has been considered by M. Jacquemier as a cause of
the retardation in the uterine circulation, and  as being calculated  to pro-
duce a venous stasis, followed by an engorgement of this system, and, as a
consequence,  the rupture of the  vessels and hemorrhage;  Avhich  venous
rupture is  further  favored  by the want of resistance on the part of the
utero-placental veins.  According to  his vieAV,  all the causes under whose
influence fioodings are found to result, merely act by producing this engorge-
ment of the uterine venous  apparatus; and hence the  immediate cause of
hemorrhage is the rupture of one of the vessels  appertaining thereto.
  But we cannot fully embrace this theory, so  far, at  least, as regards the
hemorrhages  that occur during gestation, for we do  not believe that the
retardation in the circulation is so extensive as M. Jacquemier has described.
Although the blood  arriving by the uterine arteries passes into the larger
cavities constituted originally by the arterial and afterwards by the venous
ramifications (the uterine  sinuses), yet  it seems to us that this  cause  of
delay would be compensated by the rapidity with Avhich the blood contained
in these  venous capillaries must  pass into the trunks where they  empty;
and even by virtue  of that very laAV of hydraulics quoted by M. Jacquemier
in favor of his theory, namely, " When a liquid flows in full stream through
a tube, the quantity of this liquid Avhich, at a given moment, traverses the
different .sections of the tube must everywhere be the  same.   Consequently,
as the tube becom.es  larger, the rapidity diminishes; but  increases as  the tube
becomes smaller."   If, therefore, the course of the blood  is slackened in the
arteries by its passage from the main trunks into the ramifications,  it  must
be accelerated in the veins  by its passage from the ramifications into the
trunks; and hence  there must be a compensation in its rapidity.
  But an infinity of circumstances may destroy this harmony; and Avhich
series of  vessels will then be the  seat of the congestion, and afterwards  of
the rupture ?   M. Jacquemier supposes that some point of the venous system
Avill ahvays yield to the first; for he says, " Every part of the uterine vas-
cular circle is not equally exposed  to this species of rupture ; and the arteries
would even be wholly exempt, unless they were the seat of some morbid lesion.
The utero-placental arteries themselves Avould rarely be a primitive seat of
rupture from  the mere  impetus  of  the blood, although the surrounding
delicate tissue in Avhich they ramify supports them  in  a  much less perfect
manner than the elastic tissue of the womb, and besides is easily torn; but
the utero-placental  veins, from their situation and organization, can afford
but a very moderate resistance, which Avill frequently be overcome."   No
doubt,  the venous  parietes are less resistant than the arterial ones; but
which of the  two has the  greater stress to bear ?  Do not all the causes,
under whose influence the uterine  congestions and subsequent hemorrhages
are produced, act first on the arterial, before being perceptible in the venous
system ?  And is not the plethoric condition first manifested by a fulness
of the  pulse.  M. Jacquemier  supposes that, as the circulation is impeded
in the vena cava inferior, it must determine a reflux of the blood contained
in these vessels; which reflux would be  primarily felt in the uterine veins. 
PUERPERAL  HEMORRHAGE.
751
and then in their ramifications ;  and that this would likewise be favored by
the particular structure of the  uterine veins themselves, which are destitute
of valves.
  This absence  of  valves  must certainly  favor  the  reflux of  the  venous
blood ; and it is possible that, under the influence of  some of the causes
enumerated by this  writer,  a  congestion  and then a venous rupture might
be the primitive phenomena; but Ave  cannot admit  that this is generally
the case in the hemorrhages  that  occur during  gestation.   And Avhilst
acknoAvledging that our friend has rendered an important service to the pro-
fession, by  calling attention to  a particular variety  of mechanism in the
production of uterine hemorrhages, Ave must  persist  in considering his
theory as being only applicable to a small  number of cases.  (See Archives
Generates de Medecine, 1839.)
  I must yet bring  forward another anatomical peculiarity, which, perhaps,
will serve to reconcile tA\ro  conflicting opinions.   It has  been  said by some
persons  that all  uterine hemorrhages proceed from a separation  of the pla-
centa; Avhile others contend that many of them result simply from  an ex-
halation of blood from that portion of the internal surface of the womb not
occupied by the placental insertion.  Doubtless, the floodings that occur
during pregnancy are most frequently caused by a rupture of one or more
of the utero-placental vessels; but it is not to be supposed that this rupture
is the only source  of hemorrhage, for  Ave have  already seen that, in the
early months of gestation,  the ovum only occupied the  uterus in part, all
the rest of its  cavity being filled  with the tumefied   and  very vascular
mucous  membrane,  and that, in consequence of the  greater activity of the
circulation, an exhalation of  blood  might take place from the internal sur-
face of the womb.  (See page 552.)  This fact is unquestionable; but even
after the placenta is completely formed, and the ovum  occupies the whole
cavity of  the  womb, there are still, as  described elseAvhere, some arterial
and  more  particularly some venous radicles foun'd existing  externally to
the placental  mass, that might give rise to a hemorrhage, in Avhich  the
proper utero-placental relations Avould be in no  Avise concerned.
  From the foregoing,  it would appear  that a hemorrhage may take place
during  gestation:  1st, by sanguineous  exhalation  from  torn  capillary
vessels, especially during  the  early stages ; 2d, from a rupture of the veins,
and oftener, of the  utero-placental arteries, properly so called; 3d, from a
rupture  of the veins and  arterioles that  ramify in  the substance of the
decidua  beyond  the placenta.
  Among the anatomical modifications impressed on the uterus by gestation,
the development of  its muscular structure has recently been pointed out by
M. Gendrin as a predisposing cause of hemorrhage.   At the close of preg-
nancy, the womb is  formed  of three evident layers; and  it is the relation of
these three muscular laminae Avith the vascular one that explains, according
to his vieAV, the influence that it has over the production of flooding.
  This triple muscular layer may, under the influence  of various external
or internal  irritants, become affected Avith spasms, Avhtcb produce irregular
contractions in some part of the organ.   He states that such spasmodic con-
tractions are very frequent  after the  third  month, and  that they are often 
752
DYSTOCIA.
noticed after  external, moral, or physical impressions, or the tumultuous
movements of the foetus, or, indeed, when the vitality of the latter has ceased.
The patient first becomes  conscious of it by some peculiar sensations and
movements in the uterine globe; and when the gestation is somewhat more
advanced, the hand, applied on the abdomen, enables us to ascertain  that
the sense of movement felt by the woman is dependent on a real contraction
of the uterine walls;  which give rise to certain irregular elevations, that
slip about and become displaced under the hand by something like a peri-
staltic movement, of which the patient has  always a very distinct percep-
tion.   These contractions frequently accompany  the hemorrhage, sometimes
they precede it, and seem to be the earliest phenomena  that  succeed the
action of the  pathological cause.  Although they may  be  considered as
resulting in the first place from the discharge of blood, and,  possibly, from
the formation of coagula, whose  presence incommodes  and  irritates the
womb; yet, in the  second  place, they must be regarded  as an active cause
in the production of the flooding.
   In fact, it is impossible for any contraction to take place in the external
muscular layer, without modifying the circulation in the subjacent vascular
one; hence, when the vascular plexus of this intra-uterine lamina is irregu-
larly compressed by the muscular contractions of the organ, the t)lood must
flow back into  some part of the placental disk, thereby determining a partial
congestion, which may cause the rupture of one of these feeble venous rami-
fications, and, as a consequence, a sanguineous extravasation.   But the
influence of the  spasmodic  action is not  limited to this;  for, by effecting a
retraction that is confined exclusively to segments of the uterine globe, they
necessarily draw  upon the placental adhesions,  and may perhaps  rupture
them.
   Besides these local  modifications, whose  power to produce  hemorrhage it
is impossible to,deny,  there are still numerous other circumstances  that we
might  point out, which have the same effect.  But, let it suffice to recall the
physiological and pathological changes that gestation impresses on all the
functions, Avhich have  already been studied under the titles of the Physiology
and Pathology of Pregnancy.  Let us remember the almost constant presence
of serous plethora, the habitual fulness of the pulse, flushing of the face, and
increased activity of nutrition and circulation which are manifested in most
plethoric women  during the early months;  also, that  susceptibility which
the least emotion excites and irritates; that delicacy of sensation natural to
most nervous  females, but carried to the  highest degree  in pregnant ones;
and, finally, let us recall the fact that, during the  gravid state, the uterus
is, as it were, the common centre, upon which  all  the general disorder caused
by any moral or physical excitement is directed.  Then we will understand
the reason Avhy most authors have considered a plethoric constitution, a pro-
fuse normal menstruation, and  the lymphatic temperament, which so often
accompanies great  nervous irritability, as  predisposing causes of  puerperal
hemorrhage ; why plethoric females are so often affected with flooding at the
return of the monthly periods, since their habit  determines at these times a
greater activity and a more intense congestion in the womb ; Avhy venereal
excesses have often  been followed by a profuse flooding, by causing a long- 
PUERPERAL  HEMORRHAGE.
753
continued and over-excitation  in  all the  genital organs;  and, lastly, why
every circumstance  calculated  to  determine or to keep  up  an  unusual
activity in the general circulation, and particularly a  more  considerable
afflux of fluids tOAvards the gestatory organ, has been at all  times considered
as predisposing the Avoman to hemorrhage ; such, for instance, as fatigue, the
frequentation  of balls, of plays, and  crowded assemblies, where the  air is
impure and  at a high temperature; prolonged Avatching; overheating diet,
and the  use of alcoholic drinks;  as well as all local irritants, such  as the
abuse of drastic purgatives, Avhich,  by producing excessive irritation of the
intestines, may react on the uterus; hip-baths, the frequent application of
leeches  to the vulva, the existence of any organic alteration,  or an  acute
inflammation in the neighboring organs, or in the womb itself; because all
these circumstances are calculated to maintain an habitual state of conges-
tion toAvard  the womb.

   § 2.  Determining Causes.
   The prolonged  action of the predisposing causes just enumerated may
eventually produce a  hemorrhage;  and thus, after having  acted for a long
time as the predisposing, finally become determining causes.   But  in addi-
tion to these, some other circumstances  have been  enumerated by authors,
which might  be designated as  accidental determining causes.   These are so
numerous and varied that, to exhibit them,  it would be necessary to bring
fonvard nearly all of  the cases  that have ever been published.  Besides, all
these causes may be referred either to acute  moral emotions, or to physical
disturbances ;  for example, to a violent passion ;  the-sudden arrival  of some
unexpected  person or  intelligence; a fit of anger;  sharp bickerings, &c.; to
the jolting of a rough carriage; to riding on horseback ; a fall on the feet or
nates; blows on the abdomen ; efforts to carry or  lift some burden ; to cough,
vomiting, etc., &c, &c.   (See art. Abortion.)
   But  these causes, the list of  Avhich I might have lengthened greatly, do
not all have the same mode of action; for some of them, such as most  of the
moral ones,  act primarily on the whole organism, and  only  react on the
womb secondarily ; Avhile others, like the generality of the  physical causes,
are addressed,  as it were, directly to the gestatory organ, and, by the shock
they communicate, have a tendency to disturb the relations existing between
it and the product of  conception.  It is generally conceded that the former
determine a  more considerable afflux of blood towards the uterus, than an
engorgement of the utero-placental  vessels, and finally the  rupture of those
vessels;  or,  if  the  pregnancy is but little advanced, the afflux of blood is
followed  by a  sanguineous  exhalation  from the  internal surface of the
organ.   But hoAv,  it may be asked, is  the hemorrhage produced  after a
fall, bloAv, or  any physical  commotion whatever,  especially in the  latter
stages of  the gestation ?  And  is the separation of the  placenta, Avhich is
then a very common occurrence,  the primitive phenomenon, and has it caused
a vascular rupture ? Or, indeed, has this rupture taken the precedence, and
has the elf ision of  blood  betAveen the after-birth and the uterus resulting
therefrom produced the  separation of the  placenta?  The latter  opinion
appears tc me  the more probable; for, although there can be no doubt thai
      48 
754
DYSTOCIA.
(he feeble bonds of union which  attach the placenta to the  uterus ma;, be
luptured at once, as a consequence of some very violent shock or fall from
an elevated place, since, under like circumstances, the very substance of the
solid organs, the liver in particular, has been  lacerated, yet this certainly
does not happen in a large majority of cases; because the ovum forms a full
sac, which is in immediate contact with the walls of the cavity that incloses
it, and the placenta is sustained by the waters  and the foetus within and bv
the uterine wall without.  The organ and its contents constitute a whole,
that cannot be separated by any general  concussions unless they are very
severe.  Wherefore, so long  as the  membranes remain  unruptured, it  is
difficult to conceive that the separation could be effected othenvise than by
the effort of the blood to escape into the cavity of the womb.
  In conclusion, although  these physical and  moral  disturbances are enu-
merated by authors as being capable of producing a hemorrhage, it must not
be supposed that they constantly have this unfortunate result; indeed, their
influence is far from being always in proportion to their violence and  inten-
sity.  In  general,  they only act  and  are  followed  by flooding,  because a
predisposition exists in the  patient which the determining cause excites and
brings into play.   I might  mention individuals in whom  the least excite-
ment  has been followed by a hemorrhage  that proved fatal to the  foetus,
whilst others have borne the most severe moral disturbances Avithout acci-
dent ; and several  cases were cited in  the  article on Abortion, which prove
that the most violent physical shocks oftentimes give rise  to no disorder
whatever.   We  must, therefore, admit the intervention of  a predisposing
cause in the majority of cases; a cause which often, indeed, plays  the most
important part in the production of the accident.

  § 3. Special Causes.
  Independently of the general causes just studied, there  are some  which
might be termed special causes, because they depend on certain peculiarities
in the position and structure of the ovum ; and the influence of which is
particularly apt to be felt at an advanced stage of gestation.  We allude to
an abnormal insertion of the placenta, to a rupture of the umbilical  cord,
and to some other peculiarities about to be mentioned.
  1. Insertion of the Placenta upon the Lower Segment of the Uterus.—Nearly
all the older authors detail  cases in which the  placenta was  found inserted
over the neck of the womb  at the time of labor.   But some of  them alto-
gether  misunderstood  the cause of this  disposition, and supposed that the
placenta had been detached  in totality from the point Avhere it was originally
inserted, and had fallen from mere gravity on the neck of the womb; Avhile
others, who had observed it to be still adherent by one margin to some point of
the periphery of the cervix, concluded that this  adhesion Avas only accidental
and merely occasioned by the clotted blood ; which, says Deventer, sometimes
glues the placenta so closely to the orifice that it  might be taken for an excres-
cence of the part.   There were others, again, who had noted the fact with
much care, without attempting to give any explanation of  it; Levret Avas
amang the first  to  direct attention  to this important point, for he demon-
strated its  Vequency and danger, and studied the causes and proper method) 
PUERPERAL  HEMORRHAGE.
755
  )f detecting it.   HoAvever, this abnormal insertion had oeen pointed out long
  before the time of Levret: for Giffart, in  narrating a case of hemorrhage,
  wrote, in 1730: " 1 cannot receive as  absolutely true the opinion of those
  authors Avho say that the placenta is always attached to the fundus uteri, for
  in this case, as in many others, I have every reason to believe that it adhered
  on the internal orifice, or very near to it; and that, in dilating, the latter occa-
  sioned the separation of the after-birth, and  as  a consequence the hemor-
  rhage."   (Observ., 115 et 116.)  Heister (Institutiones Chirurgicales, chap.
  cliv. part i.) likeAvise says:  " Some moderns think that the adhesion of the
  placenta over  the  neck is  a cause of hemorrhage; and, therefore, that the
  more the  os uteri dilates  the more abundant  is the flooding."   Finally,
  we find in Portal's work, Avhich appeared in 1685, observations Avhich show
  conclusively that he is entitled to the  honor of having  first described this
  faulty insertion.   In six of his cases, the placenta presented,  was in entire
  contact with the orifice of  the womb, and  was  adherent throughout.   The
  author even  endeavors to show how the hemorrhage occurs in these cases,
  giving the explanation which Avas afterwards  accepted by Levret and many
  others.
    As we detailed the various circumstances, when studying .the anatomy of
  the placenta, which, according to most authors, determine the point of attach-
  ment of this vascular mass, it  will be  unnecessary to revert to them  here.
  We would merely observe  that the  placenta  has various relations Avith the
  orifice, giving rise  to several grades or varieties of faulty insertion.   Thus,
  the placenta may be inserted near the orifice or on  the orifice, covering  it
  entirely or in part.  These various insertions have received different names,
  as, marginal, Avhen the placenta extends very  near the circumference of the
  orifice; incomplete or partial, Avhen it covers it only in part; complete or cen-
  tral, Avhen it covers it entirely; and, finally, Ave have the term intra-cervical
  insertion Avhen, as  seems to be proved  by some cases of Madame  Lacha-
  pelle's, the ovum has  happened to insert.itself in the cavity of  the  neck
  itself.  Further observations are,  however,  required  to establish the latter
  as a true variety.
    [According to Dr. Sirelius, the placenta undergoes important changes in form
  whenever it  happens to  be attached over the  mouth of the  womb.  Sometimes,
  though rarely, it is spread out in a membraniform layer over almost the entire
  surface of the chorion (membranous placenta); at other times there are  two sepa-
  rate placentas, one large and the other small ; but most commonly it is imperfectly
  divided by a fissure extending from  the  free edge to its middle, giving it a horse-
  shoe  form.  In the two latter cases the fissure, which either completely divides the
  placenta or leaves it in the form of a crescent, is occasioned by obliteration of the
  villi of the chorion, and ahvays corresponds to the internal orifice of the  uterus.
» This  remark in reference  to the pathological anatomy of the case may have a prac-
  tical  application in regard to the treatment.]

   The insertion of the placenta over the os uteri  has been considered, since
  the days of Levret, as an inevitable cause of hemorrhage during the last
  three months of gestation, and in the course of the parturition.  The flood-
  ing, then, says Gardieu, is an immediate result of the gestation, and particu*
  larly of the  labe" \  Most modern writers, supposing  that the modifications 
756
DYSTOCIA.
occasioned by pregnancy in the disposition of the neck towards tl e latter
months are the sole cause of the hemorrhages that then occur, have adopted
the same opinion ; and the folloAving, in their vieAv, is the mechanism Avhereby
the discharge is produced.   Up to  the  fifth month, the body of the womb
undergoes numerous changes, but after that period, the neck is also involved
and  participates therein.   (See Pregnancy.)  The diminution in its length
is accompanied by a more  considerable enlargement of its base on a level
with the internal orifice.  The placenta, being fixed and immovable on the
spot  where it is implanted, cannot folloAV.this spreading out of the  upper
part  of the neck, and hence the bonds of union which  it has contracted Avith
the womb necessarily become ruptured, as do also the utero-placental vessels;
and this rupture produces a more or less considerable discharge.
  But it is only necessary to recall what Avas stated in the article on Preg-
nancy, to  be convinced that this  explanation, which  is founded on a false,
though hitherto admitted fact,  ought to be rejected; since it is at the lower
part  of the neck, at least  in Avomen who have  previously borne  children,
that  the eversion of its cavity commences; and, in  all, the  internal orifice
often remains closed until the last few weeks of gestation.   The neck, there-
fore, does  not spread out at its  superior part, and, consequently, we are  not
to search there for the cause that produces  the hemorrhage, when the pla-
centa is inserted over the cervix.  The folloAving explanation, by M. Jacque-
mier, appears to me more plausible:   During the first  six  months of
gestation the uterus is developed more especially at the expense of the fibres
of the superior part of the body or fundus of the organ;  while in the last
three months, the fibres appertaining to the loAver third of the womb  are
developed in a rapid manner, and the  cavity of the  organ  is enlarged in
consequence of the distention and growth of this loAver  part; a proof of Avhich
is, that the body of the uterus,  which was pyriform in the  earlier months,
is  perfectly ovoidal in shape  toAvards the close of pregnancy ; and  I will
further remark, that the development of the placenta is far more rapid in
the first six than in the last three months.   Noav, this double circumstance
seems to me quite sufficient to  account  for the production of hemorrhage;
for Avhen the placenta is attached to the fundus,  its growth is simultaneous
with the enlargement of that portion of the uterine walls on which it is  im-
planted, and it is evident that  no hemorrhage need  occur; but Avhen  the
after-birth is inserted over  the cervix  uteri, or on some adjacent point,  the
contrary must necessarily ensue, because the groAvth of the placenta is nearly
completed, Avhilst a more  considerable  extension of the lower third of the
womb  has yet to take place.  Of course, the placenta can no longer partici-
pate in this rapid development, by conforming to the increase of the uterus,
and  by following the extension of the wall on which it is inserted; and hence
it spreads out from the centre toAvards its circumference, the fissures between
the cotyledons become larger, and its  different lobes are thus widely sepa-
rated ; but the growth of the inferior Avail of  the uterus  is so rapid in the
latter months, that this  mechanical enlargement of the  placenta, on which
M. Jacquemier has particularly insisted, is no longer sufficient to prevent
the tension of the utero-placental vessels, or of the cellular tissue in which
they ramify; and this tension being ultimately carried to  an extreme, all 
PUERPERAL  HEMORRHAGE.
757
>)f these cellulo-vascular adhesions give way and become ruptured, and thus
give rise to the production of hemorrhage.   If this be the true explanation,
there is no necessity for invoking a diminution in  the length, and a spread-
ing out of the upper part of the neck, which really does not take place.  By
it we can also comprehend the possibility of a circumstance  that is inexpli-
cable  under the theory generally received,— I  allude  to the  hemorrhages
that occur Avhen the placenta k attached to the lower part of the Avomb, or
some point adjacent to the internal orifice;  for it is  not because the  after-
birth is  implanted over the  cervix  that a flooding  takes place during  the
latter months of pregnancy, but  because  it is in relation with the inferior
third of the uterus.
  The explanation usually given is true only Avith regard to those san-
guineous discharges that come on in the latter weeks of gestation or during
the parturition ; for then, the spreading out of the cervix uteri, and its com-
plete effacement, must necessarily have a great influence over the production
and profuseness of the flooding,  in those  cases where  some point of the cir-
cumference of the placenta is in immediate relation Avith the neck; but still
more especially in  those Avhere the insertion takes  place, as it is said, centre
for centre.
  The hemorrhages of Avhich we are speaking occur, besides, most frequently
in the latter weeks or during the labor.
  Although a hemorrhage is usually considered to be inevitable under such
circumstances, yet  it may not appear even during the labor; and the dilata-
tion of the os uteri may be effected without the loss of a drop of blood.  This
absence of discharge is doubtless a rare circumstance; but  its authenticity
at the present day  is Avell established by numerous cases; authors only differ-
ing as to the explanation given of it.  Thus Walter  supposes  that in cases
of this kind there  is  probably a  larger  and  more easy communication  be-
tAveen the venous and  arterial  radicles of the uterus than  usual, whereby
the blood may pass from the arteries into the veins Avithout escaping exter-
nally ; and M. Mercier imagines that the exhalant vessels of the Avomb  are
then in  a state of constriction,  of perversion of their sensibility, which is
sufficient to retard the course  of the blood ; but  these two explanations
appear to me inadmissible.   M. Moreau remarks that, in the reported  cases,
the children were dead, and perhaps had been so for several days; now, says
he, as soon as the infant dies in the Avomb, the cessation  of the foetal circula-
tion occasions changes in that organ ; the blood being arrested in the vessels,
coagulates there; the latter retract, or even become obliterated, and no more
blood reaches the  womb than what  is necessary to its nutrition, since  the
stimulus that heretofore determined a greater quantity  to it, no longer
exists; and hence the  dilatation of the orifice may be effected Avithout hem-
orrhage, notwithstanding the vessels  are torn that united its borders to  the
placenta.  It seems to me that, in spite of objections raised against it, this
view is correct, at least as regards some cases.  In others, it may be as  M.
Jacquemier remarks, that the accomplishment of the delivery Avithout acci-
dent is due either to the entire separation of the placenta, or to its  detach-
ment on one side only to a  point just beyond the uterine orifice; so that  the
dilatation can progress Avithout increasing  the detachment; the vessels pre- 
758
DYSTOCIA.
viously. torn  having  been  stopped by  coagulated  blood.   Thus Ave may
account for cases in which hemorrhage had occurred several times  during
pregnancy,  Avithout reappearing at the time of labor.
  Lastly, if the rupture of the membranes should occur at the commence-
ment of labor, it  is possible that the uterine retraction Avhich  would natu-
rally follow a discharge of  the waters, and the  compression  that Avould be
made by the head on the part left uncovered by the separation of the pla-
centa, might  entirely obliterate the  lacerated \-essels, and thus put  an end
to the hemorrhage; and yet the foetus be living.
  2. Rupture of the Cord, or one  of its Vessels. — It is noAV an  incontrover-
tible fact that  a  rupture of the umbilical vessels, or of the omphalo-pla-
cental trunk  itself, may take place; and, inexplicable  as it may seem, it
can  no longer be called in  question,  since it has been successively observed
by such men  as Delamotte, Levret,  Baudelocque, Naegele, &c.  This rup-
ture, and the hemorrhage to which  it inevitably gives rise, may be occa-
sioned either  by  some  disease  of  the  vascular tunics,  by a  particular
arrangement  of the vessels of the  cord, or by a brevity of the latter,
whether  this  be natural  or dependent  on numerous turns made  around
different parts of the foetus.
  A.  " The umbilical vessels," says M. Velpeau, " are sometimes ruptured:
I am in possession of several examples  of the kind; but it is because they
were previously in a diseased state."  In a  case reported by M. Deneaux,
the blood escaped through the umbilical  vein, Avhich was varicose at  several
points.  The subjoined curious instance,  which I reported in my Inaugural
Thesis, might probably be  attributed to a state of disease in the ramifica-
tions of the vessels of the cord; in this case,  the hemorrhage occurred
between  the  chorion  and the foetal surface of the placenta, in  consequence
of a rupture of all the ramifications of  the  umbilical vessels.   This case,
which I believe is unique, and hitherto but little knoAvn, has generally been
misinterpreted by those aaIio have  referred to it, and  I therefore  feel justified
in republishing it  here.J  I must confess,  that it is not without some hesi-
  1 Rocques-Marie-Joseph Herce, aged twenty-nine years, pregnant for  the fifth time,
and advanced to the seventh month of  gestation, was brought to the Hotel-Dieu on  the
fifth  of May, at midnight.  The midwife  that accompanied her informed us  that  she
had had sharp pains since five o'clock in the evening.  The patient appeared much
enfeebled ; her face was pale  and slightly jaundiced ; and this debility had been
caused, the midwife further told us, by a  hemorrhage that had  lasted since the fourth
month of pregnancy.  The flooding had  considerably increased from the moment  the
pains began; and it was owing, added the attendant, to an implantation of  the pla-
centa over  the os uteri.  The patient was placed in the ward of Saint-Benjamin, where
we made a vaginal examination, the result of  which was as follows: The os uteri was
dilated to  the  size of a  five-franc*piece,  and the cervix was soft, wholly effaced, and
did  not contract  at all.  The  finger,  having been introduced into the uterine orifice,
detected a hard,  resistant, ovoid  body, which we recognized as the foetal head in the
first  position.  No  soft  body whatever was interposed between  our finger  and  the
cranial teguments, and we concluded that, if the placenta were inserted  over the neck,
it was  not at least by its centre.  By carrying  the semi-flexed finger  around the in-
ternal periphery of the neck, we endeavored to ascertain whether the^ after-birth Avaa
not attached to one of the lips of the orifice; but as we found nothing of the kind,  th«
error of the midwife was manifest, and  though unable to determine the cause of  the hem- 
PUERPERAL  HEMORRHAGE.
759
ration that I attribute the  flooding, in this instance, to a previous disease
and rupture of the  umbilical vessels.   For, might not  such a rupture be

orrhage. we did not hesitate to reject her opinion.  The finger being still in the orifice,
we felt the womb  contracting moderately, in consequence, probably, of the irritation
produced by the touch.  The hemorrhage was arrested, the head engaged at the supe-
rior strait, and the patient, though feeble, still retained a sufficient degree of strength
to second the efforts  of nature.  We thought there was nothing further to be done
than to encourage the woman about  her condition, and to  persuade  her to aid the
uterine contractions that  began to be developed quite strongly, as much as possible.
In fact, the  labor advanced very well, without a return of the hemorrhage, and at
four o'clock in the morning she was delivered of a dead child of  seven  months, which
was pale and colorless, but  exhibited no signs of putrefaction.  Its delivery was fol-
lowed by the expulsion of three  large clots of blood, each of which was as big as the
fist; but the flooding was not again renewed.   The  cord was  about the usual length,
and there was no circulation in it;  but we were  not a little surprised, after having cut
it, to find that it was no longer attached to the mother ; but that it exhibited, on what
should have been  the placental extremity, a kind of membrane, in the centre of which
it seemed to  be implanted.   The membrane was  nearly as large as an ordinary pla-
centa, and was evidently continuous with the debris of the bag of waters ; and we at
first supposed it to be one of those membranous placentas spoken of by authors.   This
view appeared the more  probable, as some vessels, evidently arising  from the termi-
nation of the cord, ramified  in its substance.   We then thought the  opinion of the
midwife  might possibly be correct, as the want of thickness  in the placenta  might
have  prevented us from recognizing  it.  AVhen we  returned to the patient, at eight
o'clock in the morning, we found her doing very well: but what was our astonishment,
when  the nurse brought forward a placenta, which the woman had expelled after our
departure!   Thenceforth all  our suppositions were groundless,  and it  was necessary
to resort  to  an examination of the pieces for a better explanation of the phenomena
offered by  this patient.   The following was the result, as all the  members of the
Anatomical Society have since been enabled to verify :  The uterine face of the placenta
was smooth and normal, but its foetal surface was entirely deprived of  the portion of
chorion that ought to cover it, and was irregular,  nodulated,  and clearly exhibited the
anfractuosities  that separate  the cotyledons.  It was covered over by thick clots,  and
the debris of the  torn and  separated vessels that  ordinarily ramify  on  its surface
could  readily be detected; the loose extremity of some of these vessels was an inch
long.   By a  further careful  examination of that  portion of  the  pouch  hanging  to the
cord, which we had taken for a membranous  placenta, we were enabled to detect on
the surface that covered the after-birth,  some vascular debris, which had been contin-
uous with those observed  on the foetal surface of the placental mass.  The cavity of
these  vessels was patulous, and some were obstructed by fibrous coagula of recent
formation.   The principal divisions were intact and permeable to the blood.
  From that  examination, we felt authorized to conclude: 1. That the placenta was
not inserted  over  the neck; 2. That the hemorrhage was not produced by a detach-
ment of the  uterine surface of the after-birth ;  but that it resulted from a separation
of that portion of the  bag of waters  that was  attached  to the after-birth ;  that this
separation was effected at first on some point of the foetal surface of the placenta, then
over a greater extent, and  finally  separating  this  mass altogether from the foetal
envelopes; 3. That, becoming more and more considerable, this separation had pro-
duced a gradual increase of the hemorrhage ;  and it was only  when the detachment
had been  completed, and the bleeding had  become excessive, and all communication
being interrupted  between the mother and child, that the pains were manifested,  and
the  abortion .took place.  This examination likewise enabled us to account for the
cessation of  hemorrhage from the time of the patient's arrival at the hospital, as also
for Ihe quantity of coagulated blood that escaped after the delivery of the child.   In
fact, as soon as we touched the woman at the time of her entrance, the head began to 
760                             DYSTOCIA.
consecutive to  an effusion of blood proceeding from one  of the utero-pla-
cental vessels, the  ramifications of Avhich, as elseAvhere  demonstrated, get
beneath the membranes that  cover the placenta ?   This effusion would have
produced a  separation of the chorion, and then  a rupture of the umbilical
vessels.  The profuseness, and the return  of  the hemorrhage, and the con-
tinuance of the child's life  up to the commencement of the labor, Avould
certainly be more  easily explained by this  latter hypothesis than by the
former.  An attempt has  been made to misconstrue this case since its first
publication; and it has been said that numerous loops of the cord probably
existed, or  else that some artificial tractions had been made upon it; but
I can affirm that nothing of the kind took  place, and that the circumstance
occurred just as I have described it.
   B. The abnormal distribution of the umbilical vessels, Avhich was pointed
out in the description of  the cord, may also produce a hemorrhage fatal  to
the foetus, during the parturition.  The subjoined  case,  described by M.
Benckiser as occurring at the clinique of M. Naegele, can  leave no doubt on
this point.1

engage in the pelvic excavation,  thus acting the  part of a tampon and preventing an
external discharge; but the blood did not the less continue to escape and to accumu-
late internally, thus giving rise to the formation of coagula, and their discharge after
the delivery.
  1 A countrywoman, ab»ut twenty-six years of age, was admitted into the hospital in
November, 1830.  Her  labor commenced on the seventh of  December at noon; by
three o'clock the os uteri was dilated to the extent  of an inch, and the tumor formed
by the bag of waters  could readily be  felt.  While exploring with the finger, an ab-
normal cord, about the size of a writing-quill, was detected in  the substance of the
membranes, running  from behind  forwards, and exhibiting no pulsation.  After the
rupture of the bag, the waters escaped, and were followed by a few drops of blood.
The head was found in  the excavation in the first position, and it then appeared that
a fold of the cord had become placed between it and the right sacro-iliac  symphysis;
but a very feeble  pulsation could be distinguished in  it, and  attempts to push  it up
were made to no  purpose.  As the labor was  progressing actively, Professor  Naegele
terminated the labor by the forceps.  When the right blade was applied, a large quan-
tity of  water mixed with blood came away; indeed, this latter fluid had not ceased to
flow during the four hours that elapsed between the rupture of the sac  and the ter-
mination of the labor, and the patient must have  lost six or eight ounces of it; the
delivery of the placenta took place half an hour afterwards.  The child,  though pale
and colorless, still presented some evidences of life, but it died in the course, of a few
minutes; it weighed six pounds  and a quarter.   At the autopsy, the foetus exhibited
signs of amemia,  and everything evinced  that  its  death had  b ;en caused by hemor-
rhage.   An examination of the after-birth discovered the source of the bleeding; the
placenta had its usual form and texture, but the membranes were somewhat thicker
and more dense,  and  their laceration was just sufficient to permit the child's escape;
the umbilical cord was  attached  to the membranes  at a.bout two  inches from the pla-
cental border ; and, starting  from this point, the vessels  of the cord were  no longer
held together, but they separated and ramified in different directions  on the mem-
branes ; and then, after these divers ramifications  of the arteries  and vein had run
over their internal surfaces for  a more or less considerable extent (though variable
for each, from two inches up to ten), they entered the  placenta, some  at its centre,
but the greater number by its margin.
   The  author of the thesis alluded to, carefully describes the course and disposition
of these various branches ; but,  as  the limits of this work do not permit me to give
his description in da ,ail, I will only quote the principal points.  The first branch aria 
PUERPERAL  HEMORRHAGE.
76!
  c. The shortness of the cord may prove a cause of its laceration, not only
after the rupture of the membranes, but even before  the commencement of
the labor and the discharge of the waters ;  and thus produce that variety of
hemorrhage Avhich  has  been  designated  as  the  intra-amniotic.   I repeat
again, that I am umvilling to reject any fact,  hoAvever extraordinary it may
be, Avhen it is advanced  by experienced and conscientious observers, who

ing from the division of the umbilical vein at the point of its insertion in  the mem-
branes, ran towards the right, traversed  a considerable portion of their internal  sur-
face, and was ultimately prolonged to the opposite border of  the placenta; the rupture
of the membranes took place just in this route at its most distant point from the pla-
centa, and this had necessarily produced a rupture of the venous trunk just described;
and to it, without any doubt, must be referred the flooding that occasioned the child's
death, as proved by the autopsy.   The mere descent of the  cord could have no influ-
ence on its death; for, in cases dependent on that cause, the  opening of the dead body
exhibits the symptoms of congestion.
  Dr. Panis, Professor of Midwifery in the Medical School of Reims, has kindly fur-
nished me with  a similar case:
  "Madame H----. of Reims, thirty-six years of  age,  has had four children ; her
labors were fortunate, and the children  were large and living.  I was called to her in
her fifth labor about six o'clock on the morning of the 17th of January last.  I learned,
on my arrival, that  the waters were  discharged at five  o'clock, and that they Avere
accompanied with blood.  The motions of the child were felt  the day before until even-
ing.  Mad. H----had slept all  night, and was only awakened by the  rupture of the
membranes.   On examination I found the vertex in the  left posterior occipito-iliac
position, and the os uteri dilated to the extent, of an inch and a quarter.  At first, the
labor advanced regularly though rather slowly; blood  continued to flow, though in
small quantity, and at ten a. m., Mad. H----was delivered of a dead child, which was
disengaged in an anterior position.
  "Being surprised at the death of the child, whose face was but slightly colored and
its development perfect, and whose motions had  ceased to be felt only at tlie time the
mother fell asleep, I sought for the cause of the accident, and found it in the umbilical
cord as soon as  I had extracted  the  placenta.  The cord was, in fact, inserted upon
the membranes, at the distance of about three inches from the placenta.  The vessels
composing it were  separated, and, after traversing the membranes, entered the cir-
cumference of the placenta.   One of these vessels belonging to the umbilical vein, was
ruptured at the distance of about an  inch and a quarter from its insertion in the pla-
centa, precisely at the spot where the membranes  themselves had  been torn.  I im-
mediately concluded that death had  been caused by the hemorrhage  following the
rupture  of the vein.  It also  explained why the discharge of blood had occurred ai
the  instant the  membrane gave way.  I have preserved the specimen,  which will be
placed in the Museum of the Medical School of Reims."
  Although cases of this kind are very rare, they may nevertheless occur again, since
this disposition of  the vessels in the cord has already been  reported quite a number
of times; but it can only endanger the child when the rupture of the sac takes place
in the course of one of the venous or arterial ramifications.  Where the vascular trunk
exists on the portion of the membranes engaged  in the os uteri,  as  in the case under
consideration, we might anticipate the consequences ; but what measures should then
be employed to prevent the flooding ?  It would appear to us advisable to retard the
rupture of the membranes as  much as possible, if they be still whole, and to termi-
nate the labor immediately after their rupture. In the former case, the os uteri should
be permitted to dilate sufficiently; but  in the latter, an  attempt ought to be made to
terminate the labor before the discharge  has been profuse enough to  cause the infant's
death.  These measures would evidently  be more urgent if, instead of a venous trunk
without pulsation, it should be an arterial one, recognizable  by its throbbing, which,
from its position on the membranes, was threatened  with laceration. 
762
DYSTOCIA.
 declare they have taken every precaution to avoid all sources of eiroi , con-
 sequently, I admit that this  rupture may take place, Madame Lachapelle
 and  Boivin,  and M. Velpeau, to the contrary notAvithstanding.   In such
 cases, the rupture has doubtless  been favored  by an abnormal weakness in
 the vascular walls, and by the diminished resistance of the sheath that sur-
 rounds the vessels; but it may be more particularly attributed to the ten-
 sions on the cord itself, that  are  probably produced  before the membranes
 give  way, by the immoderate movements of the foetus; which movements
 are probably excited  by the  annoyance that the turns of the cord occasion
 it.   After the  discharge of  the  Avaters, and during the  expulsion of  the
 child, the shortened cord becomes stretched, and its tension augments as the
 head  approaches the vulva ; Avhen, as a general  rule, its rupture  alone can
 permit the expulsion to be effected.1
   According to most  accoucheurs, this unusual  shortness  of  the cord may
 give  rise to flooding by determining a premature detachment of the placenta.
 But it appears to me that such a separation can scarcely occur from a mere
 dragging on the cord, because, during the uterine contraction, the placenta
 is  strongly pressed by the womb externally, and by the  amniotic liquid
 internally, or, still more, after the escape of the  waters, by the body of  the
 child.  Noav, these  parts must evidently react on the foetal  surface of  the
 after-birth Avith all the force of impulsion communicated by the contraction;
 of  course, the foetus can only  advance, and,  consequently, the  tension of  the
 cord  can only take  place  under the  influence of this contraction; and I
 repeat that, Avhile it lasts, the placenta is moulded on and forcibly pressed
 against  the parts contained within  the  sac, and, of necessity, cannot be
 separated  from  the  Avomb.  I believe, therefore, that a separation of  the
 placenta  from a tension of the cord is almost impossible  during the con-
 tinuance of  the contraction ;  but it may take place before or during  the
 labor, and prior to the  escape of the waters, if the cord be very short and
 the movements of the foetus are very active.  As to those cases, in Avhich
 it is commonly said  the child is born Avith a caul, that is, where  the head
 pushes the membranes before it, it may happen that the dragging to Avhich
 these latter  are subjected, being communicated  to the  placenta, may occa-
 sion  its premature separation and give rise to uterine  hemorrhage; more
 particularly where this body is not attached  directly to the fundus of  the
 organ.

   § 3. Rapid Contraction of  the  Uterus.
   Sudden and rapid contraction of  the Avomb may likeAvise produce a
■ disastrous -hemorrhage, by destroying the  cellulo-vascular attachments of
 the placenta;  for this contraction, which, when restricted to proper limits,
 is a physiological  condition  of labor, becomes  a  cause of premature sep-
 aration of the  placenta, when it takes  place too rapidly or at too early a

  1 For further details relative  to the rupture of the cord, see the observations jf
 Portal, Pratique des Accouchements. p.  257 ; Lamotte, Traite des Accouchements, p. 362;
 Levret, Accouchements Laborieux,  p. 199; Baudelocque, Recueil Per.odigue de la Sociitidt
 Medecine de Paris, t. iii., p. 1; Nsegele,  Annates Cliniques d'Heidelberg, 1826; and of
 Busch, Siebold's Journal, ann. 1828. 
PUERPERAL  HEMORRHAGE.
763
period of the travail.  This is apt to occur in cases of dropsy of the amnios,
where a large quantity of the waters  escapes at once; for the uterus  then
passes from an enormous bulk to a much more circumscribed volume than
Avhat comports Avith the dimensions of the foetus on which it is applied.  It
likeAvise happens after the expulsion of the first child in twin pregnancies;
for the contraction that folloAvs this process may, by separating the placenta
appertaining to the other twin, cause a flooding that might prove fatal to
both mother  and child, if  a long interval should elapse betAveen the two
deliveries.
  The hemorrhages that so often complicate a rupture of the buly or neck
of the womb, and  those which  constitute the thrombus of the vulva  and
vagina, have  already been  considered in separate articles, and Ave shall not
again revert to them here.

                          ARTICLE  II.
                SYMPTOMS of  uterine hemorrhage.
  The  symptoms of uterine hemorrhage may be divided into general and
local.
  1. General Symptoms. — In some cases,  the flooding  commences in so
sudden and rapid a manner that the discharge of blood is the  first symptom
manifested ; this is more apt to occur in those instances where the  hemor-
rhage folloAvs  the violent action of some external  cause.  Most  generally,
the woman experiences, during  the feAV days  preceding  the accident,  some
uneasiness in her limbs, a general and unusual malaise, a sensation of Aveight
and of numbness in the pelvis, and a dull and obscure pain in the loins, in
the upper part of  the thighs and groins, which is augmented by the erect
position, by strainings at stool, and by the  act of urinating;  and, in many
cases, there is a constant desire to pass the urine.   These phenomena, which
are characteristic of  a local uterine  congestion, are accompanied by the
symptoms of general plethora ; that is to say, by pains in the head, vertigo,
dimness of vision, flushing of the face, and by frequency and  fulness of the
pulse.  After  these general disorders have lasted some days, it is not unusual
for  the  active movements of the foetus to die aAvay, and  to become very
feeble, or, perhaps, not at all perceptible to the patient.   After the lapse of
some  time, varying from a feAV hours to several days, these precursory
phenomena give Avay to the general  symptoms of hemorrhage,  which are
the same as  accompany every loss of  blood: namely,  pallor of the  skin,
feebleness of the pulse, and coldness  of the extremities; the intensity of
which, it is needless to add, varies according to the abundance and rapidity
of the flooding, the strength of the woman, &c, eVe.
  2. local Symptoms.—With regard to the local symptoms that characterize
its existence,  uterine hemorrhage has been divided into the external and
the  internal.  The flooding  is called  external, Avhen the blood flows to the
exterior, ami  internal, when it is effused  into the cavity of the organ; but
we shall hereafter see that it may be both external and internal at the same
time.
  A. External Flooding.—A discharge  of blood externally is of  itself a
sufficient sign of hemorrhage during  pregna*ncy or pari urition;  but  there 
761
DYSTOCIA.
are certain  peculiarities dependent on the various causes indicated  above
that demand attention, and which will  be pointed out  in detail in the fol-
lowing article.   (See Diagnosis.)
  B. Internal Flooding.—An internal discharge may take place, during the
earlier months of pregnancy, and yet may escape detection ; if, however, the
amount of blood should be considerable, the clot formed by its coagulation
constitutes a foreign body, Avhose  presence excites colicky gripings  and
pains in the loins, and a feeling of weight about the fundament; and these
symptoms obstinately  persist until a  miscarriage  takes  place.   Besides
which, as M. Baudelocque  remarks,  there  are some  instances where  the
symptoms of occult  hemorrhage  are  either  preceded, accompanied, or fob
loAved by an external  discharge of blood.  In the former case, the blood,
finding a free issue outwardly, continues to escape until its further passage
is prevented by the formation of a coagulum, Avhich forces it to accumulate
internally;  in the latter, the effusion of blood  into the cavity constantly
goes on, until it reaches the orifice of the womb by gradually separating the
membranes;  while, in the third case, an external discharge will accompany
the occult hemorrhage Avhenever one part of the blood has a free issue, but
the other collects in the cavity of the organ.
  At an advanced stage of the gestation, Avhen the hemorrhage is more pro-
fuse, we must add to the precursory signs before mentioned  a considerable
and rapid development of the  belly, and a greater resistance, tension, and
hardness of the uterus than usual; sometimes even  it presents a very irregular
form, seeming to be divided  into two parts, one of which is occupied by the
ovum, and the other  by the effused blood;  and  most generally the active
movements  of  the  foetus disappear.   In some feAV cases,  a well-marked
fluctuation has been detected.
  Finally, when  the flooding is first manifested in the course of the labor,
the interval  of each pain is characterized by the escape of clots of blood in
greater or less profusion.  This discharge of  coagula can be explained by
the fact that, during the interval, the child's head does not seal up the neck
hermetically, and thus  its orifice is left comparatively free, and the blood is
permitted to escape.
  Seat of the Effusion. — The point at Avhich the accumulation of blood takes
place in those internal hemorrhages that come on at  an advanced period of
gestation must necessarily vary, according to the part of the utero-foetal vas-
cular apparatus  Avhich  has been the source of the  flooding.  For instance: —
  1. The  blood  may be primarily effused between the uterine  face of  the
placenta and the corresponding uterine  wall; as the discharge progresses, it
ordinarily dissects off the placenta towards some  one point of its circumfer-
ence, and is  then effused all  round the ovum, by displacing the membranes.
But it may also happen  that  the whole placental circumference remains
adherent to  the Avomb, Avhilst  its  central portion is entirely detached, the
effusion being limited by the margins of this  mass ; and the hemorrhage may
be copious enough in such instances to kill the patient promptly, as the case
of Laforterie (whatever may be said of it) fully proves.
  The reader will likeAvise find, in the New Medical and Physical Journal,
(1813 No. 38, p. 535,) the  following  case,  which, though less known in 
PUERPERAL  HEMORRHAGE
765
France than the one of Laforterie, is not the less extraordinaiy: "A lady,
of a weakly constitution and delicate habit, Avas  attacked in the latter
months of pregnancy with a slight discharge of blood from the vagina, not
amounting altogether to half  an ounce, accompanied Avith alarming symp-
toms of exhaustion and debility.  The os uteri was  scarcely dilated to the
size of a sixpence, and Avas in  such a state of rigidity as precluded the possi-
bility of affording any manual assistance.   The lady in consequence died ;
and, on examination after death, it was found that a separation of the centre
of the placenta from the parietes of the uterus had taken place, Avhilst  its
edges Avere completely adherent,  forming a kind of cul-de-sac  into Avhich
blood had  been poured to the amount of a pint and a half, Avhich had be-
come coagulated Avithin the cavity thus formed."
  2. The  blood may be effused  into the proper tissue of the placenta, and
thereby constitute those sanguineous  collections which have been designated
of latter time as placental apoplexy.   The woman's life is never compromised
by a discharge of this nature, but the death of the foetus and, as a conse-
quence, its premature expulsion, most generally results therefrom.
  3. The blood may be effused  on the foetal surface of the placenta, as in
the case referred to above; but the flooding here evidently must have been
internal before it Avas external.  Indeed, several observers  have reported
that they found coagula  lying  between the chorion and a portion of this
foetal aspect of  the placenta.
  4. The  numerous obserArations detailed  in  the memoir of M. C. Baude-
locque, prove that blood  may be effused between the various membranous
laminae that constitute the amniotic sac, at  all stages of pregnancy.
  5. Lastly, notwithstanding the strictures Avhich the cases narrated  by
Delamotte, Levret, Naegele, Baudelocque,  and others have  been subjected
to, they constrain us to believe that both a  partial and complete rupture of
the umbilical cord may take place;  in consequence of Avhich an effusion of
blood is made into the cavity of  the amnion.

                         ARTICLE   III.
                              DIAGNOSIS.
  A. External Discharge.—The difficulties hitherto described, (see Diagnosis
of Abortion,) as complicating the  diagnosis of  hemorrhage during the first
six  months of pregnancy, are  scarcely ever met with  at a  more advanced
period.  In fact, it is so rare to find Avomen regular as late as the last three
months, that every discharge of blood from  the vulva at that period may be
considered as a symptom requiring immediate attention; for, at the most,
we could only confound a very slight hemorrhage with a return of the men-
strual discharge, and, in both cases, the precautions to be taken Avould  be
the same;  or, at least, if indifferent in the one,  they might prove very ser-
viceable in the other.
  When a hemorrhage does come on  in the course of the last three months
of gestation, or  during labor, the question  arises, Avhat is the cause?  But
this question, though very important  both as regards the prognosis and the
treatment, is sometimes exceedingly difficult to ansAver.   It has been shoAvn
that often, perhaps even, according to certain authors, the most  frequently, 
766
DYSTOCIA.
it is owing to an insertion of the placenta either over the os uteri, oi on some
adjacent point;  and most of them go further, and endeavor to point out the
signs whereby this abnormal situation of the after-birth may be recognized.
  The absence of any signs  is a sufficient reason for supposing the hemor-
rhage to be due either to a simple detachment of the placenta or to rupture
of some of the utero-placental vessels.  To enable us to make out this diag-
nosis by the method of exclusion, Ave have next to give an account of the
signs of abnormal insertion of the placenta.

      HEMORRHAGE FROM ABNORMAL INSERTION OF THE PLACENTA.
  The signs that announce the existence of this anomaly may be divided
into the rational  and the sensible.    The first are derived from  the mode of
development of the accident,  and  its attendant circumstances;  while the
second are furnished by the touch.
  When the flooding comes on at an advanced stage of the gestation, more
particularly in a Avoman Avho has previously borne children, it is  most gen-
erally possible to detect the presence of the placenta over the internal orifice
by the touch.   In this case, says Levret, there is sometimes difficulty in find-
ing the neck, notAvithstanding it be  in a measure Avithin reach of the finger;
for  a great quantity of coagula,  a  part of which is adherent, is ordinarily
found  in the A'agina, and their  detachment augments the hemorrhage;  be-
yond  all these, a soft, fleshy, and,  as it Avere, a pulpy tumor is  detected.1
When the  accoucheur examines this tumor with the  extremity of his finger,
it feels as if he Ave re touching the  head of a small caulifloAver, and he recog-
nizes there the anfractuosities peculiar to the external  surface of the placenta;
then, by searching  out the circumference of the tumor, the uterine orifice,
which surrounds  it toAvards its superior part, is made out; but all attempts
to pass the finger between the tumor and the orifice will prove unsuccessful
Avithout  a  resort to violence, and  a detachment of the  tumor at  the  point
where the index is passed up ; or if some one place should happen to be free,
the same Avould not be true for the Avhole periphery of the cervix.
  A someAvhat  voluminous  coagulum, situated in the  os  uteri,  might be
mistaken for the after-birth; but, by a little attention, it Avill  generally be
found that the clot is much less resistant, more friable  and movable than
the placental  mass, Avhich latter  can scarcely be changed  in position, and
whose parts are separated with  much more difficulty.   Sometimes, quite a
thick layer of coagulated blood  covers the external surface of the after-birth,
and prevents the finger from reaching its  proper tissue, though the clot can
always be detached by a slight effort,  and the intervals between the cotyle-
dons be  made out.   Fungous or cancerous  tumors of the  cervix, syphilitic

  1  In general, this examination has to be made with the greatest, possible care, because
the  separation of the  clots often causes a  return of the hemorrhage.   Where the os
uteri is not sufficiently dilated to permit the introduction of the finger without diffi-
culty, it would be proper to wait until the discharge had continued long enough to
produce its  relaxation.   Indeed, unless  the flooding be profuse enough to render a
premature labor inevitable, and unless there be an actual commencement of the labor,
<ir the patient be very near her full term, all explorations of this kind should be
suspended, and  the general measures  calculated t  subdue the  symptoms be employed
instead 
PUERPERAL  HEMORRHAGE.
767
vegetations, polypi, and hydatid tumors, might be mistaken for the placenta
inserted upon the neck;  but a consideration of the antecedents of the patient,
the general symptoms she has presented, and especially a minute and atten-
tive examination, will, I think, enable us  readily to avoid  mistakes of this
character.
   As stated above,  the flooding may be dependent on an improper insertion
of the. placenta, and the latter be so  far  removed from the internal  orifice
that the finger, introduced into the os uteri, can only detect the naked mem-
branes ; if the patient be examined during labor, the extremity of the index
should be passed over all  the parts adjacent to the orifice, when the margin
of the after-birth  Avill most generally be  felt, or, at  least,  the  membranes
Avill be found thicker than common ; or, still more likely, an epichorion that
is softer, and of a triple or quadruple thickness, will be  detected toAvards that
side of the os uteri  Avhere the placenta is inserted.
   In  certain cases, the diagnosis may be further  facilitated  by an examina-
tion of the loAver part of  the uterine tumor,  even Avhere the cervix does not
permit the  introduction of a finger.  Thus, for  instance, in a Avoman, used
in my course for the practice of the " touch," who had advanced to the fifth
month of her  gestation, I observed  the  following  condition of  things:  All
the superior part of  the  excavation Avas  occupied by a thick, fleshy, and
comparatively soft  tumor, Avhich Avas very nearly of the consistence of the
uterine walls at the second or third month of gestation.   ToAvards whatever
part of the superior strait I carried the finger,  it still encountered  the same
resistance, and I found it impossible to detect any portion of the foetus, or
to perform the ballottement.  From this single fact I suspected  an insertion
of the placenta over the  os  uteri, but Avas  unable to verify my diagnosis;
though  I have since ascertained that  she Avas delivered, six weeks subse-
quently, after a moderate flooding.
   M. Gendrin has made a similar observation ; for he says that, in cases of
implantation of the after-birth over the os  uteri, the only unusual phenome-
non that can be recognized is the absence of  the ballottement.
   When the hemorrhage takes place either in a Avoman Avith her first child,
or at  an early stage of the gestation, Avhen, in a Avord, the cervix uteri is not
sufficiently-dilated to permit the introduction  of a finger, we might still be
enabled to determine the cause of the flooding by the following signs, namely:
  1. A  hemorrhage caused  by insertion of  the  placenta over  the internal
orifice never occurs before the end of the sixth month ;  and, most frequently,
not until the last four or six weeks of gestation.  Besides, it is highly prob-
able that the period at Avhich the flooding  comes on, is usually  subordinate
to the greater or less extent of the placenta corresponding to the neck ; that,
in cases of insertion,  centre for centre, it  is manifested much sooner than
where only one of  its margins is in apposition  Avith the orifice.   Neverthe-
less, there are numerous exceptions to this (as M. Naegele considers it) nearly
general rule; for, in a large number of the  cases  of central insertion, the
hemorrhage is not developed prior to the commencement of labor.
  2. It commences spontaneously, Avithout an  appreciable cause, and with-
out any precursory phenomena; the Avoman  being often  suddenly aroused
in the middle of the night by the escape of blood from the genital parts. 
768
DYSTOCIA.
  3. When manifested for the first time, it is generally inconsiderable in
amount, and soon over; but, after having disappeared altogether, it returns,
sometimes in the course of a few hours, at others, not for several days; but,
at each reappearance, the discharge is a little  more abundant, and lasts
someAvhat longer.
  4. The cervix uteri (considering the period of gestation) is usually thicker,
softer, and more spongy, because  the placenta, by becoming fixed over this
point, determines there a more considerable afflux of blood.
  5. If the labor has commenced, and  the  membranes are still  intact, the
flooding constantly augments during the uterine contractions, and diminishes
in the intervals.  But the contrary is observed Avhen the discharge is occa-
sioned by  a separation of the placenta attached to any other point; for then
the Avomb, by contracting, obliterates the vessels, either  by a retraction of
its own proper tissue, or by the compression they are subjected to from the
parts inclosed Avithin  its  cavity ;  but, in the case under consideration, the
contractions that effect the dilatation  of  the  cervix, destroy the vascular
adhesions  which unite it to the placenta, more and more, and thus multiply
the sources of hemorrhage.  This sign is one of great value before the mem-
branes are ruptured; but after the  Avaters  are  discharged, the  child's head
presses on the orifice  during the contraction, and prevents the blood from
escaping.
  6. When the insertion is complete or central, the  bag of Avaters does not
form as in an  ordinary labor;  for  the  insertion  of the placenta over the
neck closes  its orifice, and prevents the lower segment of the ovum from
engaging therein, and from being  accessible to the finger.  But when the
placenta covers but a part of the orifice, the finger discovers a greater or less
extent of  membranes, one point only of the orifice being occupied Avith the
edge of the placenta.
  7. Lastly, according to  Dewees, the blood has  a brighter  color  at the
onset of the hemorrhage than when it comes from the fundus, and coagula
never come away, excepting Avhen the discharge has lasted for some time, or
is on the point of disappearing.

        HEMORRHAGE FROM RUPTURE OF THE  UMBILICAL CORD.
  In the case I have reported, Avhere the flooding Avas produced by a rup-
ture of the umbilical vessels, itself caused by a separation of the  chorion
from the  foetal surface of the  placenta, the symptoms Avere very similar to
those Avhich accompany a hemorrhage  induced by insertion of the placenta
over the os uteri.  Thus, the discharge  commenced  toAvards the middle of
pregnancy,  was several times reneAved at irregular intervals, and always
in  increasing  abundance; and  it was manifested anew  at the onset of
labor.   The vaginal  examination could alone determine the diagnosis, by
enabling us to ascertain the absence of the placenta from the internal orifice.
  Finally, in  the case detailed  by Benckiser, there was  something like a
cord that  crossed the opening  in  the neck at an acute angle, and this was
detected before the rupture of the membranes.  This cord Avas devoid of
pulsations, but it certainly would have exhibited  them if, instead of a venous
branch, it had been one of the  ramifications  of the umbilical arteries. 
PUERPERAL  HEMORRHAGE.
769
Should another case of the kind be met with, the presence jf such a vascular
trunk on the membranes ought to receive attention, and arouse a suspicion
of the possibility of a hemorrhage from  its rupture.
  b.  Internal Discharge.—The diagnosis of the internal hemorrhages be-
comes more easy as  the gestation advances.   The general phenomena that
accompany all profuse discharges Avould first attract  attention; Avhile the
unusual and rapid development of the abdomen, and occasionally its irregu-
lar form, Avould confirm the surmise.   The hemorrhage can ahvays be recog-
nized Avhenever it is abundant enough to endanger the  mother; though  it
must be acknoAvledged that a quantity of blood may be  effused betAveen the
Avomb and the placenta, Avhich may  effect nearly an entire separation of the
latter, or destroy the child, without giving rise to  any other phenomena than
a  manifestation  of labor.  Internal hemorrhage is especially to be feared
after the membranes  are ruptured,  because then the  blood may escape in
large amount into the cavity of the ovum, or press the membranes aside Avith
the greatest facility.   In  this case, the danger will  be indicated by the gen-
eral symptoms, and  the  diagnosis confirmed if the uterus,  which  had con-
tracted firmly after the discharge of the waters, is  now found  to have attained
a size equal to or greater  than its original volume.
   A  considerable enlargement of the belly is a sign of the first importance ;
but it must not be forgotten that this may be occasioned by an entirely dif-
ferent cause.  Thus, for instance, a tympanitis of the abdomen or a dropsy of
the amnion may give rise  to it; hoAvever, the sonorousness in the former case,
and the sloAvness of the development of the abdomen in the latter, conjoined
with  the absence of  any general phenomena, will ahvays prove sufficient to
avoid an error.  Again, the patient  may be affected with a syncope during
the labor that is wholly foreign to any discharge of blood ; but then the size
of the abdomen Avill not increase.
   On the Avhole, therefore, the general phenomena that accompany all losses
of blood, and  a rapid enlargement of the belly,  are the tAvo characteristic
signs of internal hemorrhage, Avhether it occurs in the  latter stages of preg-
nancy or during the parturition.
   Finally,  internal  hemorrhage  during labor  is  frequently  followed by
Aveakening  or even  suspension of the pains.  The abdomen sometimes be-
comes painful, (Levret,)  and in some cases an  obscure fluctuation can be
detected, (Leroux.)
   Nevertheless, M. Henning has observed that, under certain circumstances,
the abdominal SAvelling may be altogether Avanting, and  yet the syncope be
dependent on an internal  discharge.   Thus, he says, the patient is  taken at
first with violent uterine pains, that  reappear at  certain intervals, and each
one of Avhich is folloAved by a slight  issue of blood from the vulva; then, at
a moment when least expected, the symptoms of a most alarming syncope
come on, though but little blood can be found upon  the cloths, and the
uterus is scarcely distended.   But, by making a careful examination, the
accoucheur aviU find, that although this organ may inclose but an inconsider-
able  coagulum, and although  the blood does not escape freely to the exterior,
yet it is because the vagina is distended  by an enormous clot as large as a
child's head   I deem it  necessary, he  adds, to insist on  the  presence of
      49 
770
DYSTOCIA.
uterine pains, in these cases of intra-vaginal hemorrhage; for they are gen-
erally regarded as an evidence that nothing is to be feared from the discharge,     I
whilst, in reality, they are  often a distinctive  character of the hemorrhage      '
in question.
                          ARTICLE  IV
        PROGNOSIS OF  EXTERNAL AND INTERNAL HEMORRHAGE.
   As a general rule, the prognosis of uterine hemorrhage is unfavorable;
though, perhaps, in a single instance, the discharge occurring in a pregnant
female may prove advantageous—it is Avhere the patient is harassed by all
the symptoms of a general  or local plethora, and a moderate discharge takes
place that relieves her of the surplus that gave rise to all these symptoms.
But as we cannot always moderate a flooding  at will  that has already com-
menced, it  would be better both to relieve the patient and to prevent the
menorrhagia by resorting to venesection.
   The gravity of the prognosis depends very much on the amount and ra-
pidity of the discharge,  and the period at Avhich it takes place, being ahvays
so much the more dangerous both  for  the mother and child  as the blood
escapes in larger quantities.  Other things being equal, the infant's existence
will be more seriously compromised  when the flooding comes on at an early
stage of  gestation; as regards the mother, it is generally much more serious
at an advanced  period ; yet it is Avell to observe that the danger is greater
in the seventh and eighth months than toAvard the end of the ninth.  Thus,
of 137 cases of hemorrhage occurring  in the seventh and eighth  month, 38
were fatal; whilst, of 78 occurring in the course of the ninth month, 10 only
were fatal.  This difference is certainly due to the sloAvness with which the
neck dilates in the earlier months.
   During childbirth, this accident will be more serious both for the mother
and child Avhen it is manifested  at an early stage of the process;  and it will
be still  more dangerous in a primiparous woman than in one Avho has pre-
viously borne children.   For it must be evident that, if the flooding should
occur at the commencement of  labor, that is, long before the dilatation of
the os uteri is effected, and before the external parts of generation are suit-
ably prepared for the free and  easy passage  of the foetus, the means ade-
quate to and calculated for, the termination  of the labor Avill be of much
more difficult application, and  more delayed;  and,  consequently, a larger
quantity of blood might escape.
   Finally, the risk  is also modified by the poAvers of endurance of different
patients; the loss of a given  amount of  blood may be of small moment to a
very vigorous Avoman, but very dangerous to  a weak one.
   Internal  hemorrhage is generally more dangerous than the external, be-
cause it often takes  place imperceptibly in the commencement of gestation,
and thus destroys the foetus; Avhile,  at a more advanced period, it compro-
mises the mother's  life, before  having given rise to any symptom Avhereby
its existence could be positively recognized, so that the accident is often de-
tected too late to be remedied.
   When the blood collects in the  uterine cavity, the accumulation cannot
take place without detaching a new portion of the placenta, and this secon- 
PUERPERAL  HEMORRHAGE.
771
diry separation becomes a fresh cause of vascular rupture, and, as a conse-
quence, augments the chances of flooding.  For even suppose the  hemor-
rhage Avere  arrested, Avhether spontaneously or  under the influence of the
measures  employed, there does not the less remain  a voluminous coagulum
in the uterus, a veritable foreign body, whose presence will irritate its Avails,
will determine there a more considerable sanguineous fluxion, and Avill ex-
cite premature contractions, and  thus  become  perhaps the cause of another
discharge.
   Lastly, during the parturition, the internal hemorrhage is less to be feared
before than  after the membranes are ruptured; because, in the former  case,
the Avomb, being already occupied  by the amniotic  liquid, will  yield less
readily  to a neAV distention, and, consequently, will  prevent a great effusion
of blood.  Besides this, the integrity of the membranes will admit of  their
artificial  rupture, which, by the salutary retraction  that follows it, is one of
the most  valuable resources of our art in these  unfortunate cases; and of
which,  it  is  unnecessary to add, Ave are deprived  when  the waters escape
prematurely.
   But the dangers that threaten  the woman while the hemorrhage lasts are
not the  only ones to be dreaded; for  her  constitution and health mav be
broken  doAvn for a long time by these grave accidents.  The labor is gener-
ally tedious, the pains being short and distant, and  inertia of the uterus a
consequence of the general Aveakness.  After delivery, Avhen all hemorrhage
has ceased, some women are so completely exhausted as  to have frequent
attacks  of fainting.   Whatever solid or  fluid nourishment is taken into the
stomach is rejected, and they often die a few hours  or days after the termi-
nation of  labor.  Even Avhen the patients have  the good  fortune to escape
with their lives, they ordinarily suffer for a  considerable period ; they are tor-
mented  with constant pains in  the head; their digestion is painful,  their
vision and'hearing  are defective;1 and there are often Avandering pains in
the limbs, trembling, &c, itc.   Most  frequently the labor is  lingering, the
pains are  short and distant, and inertia of the uterus results from this  gen-
eral weakness.   Those females who  have been afflicted Avith profuse  hemor-
rhages  are  far  more  disposed than others, during the  lying-in, to acute
inflammations, and  to peritonitis especially; which  inflammations  then
advance more rapidly to a  fatal  termination, because the  general condition
of the  patient does  not permit an active  resort  to the antiphlogistic treat-
ment.                                  .
  The  cephalalgia  noticed by all observers, and Avhich I have frequently
had opportunities of verifying  myself,  only disappears  after  a  very  long
time, and  not until the reparation of the blood and the re-establishment of
the strength have taken place.   M. Baudelocque supposes that the pain is
particularly apt to be seated in the hinder part of the head.  Leroux attri-
butes this  affection to a diminution in the quantity of blood contained in the
vessels of  the brain, Avhich  occurs as  an immediate consequence.   I would
rather explain it like  Baudelocque, by the direct influence Avhich the  loss
of blood must exercise over the nervous  system.
  1 In a ciise reported  by Ingleby, the patient became  suddenly blind; for five  daya
she could not distinguish anything at all,  and  her sight was not perfectly restored til!
Bix months afterwards. 
772
DYSTOCIA.
   The child's death does not  necessarily result from  the  hemorrhage  f(> ,
 when the latter is inconsiderable, the gestation continues its regular course.
 The loss of blood has even been carried to an extent calculated to inspire
 just fears for the mother's  life, and yet Avithout being folloAved  by abortion.
   But although the foetus may have resisted the violence of the first acci-
 dents, it must not be supposed that it experiences  no injurious  effects there-
 from.  Though but a small portion of  the  placenta may have been  sepa-
 rated, the foetus  is nevertheless deprived thereby of a portion of its means
.of respiration and of nutrition, and this  deprivation, though  partial, may
 eventually prevent its complete development, and even destroy it before the
 termination of pregnancy.  Therefore, when born alive, it is often emaciated,
 and Aveaker than under ordinary circumstances; and  this congenital debil-
 ity, which is generally regarded by authors as a consequence of the  anemic
 condition of the mother,  should, in my opinion, be attributed to the partial
 separation of the placenta.
   When the mother has Jiad the good fortune to escape the  danger that
 menaced her, and the pregnancy continues, 1ioav  then is the  hemorrhage
 arrested ?   The mode of  termination  varies somewhat,  according to the
 cause that has determined the accident.  Thus, Avhen the  flooding has been
 preceded by general plethora, or by uterine congestion, it  may happen that
 the escape of blood removes this condition, and thus remedies the symptoms
 itself; and this must nearly always be the case Avhere the discharge resulted
 from a sanguineous exhalation.  But where there is a rupture of one of the
 utero-placental vessels, it is possible that the flow of  blood,  by relieving
 their distention,  will permit these  vessels to become flattened down and de-
 pressed, from the double pressure of  the  ovum and womb, and then the
 hemorrhage is arrested.  Again, where the placenta has been detached from
 the Avomb to a moderate  extent, the bleeding  can  only be checked by the
 formation of a coagulum, Avhich creates an obstacle to the ulterior issue of
 the blood, by being placed betAveen the uterus and the placenta ; for, "while
 the blood is endeavoring  to glide towards the os uteri," says  M.iVelpeau,
 " a more or less extensive portion of the placental  mass becomes  fully satu-
 rated with  it: first one clot forms, then a  second, then a third, and  these
 several layers, of various thickness, soon become sufficiently numerous, pro-
 vided the energy of the hemorrhagic affluxion becomes diminished, to  exert
 such a degree of pressure as to retain the blood Avithin its own vessels."  All
 the vascular tubes corresponding to the point Avhere this coagulum is formed,
 are thenceforth  rendered useless  to the utero-placental circulation, Avhich
 can only be kept up through those that have not been lacerated.
   The authors of the Dietionnaire de Medecine (art. Hemorragie Uterine)
 seem to admit, from a case reported by Noortwyk,  that the detached portion
 of placenta  may contract  new adhesions with the uterine wall;  but  from
 what has just been said respecting the formation of the coagulum, which,
 by its presence, puts an end to the symptoms, it is impossible to admit that
 this re-attachment can take place Avithout the intervention  of a fibrinous clot,
 which evidently precludes  the  re-establishment of the circulatory relations.
 Besides,  this matter  is  satisfactorily proved  at the time of labor; for, by
 examining the uterine surface of  the placenta, Ave can  then detect one or 
PUERPERAL  HEMORRHAGE.
773
 ,uore fibrinous laminae of a variable size, and differing from each other in the
 degree oI degeneration, according to the  period at which the separation was
 effected;  in  addition to AA'hich, the portion of placenta  that had  been de-
 tached is often atrophied and deprived of juices; in a Avord, the correspond-
 ing placental cotyledons have Avithered aAvay completely.

 PROGNOSIS OF HEMORRHAGE CAUSED BY ABNORMAL  INSERTION OF THE
                                PLACENTA.
   As regards the cause  producing  the hemorrhage, that variety Avhich  is
 .lependent on an  implantation of the placenta over the  inferior segment  is
 the gravest of all: to the mother, because it is reneAved several times  during
 the latter months of her gestation in a  constantly increasing  amount, and
 because, being always present during the labor, it usually requires the inter-
 vention of art; to the child, because  such an  intervention is not Avithout
 danger to it, and the interruption of the utero-placental circulation, resulting
 from the detachment of the placenta, produces an asphyxia that oftentimes
 proves speedily fatal.1  The following  statistics,  by Dr. Simpson, prove the
 danger of this complication, namely: of  399 women in Avhom this misplaced
 insertion  of the placenta Avas  observed, 134 perished.
   When the placenta is inserted over the neck, centre for centre, the hemor-
 rhage would evidently be much more profuse than in the cases in which  it
 is in contact with the orifice by one  part of its circumference  only.  We
 would add the remark of M.  Duval, that as the ovum can then  yield only
 with great difficulty, because of the  strength of that part  of the chorion
 which bears  the umbilical vessels, the labor is greatly prolonged, the fruit-
 less  contractions weaken at last,  and the hemorrhage is  increased by  inertia
 of the Avomb.
   A singular circumstance sometimes takes place  in cases of central  inser-
 tion.  The gradual dilatation of the cervix may effect the  complete detach-
 ment of the placenta, which may, perhaps, be entirely expelled through the
 vulva several hours before the expulsion  of the child.  This accident,  Avhich,
 at first vieAV, Avould seem likely to have the most disastrous consequences,  is

   1 The foetus then  dies by asphyxia, and not by hemorrhage, as has been asserted,
 and again  repeated  in  the recent work of M. Gendrin.   For the foetus can only lose
 its blood when the source of the  hemorrhage  is in  a lesion of the umbilical vessels;
 while, in a case of simple detachment of the uterine surface of the placenta, the child
 dies only because the circulation is interrupted in  the utero-placental vessels,  and its
 respiration can no longer take place.   (See Functions of the Foetus.)  The  blood, being
 shut  up in  the umbilical vessels, cannot come any more  into the usual mediate  contact
 with  the maternal blood, and the infant is then in the same condition as an adult
 deprived of respirable air, and like him must, die  asphyxiated.   Besides, the autopsical
 examination in such cases exhibits the anatomo-pathological characters of asphyxia.
  There are some rare cases reported, in which the child's head, being forcibly urged
 on by the  powerful contractions  of the womb, has perforated  the placenta near the
 middle, and thus opened for itself a passage  through  the central opening. This oc-
 curred in Portal's  twenty-ninth observation; and W. White reports that,  in  a case
 where the  placenta  appeared  to be inserted over  the  os uteri,  centre  for centre, the
patient suffered two  or three very intense pains, during  which the head perforated th*
nfter-birth  and was delivered.   The child was  still-born, but the woman recovered. 
774
DYSTOCIA.
 nevertheless proved by experience rarely to compromise the mother's life,
 though it is generally fatal to the  child.1
   In some  rare cases  it has happened that the head, under the influence of
 poAverful contractions, perforated the centre of the placenta, and was expelled
 through the passage thus formed.  Portal's twenty-ninth observation relates
 to a case of this kind; and W. White informs us that in an instance of ap-
 parently central insertion upon the neck, the woman  had tAvo or three very
. strong pains,  during which the head perforated the  placenta, and Avas ex-
 pelled.   The  child was still-born, but the mother recovered.   In an autopsy
 made by Dr.  Ingleby  of a  woman  Avho died of hemorrhage just as the child

   1  Chapman relates an instance in which the after-birth was thus expelled four hours
 in advance  of  the child; and Perfect  furnishes a very similar case.   (Cases, vol. ii.
 page 288.)
   "I was once consulted," says Merriman, "by a very  careful and judicious practi-
 tioner, respecting a  woman, who, when I first saw her, was  rapidly sinking  under
 puerperal fever.  In this case, the placenta was expelled many hours before the child
 was born, and no extraordinary means  were used to expedite  the delivery of the child;
 a physician-accoucheur,  who was consulted on the occasion, having deemed it more
 prudent to leave the case to  nature.  The fatal event, however, would  lead one to
 doubt whether  it was wise, under such circumstances, to decline  the interference of
 art."  (Synopsis,  page 126.)
   Smellie has reported three  cases of  the same kind; Lamotte, three (Obs,, 321, 322,
 323);  Lee, three  (Med. Gaz., 1839); Ramsbotham, Sen., five (Practical Obs., Case 153);
 Baudelocque and Barlow, each one; and  Dr. Collins (Practical Treatise,  page 91) nar-
 rates an instance in which the placenta was expelled about eighteen hours before the
 foetus; the membranes were ruptured,  and the waters escaped two weeks before the
 entrance of the patient into the hospital;  from that time until the eve of her admission,
 the flooding had continued with more or less abundance.  We satisfied ourselves, says
 he, that the placenta had been extracted the evening before by the midwife who attended
 her.   This woman recovered perfectly, and left the hospital on the thirteenth day.
   Cases of this kind are  much more common than might be supposed; thus, Dr. Simp-
 son has collected  141 authentic observations, and, in order the better to appreciate the
 effect of this premature separation,  he  has divided them  into  four categories.  In the
 first, 47 in number, there were 41 still-born children, and  10 of whose condition nothing
 could be learned, but all  the women except three recovered.   In all, the  hemorrhage
 diminished greatly,  oi- ceased  altogether, immediately after the expulsion of the pla-
 centa, although an interval of ten hours at the most, and of  ten minutes at the least,
 had elapsed between  the expulsion of the after-birth and  the  birth of the child.   In
 the second are  placed 24 cases.  In all of these rather less  than ten minutes inter-
 vened between  the expulsion of the placenta and that of the  foetus;  9 of the children
 were still-born, 2 were putrefied, and 11 were alive; no information respecting the two
 others; all the mothers but three recovered.   The third contains 29 observations, in
 which the expulsion  of the child followed that of the after-birth immediately; 14 still-
 born, and 11 living children; no information  respecting the others;  all the mothers
 recovered, except one.  Finally, in 10 cases, the  time between the birth of the child
 and the delivery of the placenta was not noted.   Only 3 mothers died, and 9 children
 Burvived.
   Thus, according to these facts, the premature separation of the placenta, which does
 not appear to have had a very serious effect upon the mothers, is extremely dangerous
 to the child,  since all the children of the first  series died; half only of the second, and
 eleven of the third category, survived.
   We shall refer to these figures hereafter, in order to appreciate the practical conse-
 quences which  Dr. Simpson thinks himself able to deduce from them. 
PUERPERAL  HEMORRHAGE.
775
was  about being born, he found the head in the  vagina, having passed
through a central perforation of the placenta.
   When the placenta is situated only in the vicinity of the neck, the hemor-
rhage  may not appear  during the  labor, although it may have  occurred
several times in the latter stages of'pregnancy; for, should the membranes
rupture prematurely, and the head be  presenting,  it is possible that its
engagement might compress the  torn vessels sufficiently to prevent the dis-
charge of blood 1
                            ARTICLE  V.
                               TREATMENT.
   The management of uterine hemorrhage  may be subdivided into the
preventive and  curative  treatment.  The  prophylactic measures  are a3
numerous  as the predisposing causes, and  they consist in preventing the
action of those causes ; hence, to furnish a detailed account of them, it Avould
be necessary to enter into  a series of repetitions.   Besides, they are included
in the hygienic and  general therapeutic management of  pregnancy, and,
therefore, Ave need not dAvell further upon them here.  But if, notAvithstand-
ing  all the  preventive means employed, or if, from  the influence of any
unforeseen causes, a hemorrhage is developed, what course shall we adopt to
subdue it?   The frequency of this  accident, and its  great  danger in many
cases, have at all times claimed  the attention of practitioners;  and Avith a
vieAV of facilitating the study of the  numerous  measures  that  have  been
recommended, we shall divide them into the general and  the special  ones.
The first being  applicable in all cases, are nearly ahvays the same; but the
second vary according to whether the flooding takes  place  in the course of
the  gestation or during parturition, and  according to the abundance or the
trifling character  of the discharge.

   [The measures taken to arrest hemorrhage ought not to be used indiscriminately,
because each has a special mode of action which should  be well understood before
having recourse  to it.  Thus, bleeding and  general remedies such as acidulated
drinks, absolute  rest and reduction of temperature, are  intended to lessen the
activity of the general circulation  and, as sedatives, are useful in uterine as well
as other forms of hemorrhage.   Cold applications to the hypogastrium and thighs,
cold  injections and raising the breech by a cushion are, on the contrary,  addressed
directly to the uterine circulation which  they  are  capable of reducing.  Ergot,
which has an excellent effect, may be used with a double purpose: some authors
believing  that it acts  as a true specific, in virtue of a power of altering  the  char-
acter of the blood or of exciting the contractility of the vessels, Avhilst others think
that  it arrests hemorrhage only by producing contraction of the  uterus,  the effect
of which we know  is to lessen  the circulation in the organ.  Rupture of the mem-
branes, by giving issue to the amniotic fluid, causes the walls of the Avomb to con-
tract, and in so doing constrict  and lessen  the  calibre of  the vessels which  they
contain, thus becomes a very valuable  means of  checking  hemorrhage.   We have

  1 When, says Plenck, the orifice is half covered  by the adherent  placenta, the case
should be left to nature: for the head of the child  pushes the presenting part of the
placenta aside, compresses the blood-vessels, and thus prevents hemorrhage.  This
precept, though too absolute, at least proves that Plenck had  made  the same observa-
tion that we have just mentioned. 
776
DYSTOCIA.
already stated in regard to the treatment of abortion (see Abortion), that injections
of laudanum are capable of arresting the contraction of the womb, and may there-
fore be very serviceable whenever the loss of blood is due to irregular contractions.
Lastly, the tampon is a plug which arrests the discharge of the blood  and  allows
the progressive formation of a clot which finally obliterates the torn vessels.
  Each of the above-mentioned  measures  has its  special application according to
the  object in view, and  ought not, therefore, to be used without judgment.  What
has been said will, I think, be sufficient to indicate the  course to be pursued, and
Bimplify the account of the details of treatment which we are anxious to present in
the fullest manner.]

  § 1. General Therapeutic  Measures.
  Whenever an  accoucheur  is summoned  to a pregnant Avoman Avho is
affected Avith flooding, he should  immediately  attend to certain precautions
that we are about to point out, namely:
  The woman ought to be kept in a horizontal position, care being taken to
have the pelvis elevated  someAvhat higher  than the rest of the body.  All
feather beds must be proscribed, and, Avhenever possible, she should lie on a
hair mattress that is rather hard.  The bed is to be placed in a large, well-
ventilated  chamber, so as to be easily accessible on all sides ; in the summer
season, the room  might  even  be sprinkled; and the Avoman  is to be lightly
covered.  It is desirable to have the chamber somewhat darkened, and the
attendants should be advised to discharge  their respective duties without
making  any unnecessary noise.  He should endeavor to satisfy the patient
as to her condition, and  to remove all  sources of vexation and  opposition;.
for calmness of mind is not less essential than rest of the  body;  especially,
when the discharge has  been occasioned by violent passions  or acute moral
affections.
  Cold  drinks, slightly acidulated with vinegar, gooseberry, or lemon  syrup,
or  even Avith lime  or orange juice,  are the most suitable.  We should
endeavor to obviate the strainings the patient might make on the close
stool, because they might possibly increase the flooding; for this purpose,
the boAvels are to be kept free by injections, or, if these are not sufficient to
remedy the constipation, by mild laxatives; and, lastly, if the woman has
the least difficulty in urinating, it Avould likeAvise be necessary to empty the
bladder by the catheter.

  §  2. Special Therapeutic Measures. •
  These vary, as stated,  according to the abundance or  trifling character of
the  discharge, and  according to Avhether  the latter is manifested  in  the
course of the gestation, or during the labor.   We shall  first  examine them
during pregnancy.
  A. Moderate Hemorrhage, occurring in the last three  months. — If the flood-
ing has been preceded by the general  phenomena of plethora, and if at the
time Avhen the Avoman  is  examined the pulse be found full, strong, and devel-
oped, the face flushed, &c, in  a word, if the hemorrhage  appears to be owing
to, or kept up by, the plentitude or morbid action of the vessels,  it is neces-'
3ary to  hav*  recourse to general venesection, which Avill act both  as a revul-
sive and as an antiphlogistic;  but  this measure is recommended in  those 
PUERPERAL  hemorrhage.
7,77
cases only in Avhich labor has not yet commenced, and where the discharge is
inconsiderable, and has lasted but a short time.  Blood-letting must be pro-
scribed  under the opposite  circumstances, as also in those instances Avhere
the flooding is not associated with plethora.
   When the hemorrhage is not very abundant, and,  as a consequence, when
there is some reason to hope that the pregnancy Avill continue on its regular
course, opiates may be administered;  they might be given by the mouth,
but it is much better, in general, to exhibit them  by injection, in the  dose
of twenty drops  of Sydenham's laudanum,  diffused  in a small quantity of
some mucilaginous vehicle; and this may be repeated three or four times, at
intervals of an hour or more, Avhere the first have not been sufficient to arrest
the symptoms.   A long experience,  says Burns, enables me to recommend
this measure in all cases Avhere blood-letting  is not practicable.  For the
first tAventy-four  hours, the patient must be subjected to a strict regimen.
   Such  are the measures to  be employed in cases of moderate hemorrhage
occurring in  the  last three months of gestation; and  they should be con-
tinued until it has entirely disappeared.
   After the symptoms are Avholly subdued, the Avoman  ought to take the
greatest  precautions to avoid a relapse, by keeping in  bed for a week at
least, eating but  little, and that of non-succulent  articles, especially if the
discharge had been attributed to plethora, etc., etc.
   B. Profuse  Hemorrhage occurring in the last three months.—Where the
flooding  is more abundant,  the remedies  to be employed are also more
active, and, to the measures  already enumerated, except venesection, Avhich,
as before stated, must be rejected Avhen the  discharge  is very profuse,  Ave
may iioav add :
   1. The application of compresses, steeped in some  very cold liquid, to the
upper part of the thighs, hypogastrium, or   loins (in one  instance, M. Gen-
drin successfully  administered an opiate injection  at the temperature  of
melting ice) ; and, Avhere the heat is  very  great, cold sponging  over the
legs, arms,  and even the body.  But the action of  cold is not to be resorted
to Avithout discrimination ; nor, as  a general rule, should it be kept up for
a long time;  because, although its  application  may be useful at the com-
mencement of the attack, when the phenomena  of local  congestion  are
manifest, it Avould certainly prove injurious if a very copious and persistent
flooding had  already enfeebled the patient, and if there Avas reason to fear
the poAvers  of life Avere giving Avay, and that the woman Avas likely to  sink
into a state of complete prostration.
   When the skin is cold and the pulse small and feeble, the refrigerants are
not indicated, and they should be suspended at once, if already in use.
   2. In  this latter case, if the flooding continued and the prostration  aug-
mented, it Avould be necessary to haA'e  recourse to revulsives applied to the
superior parts.  I  have seen, says  M.  Baudelocque, a  profuse hemorrhage
suspended almost instantaneously by placing the hands in very hot Avater.
  Under the title of revulsives it has been recommended, since the days  of
Hippocrates, to apply cups either above or  just  under the breasts, and be-
tween  the shoulders.
  M. Velpeau advises the employment of a sinapism at the upper part  of 
778
DYSTOCIA.
the back; for he has found this  remedy beneficial in a great number of in-
stances, and at all stages of gestation; " nevertheless," he says himself, "there
would be little Avisdom in relying upon it to completely suppress a hemor-
rhage that  had already  become serious and alarming."  It is, hoAvever, an
auxiliary measure that  should never  be  neglected, for it can have no dis-
astrous tendency;  but, in my opinion,  the same cannot be said of revulsives
applied to the breasts, since it is  by no  means certain that they may not
prove injurious.  Indeed, many  authors, relying on the  sympathy existing
between the uterus and the mammae, have supposed  that  every stimulant
applied to the latter must excite the action of the former, and, consequently,
tend to reneAv, or to keep up,  the  hemorrhage.
  3. If the measures hitherto enumerated be not sufficient  to  arrest the
flooding, the ergot might be exhibited  in the dose of half a drachm divided
into three parts, one of Avhich  is  to be taken every ten minutes.   This medi-
cine, which  is  recommended  by M. P. Dubois under such circumstances,
appears to him to have  nothing  more  than a hemostatic action;  "for, if it
be objected," says he, " that this remedy might excite uterine contractions,
and thus provoke a premature labor, Ave answer that, up to the present
time,  not a single well-founded observation proves that the spurred rye has
the property of provoking the uterine contractions;  though,  where  these
exist  already, it increases them, or  restores them Avhen  suspended; but it
does not cause them to appear if the uterus is in a state of perfect rest.  On
the other hand, even supposing that it had this virtue, that Avould not be a
just ground of exclusion, for  it must  not be forgotten that the question is
before us of arresting a serious accident, one which cannot continue without
prejudice to both mother and child;  and that the only other resource is the
use of the tampon, Avhich even more than  the ergot would expose her to the
hazard of a delivery before term." (Journ. de Med. et de Chir. Pratique, 1836.)
  4. But it sometimes happens that,  notwithstanding the  employment of
refrigerants and ergot, the flooding continues, the  woman becomes pale and
colorless, the pulse small and thread-like, and  she has vertigo, &c.;  and
the violence of the symptoms endangers the lives of both mother and child.
Under these  grave conditions, the accoucheur  has only to choose between
an application of the tampon and  a provocation of the labor  by rupturing
the membranes.
  A.  Use of the  Tampon.—When  speaking of the  natural  termination of
those  hemorrhages that come on during pregnancy, we stated that the dis-
charge Avas  arrested in  consequence of the formation of coagula,  Avhich, by
becoming applied  over the orifices  of the vessels, perhaps  even by being
continued into these orifices, prevented a subsequent  discharge of blood;
and that it is on the formation of these salutary coagula that Ave must found
our hope, so long as there is a  chance of preserving the infant.   It Avas Avith
this vieAV that the older physicians resorted to the  use of astringent injec-
tions,  and more especially to  pessaries made of some  old linen  saturated
Avith  such  liquids.  But they did not depend upon  the coagulating and
astringent properties of these substances alone; but also relied on their me-
chanical effect in retaining the blood.  For this purpose, therefore, Leroux,
of Dijon, proposed his tampon  in 1776.   This remedy, says he, is exceed- 
PUERPERAL  HEMORRHAGE.
779
ingly simple;  it consists  in  the creation of an obstacle to the escape of the
blood by filling up the vagina Avith balls  of linen  or tOAv, saturated Avith
pure vinegar.   Desormeaux thought it was  better to first double a large
piece of fine linen, and then carry up the fold to the fundus of the vagina;
and afterwards to fill the pocket thus formed by the linen AA'ith bits of char-
pie, or toAV, or any other soft substance that  may be at hand.   M. Moreau
condemns this procedure, because, he remarks, it  is difficult and painful,
and it would  be almost  impossible not to leave some space  betAveen the
tampon  and the cervix uteri.  He recommends the  mode of application to
be altered to suit the particular case :  for instance, if  the os uteri is a little
dilated,  he advises the use of a roller, Avound tightly in the form  of a cone,
and Avell fastened; then  the conical extremity of this plug is introduced
into the uterine orifice itself,  and is retained  there  by the "finger.   When
the dilatation  is someAvhat more advanced, he makes use of a lemon, having
the rind pared off at one  extremity,  and he introduces this into the neck of
the Avomb, Avhere its bulk obliterates the orifice, and its juice  irritates the
organ;  and  lastly, Avhen the os uteri is freely dilated, he  recommends the
vagina  to be  crammed Avith lint  steeped in vinegar, and the whole to be
secured  Avith a T bandage.   Leroux Avas also in the habit of saturating the
tampon  with vinegar.  The  astringents  were considered  useless  by  Desor-
meaux ; for, he says, it is only on the mechanical action of the tampon that
we can  rely, and not upon  the irritation which  its contact, and that of the
acids Avith Avhich some persons saturate it, may have on the uterine Avail.  It
would be very fortunate, indeed, if  the  only effect  of the tampon was to
prevent  the issue of the blood, and  to determine its  coagulation; for then,
by arresting the. hemorrhage, Ave might preserve  the life of the foetus much
oftener  than  is  now done.   But, unhappily, it has yet another effect; that
is, it frequently irritates  the  organ  by mere presence, and by forcing the
blood to coagulate in the uterine cavity, Avhereby a more or less voluminous
coagulum is formed there, which further adds to the irritation  produced by
the tampon  itself; contractions  are excited, and, in most cases, the Avomb
soon drives out the tampon,  coagulated blood, and  foetus altogether.  This,
we may observe in passing, is the most serious objection that can be urged
against  the use of the tampon, a reproach  that  it often  merits,  especially
when it  is saturated with vinegar.
  But,  after  all, notAvithstanding  these disadvantages,  the tampon is  a
remedy  that cannot be dispensed with in practice; and Ave do not knoAV how
to better describe the cases in  Avhich it may be resorted to Avith advantage,
than by furnishing the folloAving extract from the memoir published  by
tiardien, in the ninth volume of Leroux, Boyer, and Corvisart's Journal.
  The tampon may be applied:  1.  To arrest any hemorrhage that  might
arise from the rupture of a varix on the uterine neck,  or in the vagina.  2.
In a case of laceration, occurring at the orifice  of the Avomb during labor,
and Avhen  there  is any inertia, by a  direct application to  the torn surface.
3. In casts Avhere the placenta is inserted over the os uteri centre for centre;
the blood  being retained  by the tampon, forms  a coagulum which is com-
pressed between it and the after-birth, Avhereby the serous part  is expressed,
and a concretion takes place which contracts adhesions with  the adjacent 
780
DYSTOCIA.
parts, and  suspends the discharge until the rupture  of some othei Aessel
reneAvs the hemorrhage.  Nothing is to be feared in these cases from an in-
ternal bleeding; for, although Ave have quoted  some examples of the kind,
these are so rare that they cannot counterbalance all the advantages of the
tampon; besides, the mere fact of its employment  does not  dispense with
the necessity of carefully watching the patient.  4. It is likeAvise serviceable
in the floodings attending the abortions which take place in the course of
the first three months, whether before or after the delivery of the after-birth :
before, because Puzos' method might render this delivery  impossible, or at
least very difficult;  and after, because there would be no cause to  fear an
internal hemorrhage, for the reasons before  given.   5.  It  might answer in
those instances where there is no dilatation  of  the os uteri, or when this  is
impossible, and consequently where it Avould be impracticable to pierce the
membranes.  6. And lastly, where the flooding continues after the mem-
branes have been punctured,  and it is'impossible to effect a forced delivery;
as in the cases reported  by Lamotte and Smellie.  Nevertheless, its employ-
ment then should always be Avatched  over Avith the greatest possible atten-
tion ; for the uterus, in Avhich a void  is created after  the discharge  of the
waters, is  susceptible of becoming distended, and an  internal hemorrhage
might take place.  Under such circumstances, artificial delivery must be
resorted to.
   But the  tampon  should  be rejected: 1. Whenever Ave might reasonably
hope to prevent an  abortion;  for  even  Leroux himself made use  of the
ordinary means before resorting  to  this measure; because,  by  retaining
within the womb the  blood that  Avould otherwise  escape, it distends  this
organ by forming a coagulum, Avhich may increase  the  detachment  of the
membranes and placenta, and may likewise irritate the womb by its presence,
and thus bring on the contractions;  and 2. Whenever (as hitherto  stated)
the placenta is inserted over  the os uteri, and the labor  is sufficiently
advanced for turning or the forceps to be resorted to.
   B. Rupture of the Membranes.—When the hemorrhage is profuse, and has
made its appearance during the  latter months  of gestation, more especially
if the labor has already begun, a rupture of the  membranes should generally
be preferred to the use of the tampon.  The child's life is then almost as
precious  as the mother's, and  we must endeavor  to remove it  from  the
threatened danger.   It was with this  view that our predecessors resorted to
an artificial labor  under such circumstances.   But Puzos has proposed a
measure which conjoins the advantages of the natural with those of a forced
delivery.  It is necessary for this purpose, he says, to introduce one or more
fingers into the uterine orifice, by Avhich an attempt is made to dilate it with
a  degree of force proportioned to its resistance;  this  gradual dilatation,
Avhich is interrupted by intervals of rest  from time to time, excites the
pains:  the womb contracts, and  during its  contraction  the membranes
become tense, and engage a little at the upper part of the cervix, and these
latter are ruptured  as soon as possible, in order to  effect a discharge of the
Avaters.   The presenting part, particularly if this happens to be the head,
should be carefully pressed up by the finger  for some moments, so as to  per-
mit the liquid to escape.  The objects to be accomplished are obviously to 
PUERPERAL  HEMORRHAGE.
781
 encourage a discharge of the  Avaters, to arouse  the  contractility  of  the
 uterine tissue by their evacuation, and to  solicit its retraction ; AvherJby the
 vessels situated in the thickness of its Avails Avould undergo certain modifica-
 tions  favorable to an arrest of the hemorrhage.   Further, when the womb
 is well contracted on the body of the child, and some portions of the latter
 arc forcibly applied  against the  patulous  vessels that furnish the blood, the
 compression thereby produced must evidently arrest the*flooding.
   This method, which has been adopted by Dr. Rigby, of England,  has
 been severely criticised by his countryman, Duncan SteAvard, Avho endeavors
 to support his own opinion by the folloAving observations: by rupturing the
 membranes before the uterus is dilated, Ave retard rather than accelerate the
 expulsion of the child; and, besides, it is by no means certain, as experience
 has demonstrated, that this measure Avill  arrest the  hemorrhage; Avhile it
 often  diminishes the chance of saving the life of the  mother and child, by
 rendering the version  much  more difficult, if this operation should subse-
 quently become necessary.
   Notwithstanding these objections, Avhich, after  all, have no  great force,
 the rupture of the membranes is advocated  by most of the teachers of  the
 present day, in cases of profuse  flooding, occurring at an advanced stage of
 gestation.  Nearly  all  teach, hoAvever, that a  regular commencement of
 labor,  manifested by evident uterine contractions, should precede  its  per-
 formance ; but, as M. P. Dubois remarks, it is important to bear in mind
 that, when a considerable hemorrhage takes place, the contractions of  the
 womb are often feeble, and that the labor may actually be  progressing,
 though the pains have not clearly marked  its onset;  Avhile, on the other
 hand, the discharge of a large  quantity  of blood and  the escape  of volu-
 minous coagula, both relax and  dilate the uterine orifice; and these  circum-
 stances, Avhich are doubtless joined to some non-painful  contractions, may
 dilate the os uteri, without the knowledge of the patient or the suspicion of
 the accoucheur.  This phenomenon is  not at all unusual, especially in
 women AA'ho have  previously  borne  children;  and, therefore, whatever be
 the condition of the  body of the uterus, and whether there be any apparent
 contractions or not, he  should carefully ascertain  the state of the os uteri.
 In cases of profuse flooding, this will most frequently be found sufficiently
 dilated to permit the introduction of a finger, at least;  and the  membranes
 will then  be  felt tense and  protruding at intervals; which protrusion is
 a certain  proof that the Avomb  begins  to contract, and the rupture of the
 membranes will then be effected to the greatest advantage.  Besides, this
 operation  does not exclude the employment of the various stimulants cal-
 culated to excite  the  contractions; thus  abdominal  frictions might  be
 resorted to, and the finger, Avhen introduced into the neck, should first titil-
 late and irritate this part before making the rupture; and it would even be
 prudent to administer  tAvo or three doses  of ergot to the patient, provided
 the neck  is softened,  and it seems to offer no marked resistance to the
 dilatation.
  Most accoucheurs advise the application of the tampon, when the discharge
is  produced  by an insertion of the placenta over the cervix ; but M. P.
Dubois teaches that the course to be pursued in such cases Avill vary accord- 
782
DYSTOCIA.
ing to the degree of this insertion.   For instance, Avhere it takes place centre
for centre, or in other words, Avhen the placenta covers all the superior part
of the internal orifice, and the membranes are inaccessible, or can only be
reached by detaching some portion of the circumference of the still adherent
placenta, Ave should  have recourse to the tampon: but Avhere  the placenta     1
corresponds to the orifice by only one of its borders, and particularly Avhere
it is inserted at some point adjacent to this orifice, he likewise recommends
an artificial rupture  of the membranes ; being satisfied that, after the waters
have escaped, the child's head, by becoming applied on the detached portion
of the placenta, will, by compressing it, put an end to the flow of blood.
   Quite recently, M. Gendrin has entertained the idea of adopting Puzos'
method, even in those cases in which the  after-birth  corresponds to  the os
uteri centre for centre.  Under almost  identical circumstances, Rigby had
deemed it advisable  to push his finger through  the centre of  the placenta,
and thus pass directly into the amniotic cavity.  The following are the ob-
servations of M. Gendrin  on this subject: Authors, he says, have advised
that labor should be  induced by direct  manipulations, which consist in
forcing the dilatation of the os uteri and passing into the womb through the
placenta, or by detaching  this  organ from one  portion  of the  neck; but
these manoeuvres occupy  much time, and  besides are very difficult, and if
the blood continues  to flow, the  enfeebled patient may become prostrated.
We propose instead the following process, Avhich has the great advantage of
keeping up the relation between the after-birth and the uterus, as  long as
possible.   It consists in evacuating the  waters, by making a puncture Avith
a female catheter, Avhich is directed along  the  finger previously introduced
into the os uteri, and is passed into the membranes through that portion of
the placenta lying over the neck.  In the two cases in which he  adopted
this plan, the hemorrhage disappeared immediately; and this measure may,
therefore, be employed, when the  amount of the discharge indicates a resort
to the method of Puzos, and Avhen the presence of  the placenta is the only
obstacle.
   We think, however, that if the  dilatation is but slight, the  tampon had
better be applied.
  Internal Hemorrhage.— We  can only expect to overcome those  internal
discharges that are  serious enough to compromise the mother's  life,  by
emptying the womb  and terminating the  labor.  Tavo  different conditions
may then be met with, viz., one, in Avhich  the  labor has  not yet commenced,
the neck is still undilated, and its  margins hard and thick; in the other, on
the contrary, there are some labor-pains, the cervix is softened, and is more
or less  dilated.   In the latter case, the indications for treatment are obvious;
that is, to rupture the membranes and employ all the various measures which
are calculated to hasten the contractions (such as abdominal frictions, titilla-
tions of the orifice, and ergot), and to Avatch the state of the Avomb after this
rupture attentively.   Such is the course to be pursued  when the dilatation
is inconsiderable; but, on the other hand, when the os uteri is either dilated
or dilatable, the delivery should  be effected  at  once by turning, or by an
application  of the forceps, according to circumstances.  (See Version, and
art. Forceps.)   But  Avhere the symptoms  occur a short  time before the full 
PUERPERAL  HEMORRHAGE.
783
term of gestation, particularly in a Avoman Avith her first child, the complete
obliteration of the cervix may constitute an insurmountable  obstacle to the
introduction of the smallest instrument.   In these grave cases, after having
employed the usual means to moderate the effusion of blood without benefit,
such as irritations  made on the neck and over the fundus of the Avomb, with
a view of bringing on its contractions, it will be absolutely necessary to per-
forate  the membranes, and  if the hemorrhage  continues, and the  Avoman
becomes Aveaker and Aveaker, and is threatened Avith death, to have recourse
to a forced  introduction of the hand.   Generally speaking, the slightest
efforts  Avill be sufficient to overcome  the  resistance;  since it  is scarcely pos-
sible for a considerable  effusion of blood to take  place in the cavity of the
uterus, Avithout causing a development of some pains, or at  least a marked
diminution in the resistance of the  cervix.  But  if it should  unfortunately
happen that this resistance  cannot  be  surmounted, I  think that multiple
incisions ought  to be made on the  neck itself.  If the  symptoms  were not
very urgent, it  would be better perhaps to have recourse to compression of
the abdomen, Avhich  would  prevent the Avomb from becoming inordinately
tlistended.  This procedure  has so often appeared successful, that its employ-
ment under like circumstances Avould be justifiable.
   C. Moderate Hemorrhage during Labor.—When the flooding occurs during
labor,  the indications it presents likeAvise vary according to the intensity of
the symptoms and the degree of dilatation of the  os uteri.  When the blood
escapes in small quantities, and  the  accoucheur is satisfied that it does not
accumulate within the organ, he Avill employ here the  same means as Avere
recommended for the slight  hemorrhages  occurring in  the latter  stages of
gestation; except  the blood-letting, Avhich'should only be practised Avhen
evident phenomena of plethora  exist, and also excepting the opium, which
would  here be  attended Avith the serious  inconvenience of suspending the
uterine contractions.  These general measures Avill usually prove sufficient
Avhen the neck is but little dilated, and the discharge is inconsiderable.
   But  should  the cervix be freely opened, or be so softened as to offer no
resistance, Ave should rupture the membranes, if they are yet intact;  and if
the flooding still  continued  after this rupture, the labor lingered, and the
pains though at first energetic, became gradually feeble, and the  intervals
between them longer, they should be aroused by the administration of ergot.
   D. Profuse Hemorrhage during  Labor. — Whether  the hemorrhage  be
internal or external at the time  of labor,  it ahvays offers the same  indica-
tions for treatment;  and these latter are  also based on the variable degree
of dilatation of the neck of the uterus.   For, if this is but little advanced,
that is, if the cervix be neither dilated nor dilatable, the remedies Ave have
advised for  the profuse hemorrhages occurring  in the latter  months  of
pregnancy should  again  be  brought into sei'A'ice; that is, the refrigerants,
the ergot, and a rupture of the membranes, if still  intact.  Should the flood-
ing continue after the rupture, and  the retraction of the os uteri render an
introduction of the hand absolutely impossible, the tampon should be applied
at once ; and the precaution  be taken to make compression over the anterior
surface of the abdomen, particularly if there is any inertia of the womb, so
as to prevent an accumulation of blood Avithin the organ.  And Avhere the 
I
784                           DYSTOCIA.

flooding persists, notwithstanding these measures, so as to endanger seriously
the mother's life, and  if at the same time the non-dilated and undilatable
neck should make it impossible to introduce the hand, ought Ave, according
to the example of certain  authors, effect delivery at all hazards, and intro-
duce the hand  by force ?   Upon contemplating the  published cases of this
kind, we are forcibly struck Avith  the results of this style of proceeding.
Almost all the patients died (21 out of 25 according to statistics by Simp-
son), and authors universally regard  the operation as of the gravest char-
acter.   We therefore think it prudent not to risk the injuries of the neck,
Avhich result so often from  a  forcible introduction of the hand, but if, after
a few moderate efforts, the rigidity  is not overcome, Ave Avould much prefer,
if the case were urgent, to  resort to Simpson's method, and first detach and
then extract the placenta.   Whilst the author of this process has certainly
advised it too generally, it seems to us that it could be usefully employed in
these circumstances, although, for our oavu part, Ave Avould prefer the use of
the tampon.
  Professor Simpson has, in  consequence of these facts, proposed to separate
completely,  and bring aAvay the placenta, whenever its insertion upon  the
neck has given rise to a hemorrhage Avhich threatens the life of the  mother.
Although rather too absolute at the outset, Mr. Simpson has finally yielded
to the numerous and valid objections  made to his precept, so far as to con-
fine its  application to  the following conditions:  1.  When the flooding has
resisted the  principal measures, and especially the evacuation of the waters;
2. When the slight  dilatation or development of the cervix, or contraction
of the pelvis, render turning or any mode of artificial delivery dangerous or
impossible;  3. When the death or immaturity of the foetus  restricts the duty
of the accoucheur to caring  for the safety of the mother.   It is, therefore,
especially with primiparous females, in cases of premature labor, or rigidity
of the cervix and of its spasmodic contraction, of organic  narrowing of  the
pelvis or of  the genital passages, of the death or non-viability of  the foetus,
and, finally, of extreme exhaustion of the mother, that the artificial separa-
tion may be practised.  It is to be understood, he  adds, that in cases of
separation or of extraction of the placenta, the foetus should be withdrawn
immediately, unless the hemorrhage should cease, Avhich it does  in the great
majority of  cases.
  Even  Avith this reservation,  we cannot approve  of the  advice of Mr.
Simpson; for Ave think  that Avhen the flooding continues after the evacuation
of the waters, and when the neck does not allow the  hand  to be introduced,
there is some chance left of saving both  mother and child by applying  the
tampon, being careful at the same time to compress  the abdomen, in order
to prevent the occurrence  of internal hemorrhage.
  We also  think, that Avhen an obstacle dependent on the neck, the soft
parts, or the pelvis, prevents the termination of the labor,  the tampon may
be applied with  advantage until the  dilatation of the neck alloAvs of the
intervention of art; for I cannot see in Avhat Avay, under these circumstances,
the extraction of the placenta  could facilitate that of the  foetus, Avhich Mr.
Simpson recommends to be practised immediately aftenvard.  The obstacles
which prevented earlier action  exist none the less afterward.   It is, there- 
PUERPERAL  HEMORRHAGE.
785
 fore, only when caring very little for the life  of the child, in case of the
 death or non-viability of the latter, that one  could undertake to separate
 and  extract the  placenta, if the hemorrhage  were dangerous, in  order to
 spare the mother the pain of applying the tampon.
   Finally, it  is  hardly necessary to add, that if the neck is sufficiently
 dilated, the delivery should be effected as soon  as possible, either by turning
 or by the  forceps.  When describing these two  operations, Ave shall point
 out  carefully the cases in which  one or the other  should be preferred.
   A host of other remedies have been successively extolled, but I have not
 spoken of them, because I have  never had an opportunity of employing nor
 of seeing them employed ; besides, their mode of action appears, on theoretical
 grounds, to be of little value; and hence, in my  opinion, their enumeration
 would uselessly burden the memory of students.

   [§ 3.  Treatment of Hemorrhage caused by Abnormal Insertion  of the Pla-
 centa.
   Having described in  the foregoing  paragraph the treatment adapted  to hemor-
 rhage caused by insertion of the placenta upon the orifice of the womb, the reader
 is referred to the account therein contained  of the various hemostatic procedures
 applicable  to such cases, as we  have  nothing to add to Avhat will be found there
 Btated.   (See page 775, et seq.)   Still, the importance of the subject and the danger
 involved in this form of hemorrhage, makes it proper to recapitulate briefly the best
 conduct to be observed.
   Hemorrhage caused by abnormal insertion of the placenta is generally moderate
 at the outset; with each return, however,  it becomes more profuse, the patient
 grows weaker, and consequently in a more unfavorable condition  for supporting
 the inevitable  loss of blood which  Avill accompany delivery.  Therefore we do not
 advise a very long-continued expectant treatment, and have no hesitation in recom-
 mending the tampon in order to arrest the recurrent hemorrhages, Avithout waiting
 for the  commencement  of  labor.  What, indeed,  are the grounds of  complaint
 against the tampon ?   Is it that it  is likely to induce labor?   But when  the pla-
 centa is inserted upon the mouth of the womb, the tampon  is still the best means
 of arresting the hemorrhage under the circumstances.  It ought, therefore, to  be
 applied  early, even should it be uncomfortable.  At  proper intervals, though as
 rarely as possible, it ought to be removed in  order  to allow the patient to urinate
 and permit the accoucheur to watch the progress of the labor,  which usually com-
 mences before long. Then it should be reapplied until the dilatation is sufficient to
 allow delivery to be accomplished by turning.  If labor does not come  on soon, and
 the tampon give great annoyance, its application might be postponed  until a fresh
 hemorrhage appears.  Under the last supposition, plugging  the vagina Avould be
 useless, though  not injurious;  therefore it should  be had recourse to at  the first
 recurrence of the discharge.
   Next to the tampon, rupture of the membranes seems to be the most useful. But
 in order to do it with safety, there should be decided contraction of the uterus, the
 head should present, and the insertion  of the placenta ought not to be central.  If,
 notwithstanding  tlie conjunction of all these  favorable circumstances, the flow
 Bhould continue after the membranes are ruptured,  the operation  would have the
 inconvenience of rendering internal hemorrhage possible through an effusion of
 blood into the cavity of the ovum.  When the placenta is merely situated in the
 vicinity of the cervix  and  labor  be clearly begun,  rupture of  the membranes  is
almost always productive of excellent results ; still, should the state of affairs be
Berious, we would prefer to use the  tampon.
      50 
786
DYSTOCIA.
  We regard the application of the tampon as the heroic measure against hemor-
rhage from insertion of the placenta upon the mouth of the womb or near it, and
rupture of the membranes as coming the next in  order.  The other procedures,
detachment of the placenta included, we have less confidence in, and refer to what
we have said of them in the preceding pages.  (See  Treatment of Hemorrhage, page
775, et seq.)]

  § 4. Kecapitulation of Treatment.
  I do not know better how to conclude  my remarks concerning the hemor-
rhages that may affect females, in the course of the latter months of preg-
nancy, and during labor, than by placing before  the reader a short summary
of their treatment Avhich M. P. Dubois caused to be distributed among the
students that attended his clinique;  for, as the Professor states, this table
may be considered as a  kind of vade-mecum.   Besides, the  reader Avill see
by it  how far I have conformed to his ideas, in  the treatment of hemor-
rhages just given.
  [After a very profuse hemorrhage has been arrested, the patient will  be so
weakened that she cannot be regarded as out of danger.  Women sometimes  suc-
cumb  several hours after the discharge of blood has  ceased, with  symptoms which
will be described hereafter in connection with the account of hemorrhage attendant
upon delivery  of  the  placenta, as also the treatment proper in such cases.   (See
Accidents attending Delivery of the Placenta.] 
                       A  SYNOPTICAL TABLE

Showing the Treatment of External Hemorrhages before and during Labor.
BEFORE
LABOR.
Moderate Hemorrhage.
          B.
Profuse Hemorrhage.
f Moderate Hemorrhage.
DURING
LABOR.
Profuse Hemorrhage.
f Horizontal position.
 Absolute rest.
 Fresh air.
 Cool acidulated drinks.
 Restricted diet.
 Venesection, if there are any symptoms of plethora.
 Empty the bladder and rectum.
'Same measures as in A, excepting venesection.
 At first cold applications — then,
 Ergot (^ss divided into three doses, at intervals often minutes.
 And, if these are insufficient, to apply the tampon, or perforate the membranes
 Orifice not dilated J Membranes  entire.
  and undilatable.  1 ,,   ,              ,
                  ^ Membranes  ruptured
                  f Membranes  entire.
Same  measures as in A, excepting venesection, which is im-
  proper, unless the plethoric condition be well marked.
Orifice dilated.
[ Membranes ruptured.
f                 f Membranes entire
 Orifice not. dilated J
  and undilatable. 1
                  I Membranes ruptured, -j
       Idem          Id.         Id.           Id.
 Same measures as in A, then wait, or rupture the membranes.
         Id           Id., then wait;  if the pains arc slow and
   feeble, administer ergot.
         Id.           Id., except venesection, then refrigerants;
   and in case of inefficiency, and the pains are weak, ergot, then
   rupture the  membranes;  lastly, if the orifice should not per-
   mit version, apply the tampon.
f Same me-asures as in  A,  then  refrigerants; then ergot, if the
   pains are slow and feeble ; in case of inefficiency, compression
   of the uterus, tampon, forced delivery
Orifice dilated or f Membranes entire.
    dilatable.    -j
                 ( Membranes ruptured.
  Rupture tlie membranes;  if this is not sufficient, make version,
\   or apply the forceps.
f Version, if the head is above the orifice;  forceps, if it is in the
\   excavation ; simple extraction, if the pelvic extremity present. 
788
DYSTOCIA.
                        CHAPTER XII.

                          OF  ECLAMPSIA.

  Among the various convulsive  diseases that may appear  during preg-
nancy, parturition, or the lying-in, there is one which  has such well-marked
characteristics, and whose physiognomy is so  peculiar, that I can scarcely
comprehend the want of accuracy that still  exists in most  of  our  classic
works  on this subject.   This confusion evidently arises from the fact that
the authors who have Avritten on puerperal convulsions have included under
this title all the affections Avhose striking  character is a convulsion;  forget-
ting that the epithet  puerperal should be applied, not to every disease Avhich
is developed before, during,  or after  labor, for then we might admit a puer-
peral pneumonia or pleurisy, but simply to one that is intimately associated
with that state, and  which  is only produced during its continuance.  This
confusion is further  caused, in  my opinion, by designating as convulsions
some affections that do not merit the name.
  These two propositions will be easily sustained by  an expose  of the dis-
tinctions admitted by some  authors.   According  to them, the convulsions
that occur during gestation   may be either partial or general.  Under the
name of partial  convulsions, they have  described  those  affections whose
principal  character  is a rapid, abnormal, and involuntary contraction of
one or  more muscular organs, and  Avhich,  consequently, are convulsive; but
Avhich are otherwise so different  from what has usually been comprised under
the denomination of the convulsions of pregnant Avomen, that  it is with some
hesitation, and only  to avoid the reproach of having omitted  any important
facts, that I allude to them here.  Thus, to  give  an example, those  violent
contractions of the stomach, observed in certain women who are affected
with severe and  obstinate vomitings during gestation, as  also the palpita-
tions of the heart experienced by some others, have been classed among the
puerperal convulsions.
  M. P. Dubois relates having  seen the walls of the belly contract with  such
force, in a Avoman in the fifth  or  sixth  month of her  pregnancy, that the
uterus  was completely pressed back into the excavation ; and the organ was
afterward observed to return briskly to its  place, and  to  rebound like an
elastic ballAvhen  throAvn on  the ground.   Some other tumefactions appeared
in the flanks, in the epigastrium, and umbilical region, which  seemed  to
depend as much on the spasmodic contraction of the viscera as on  that of
the Avails of the abdomen..   Nevertheless, this woman recovered Avithout
aborting.
  M. Velpeau states, in his excellent thesis, from Avhich I extract the fore-
going case, that a countrywoman, aged twenty-two years, was  much alarmed
on the tenth day after her delivery  by movements that took place in her
belly ; something like a globe was observed through  the  integuments and
muscles, which would travel sometimes towards  the  excavation, at others
towards the flanks, and again in the direction of the umbilicus. This species
cff ball would transform itself at times into several lumps, which  traversed
the  abdomen Avith a rumbling noise; but the Avails of this  cavity ahvays 
ECLAMPSIA.
789
<eemed  to preserve their normal  suppleness.  This Avoman  died  insane two
years afterwards,  without  these singular movements  ever having altogether
disappeared.   Can such a case be referred, Avith truth, to puerperal convul-
sions?
  According ft certain accoucheurs, the vaginal parietes are occasionally
so violently contracted, as to prevent the escape of  the  child, and even to
benumb the hand of the attendant by their spasmodic action.  But of all
the partial  convulsions, those of the uterus are the least questionable.  We
have already treated of the spasmodic  contraction of the external and in-
ternal orifices of the neck, which are capable of retarding the labor greatly
in ordinary cases, and, in breech presentations, may  cause  extension of the
head, and thus render its extraction  difficult; and we shall see, hereafter,
(art. Delivery of the Placenta,) what influence this retraction of the orifices,
which is evidently due to a convulsive contraction at  the superior or inferior
part of the cervix, as well as the partial one of some of the fibres  in the body
of the womb, may have over the delivery of the after-birth.
  We shall only mention here, that other cases, similar to those  detailed by
M.  Dubois, have been reported, in  which the uterus  has been observed to
pass rapidly upAvards, doAvmvards, and  towards the  sides of the abdomen;
and even to descend with such violence towards the vulva, that it Avas neces-
sary to sustain the latter Avith the fingers to prevent  it  from escaping;  but,
for  further particulars, Ave refer the reader to the essays of Baudelocque and
Miquel.
  The instances just referred to, doubtless resemble some of the  features of
the disease Ave are  about to describe under  the name  of eclampsia, in-being
characterized by a rapid, abnormal, and involuntary contraction;  but they
differ from it so much, in the triple aspect of symptoms, prognosis, and
treatment, that they cannot, in my opinion, be classed  under  the  same de-
nomination, without confounding things that are essentially dissimilar.
  The question iioav recurs, Avhat is the state of the case as  regards the gen-
eral convulsions of pregnant Avomen ?   Hysteria, tetanus,  catalepsia,  and
even apoplexy, have been observed during pregnancy and  parturition, and
have, on that account alone, been fortliAvith denominated as puerperal dis-
eases; and  although  these  affections offered the same symptoms as Avhen
they occur  in  the  non-gravid  state, though they Avere  essentially different
from eclampsia, properly so called,  yet they Avere considered as mere varie-
ties, or particular  forms, of this  latter complaint.    True, there  can be no
doubt that hysteria, tetanus, etc., are modified by the peculiar condition of
the  pregnant female;  and, as  in all  other  diseases  that occur  during the
puerperal period, the  danger to Avhich they expose  the patient is increased
by that to which they subject the foetus; but the hysteria does not thereby
become  less an hysteria, and the  tetanic convulsion has  not the less its
characteristic persistence.   These are evidently, therefore, distinct affections.
  I ought, however, to add, that the form of the convulsion may vary, and
that an attack Avhich at the outset presented all the characters of eclampsia,
might finally assume  the tetanic or  even the cataleptic form.  Supposing
that no error of diagnosis has  been committed, the  latter  are exceptional
eases, in regard to Avhich it is difficult to say whether  the same disease has 
790
DYSTOCIA.
assumed two different physiognomies successively, or Avhether  one disease,
catalepsy, has  succeeded to another, eclampsia.   Dr. Schmidt, of Pader-
born, and M. Danyau, have each published a case of this kind of  transfor-
mation.  (Journ. de Chirurgie, 1844.)
  Apoplexy may occur in the puerperal state, either as the principal dis-
ease or as a termination  or pomplication of eclampsia.   Often, indeed, as
stated beloAV, the puerperal convulsions  determine a cerebral effusion; but
then it is an effect, and not a cause, of the  accident.  There are likeAvise
some cases in Avhich the general circulation, as an effect of the  remarkable
modifications it undergoes during pregnancy, is strongly determined toAvards
the brain, and  may even result in an effusion; and if so, the latter is some-
times preceded by slight convulsions, or a tetanic stiffness in one or more
limbs; but  these soon pass aAvay and do not  reappear.   Here, then, the
apoplexy is the disease;  but it is nothing more.
  In my opinion, therefore, it must be admitted that, during the gestation,
the parturition, or  the lying-in, Avomen  may have attacks  of  hysteria, of
tetanus, or catalepsy,  or  may be struck with apoplexy;  but these are  so
many distinct affections, having but one common symptom with eclampsia—
the convulsion.  We hope that the details, into Avhich we are about to enter,
will illustrate the numerous differences between  them.
  For myself, I understand by the term eclampsia an affection characterized
by a series of fits, in Avhich nearly all the muscles  of relation, and often
also those of the organic life, are contracted  convulsively, and Avhich  fits
are usually accompanied  Avith or folloAved by a more or  less complete sus-
pension of the sensorial and intellectual faculties for a variable  period.
  General convulsions (eclampsia, properly so called) constitute a quite rare
disease.  M. Velpeau  did not observe a single case in a thousand labors
superintended  by him at the Clinique.   It  is probable,  however,  that this
proportion is  too  small; for, by consulting the statements furnished  by
Madame Lachapelle, Merriman, Ryan, Pacoud de Bourg, etc., it appears
that there was  one case of convulsion in about two hundred deliveries.   On
the other hand, the  practice of the principal accoucheurs of Great Britain
Avould furnish one case of eclampsia  in four hundred and eighty-five labors,
nearly.1
  It is, however, almost impossible to ascertain an exact proportion by con-
sulting the practice of any single man, since great variations are  observed
1 Bland, in	1,897 women,	met with 2 cases.
Joseph Clarke, " .	. 10,387 "	19 "
Merriman, "	2,947 "	5 "
Granville, " .	640 "	" 1 case.
Cusack, "	398 "	" 6 cases
Maunsell, " .	848 "	4 "
Collins, "	. 16,414 "	30 "
Beatty, " .	399 "	" 1 case.
Ashwell, "	1,266 "	" 3 cases
Mantell, " .	. 2,510 "	6 "
Churchill, "	600 "	2 "
                                    38,306                79
Thus we have 79 cases of convulsions in 38,306 labors, or 1 in 485, nearly 
ECLAMPSIA.
791
in different years; in my own experience, for example, I met with but three
cases in tAvo thousand deliveries occurring under my care at the Hotel Dieu
and the hospital of La Faculte, Avhilst house physician at those institutions,
whilst, on the other hand,  I met with seven cases Avithin the months of July,
August, September, and October, 1846, Avhilst in service at the Clinique.
  Eclampsia appears  indifferently at  all  seasons  of the  year;  although
some  authors  have seemed to consider, improperly, I think, that certain
atmospherical conditions  are not altogether foreign to its production, and
that  it  occurs more frequently  in  some seasons than in others.   Madame
Lachapelle, Avho  appears  quite  disposed to  adopt this  opinion, notAvith-
standing the summary she furnishes sustains her vieAvs but very imperfectly,
relies upon the fact that  at the hospital of La Maternite, several individ-
uals  are nearly ahvays affected at  the same time.   But I am strongly  dis-
posed to believe this circumstance is rather owing  to imitation than to the
influences of the atmosphere.
  This affection is very unusual in the early months of gestation :  M. Dan
yau,  Sen., however, met Avith it in a young  girl, avIio had only reached the
sixth Aveek, and in whom nothing  but the extraction of the ovum could
remove the symptoms.   The eclampsia came on again in her next pregnancy
about the same period, and  was followed by an abortion; but, in this in-
stance, the fits continued for some time after the abortion.
  A lady of Ferrara, about tAventy-eigbt years of age, of a bilious tempera-
ment, and the mother of three children, Avas  periodically attacked by con-
vulsions  as soon  as she had conceived, and these attacks were reneAved
every two Aveeks throughout gestation; so  that their appearance constituted
in her a sign of pregnancy.   It is \rery doubtful, hoAvever, Avhether her case
was one of true eclampsia.   As  a general rule, they are quite rare prior to
the  sixth  month;  they  are particularly frequent during parturition ; and
they  appear someAvhat oftener after the  delivery than during the gravid
state.
  The period  at  which they are liable  to  occur after delivery  varies
greatly;  though the eclampsia most commonly appears a feAV  hours,  or
sometimes  even a feAV days after delivery, examples are not wanting of its
being postponed for eight,  ten, or even tAvelve  days.

  § 1. Causes.
  The causes of eclampsia have  been divided into predisposing and deter-
mining.
  Upon a  careful investigation of the individual  conditions under which
eclampsia is generally found to occur, Ave are forcibly struck Avith a singular
circumstance, Avhich entirely  escaped the notice of the older observers : this
circumstance is  the almost constant presence of albumen in the urine of
eclamptic Avomen.   I say almost constant, for, Avith  the exception of six or
seven cases  mentioned  by M. Depaul  and Mascarel, in reference to Avhich
Ave shall have more to say hereafter, I am aAvare of nothing to  limit the
assertion.   This very remarkable coincidence, Avhich is at present well de-
termined by the observations of many physicians, and Avhich I have inva-
riably remarked in all  the  cases Avhich have come under my OAvn notice 
792
DYSTOCIA.
 within  the  last eight a ears, evidently seems to be the dominant fact in the
 etiology of puerperal convulsions.  Since the presence of albumen  is dis-
 covered almost constantly in cases  of eclampsia,  the severest mind can
 hardly  avoid establishing  a more  or less intimate relation of causality
 between the tAvo facts.
   But it has been observed, the  presence of albumen in the urine does not
 constitute a disease; it  is but the symptomatic expression of a local lesion,
 or of a general affection of the economy.  The latter are doubtless capable
 of producing eclampsia as  they had already caused  albuminuria; but most
 frequently their influence  is limited to the modification of the urinary
 secretion Avithout producing any nervous disorder.  This is  true, and M.
 Blot Avas right so far as he considered these tAvo morbid conditions as merely
 concomitant, and not that one was a consequence of the other.  M. Blot's
 remark has not, however,  in  a  clinical point of view, all the importance
 that has been attributed to  it.  Though  the cause of eclampsia be attributed
 to an organic lesion of the kidneys or to an alteration of the fluids of which
 albuminuria is  the  symptom, it is  nevertheless true,  that  as both these
 general or local lesions are to be detected with great difficulty during gesta-
 tion, whilst  the  presence of albumen may ahvays be discovered Avith  case,
 it was judicious to insist upon the importance of the albuminuria, which is
 alone capable,  in  most instances, of exciting a suspicion of the organic
 condition to which the eclampsia is apparently due.
  Since albuminuria is present in the immense  majority  of eclamptic
 women, it, or rather the disease of which it is the symptom, may be right-
 fully regarded as  the predisposing cause of eclamptic  convulsions.   I say
 the only knoAvn predisposing cause ; for, since attention  has been fixed upon
 this point, of all pregnant women, those only Avho are affected Avith albu-
 minuria (a  few  cases excepted)  have  been  knoAvn to be  attacked  with
 convulsions.
  Though all eclamptic patients have albuminuria, it does not follow that
 albuminuria, hoAvever severe, necessarily gives rise to convulsions. Happily,
 it is by  no means uncommon for pregnant Avomen  to have the urine highly
 charged Avith  albumen without  presenting  a single convulsive symptom.
 Of -11 women Avith albuminous urine, observed by M.  Blot, but 7 had con-
vulsions ; and of 20 mentioned  by MM. Devilliers  and Regnault, 11 only
 Avere affected with them.  The latter gentleman, it is true, examined the
urine of such women  only as Avere dropsical, and it is very  certain that
many cases  of albuminuria are not  attended  Avith infiltration.  Still, by
taking the mean betAveen  these different results,  and  having regard to my
own  observations,  I think  that  I come near  the  truth in saying, that one
 out of every four  or  five patients with  albuminuria will  be affected with
convulsions.
  The amount of albumen in the urine increases greatly during the con-
vulsive  attack, and generally diminishes after it.  This peculiarity has led
some persons to inquire Avhether the eclampsia, instead of being due to the
 alteration of the  urine,  might not be  the cause  of it.  I can understand
 why  there might be hesitation in regard to this point, if a single case could
 be cited in which it  had been proved that the urine Avas entirely free from 
ECLAMPSIA.
793
albumen for  several weeks  before the appearance of the accidents : this, I
oelicve, has never been done, but often, on the other hand, albuminuria has
been knoAvn  to  be present for some time before the convulsions occurred.
Besides, when Ave come to reflect upon the obstruction the venous circulation
produced  by  eclampsia, we can very  readily account for the active conges-
tion Avith Avhich  the internal organs, and the kidneys in particular, may be
affected during  the  attack.   Now, it is well knoAvn  that renal congestion
increases the secretion of albumen.
  The organic conditions which produce albuminuria are certainly the most,
I Avould even say the only ones, favorable to the  production of eclampsia.
This proposition, Avhich is at present incontestable,  explains the influence of
certain circumstances Avhich most authors have mentioned  as predisposing
causes : thus, among the latter has  been classed as one of the most active,
oedema of the loAver extremities, Avhen considerable, but, above all, general
infiltration, invading successively the body, upper extremities, and face.   It
is noAV a Avell-ascertained fact, that this  general  oedema is almost ahvays
connected Avith  an  alteration of the  urinary secretion, and  that only Avhen
accompanied Avith albuminuria does it appear to give rise to eclampsia.
   If it be true, as M. Rayer  thinks, that the compression exerted by the
developed uterus upon the  renal vein may eventually produce hyperaemia,
and then  an inflammation of the kidneys, Ave are able to  understand the
mode of action of  all the circumstances capable of increasing this compres-
sion.   Thus,  Ave can explain the possible effect of,  1, the extreme distention
of  the uterus, Avhether due  to dropsy of the amnios  or to  the presence of
several children;  2, of a  first pregnancy, in Avhich  the uterus is  strongly
applied  to the posterior Avails of the abdomen, in consequence of the resist-
ance of the abdominal parietes;1 3, Avhy, according to the observations of
M. P.  Dubois, rachitis is often connected Avith eclampsia, since, in women
affected Avith this disease, the small  stature and  limited space Avithin the
abdominal inclosure,  obstruct the  development of the uterus,  which, by
reacting in its turn upon the surrounding parts, forms a greater mechanical
obstacle to the regular fulfilment of  all  the  functions, and the venous circu-
 lation in particular.  (See Albuminuria, p. 488.)
   Whatever the cause may be, long-continued albuminuria necessarily occa-
sions a notable  diminution of the amount of albumen Avhich enters into the
normal composition of the blood.  Hence it is extremely probable that this
fluid, Avhen thus altered, gives rise to a peculiar excitement of the cerebro-
spinal centre, Avhich becomes  itself the direct  cause of the convulsions, or,
at  least, Avhich is more frequently the case, renders it more susceptible of the
excitements Avhich reach  it either from without, or from previously irritated
internal organs. These excitements, Avhich, under any other circumstances,
would have no effect, become here so many determining causes of an attack
of eclampsia.  (See, Urozmia.)

  1 Seven-eighths of ihe cases of eclampsia  have occurred in primiparous women
(Lachapelle);  in  thirty-eight of  those reported by Merriman, twenty-eight were  of
this class;  and more  than  two-thirds of the instances  given by Ramsbotham, and
twenty-nine in thirty of those by Collins, refer to women who were  delivered for the
first time. 
794
DYSTOCIA.
  An alteration in the quantity or quality of the blood often gives  rise to
convulsions  under other circumstances than  the puerperal condition.  M.
Rayer, and several other observers, have called  attention to symptoms
resembling epilepsy, as one of the  modes of termination of albuminuria
caused by albuminous nephritis, and it is Avell known that convulsions often
occur in the last moments of the unfortunate victims of profuse hemorrhage.
It is, therefore, no cause for astonishment, that the alteration of the blood
produced by albuminuria may have the same consequences during pregnancy.
The reason why these nervous  disorders are more frequent in  pregnant
women with albuminous  urine than in the other diseases  attended  with
albuminuria is, that to the only producing cause of epilepsy, in ordinary cases
of albuminuria, are added the congestions to which the nervous centres are
so liable during pregnancy and labor.
  Although the convulsions are generally spontaneous, and may be attributed
simply to  the condition just mentioned, there are some whose  appearance
seems to be connected with a  more readily  appreciable cause,  and Avhich,
therefore,  may be justly regarded as a determining cause.
  In  the list of occasional causes, certain Avriters have included  the most
common  and  indifferent circumstances, the mere recital of which we shall
spare the reader; but will simply mention  strong moral emotions, Avhose
influence,  though incontestable,  is  in some cases hard  to be explained.
There are some, however, which, in reference to treatment, deserve a careful
mention, for it is especially by removing the cause that the attack may be
arrested, or at least rendered less dangerous.
  The influence of the circumstances to which Ave allude  is at first limited
to organs  at a greater or less distance  from the  nervous  centres, and it is
only secondarily that the irritation transmitted  to  the  latter excites them,
and gives rise to the convulsion.  Thus it is that an irritation of the nerves
of the uterus, vagina, bladder, rectum, or stomach, may become the deter-
mining cause  of general convulsions.
  A.  Uterus.—All the causes of essential dystocia,  which  require longer
continued and more poAverful efforts on the part of the Avomb, may occasion
an  excitement of the sensitive nerves of this organ, which, when  transmitted
to the spinal marrow, is calculated to aAvaken the reflex action of the motor
nerve's.   Under this head we would indicate a malformation or obstruction
of the pelvis, a  partial  or complete obliteration of the  vagina or vulva,
organic alterations, and  spasm of the body or neck of the womb, foetal
deformities, or monstrosity, &c.  Unfavorable  positions of the child have
not, certainly, so great an influence as might at first be supposed.  Churchill
says that  " the effect of unfavorable positions has been greatly exaggerated,
for Drs.  Ciark,  Labatt,  and myself have witnessed but  a  single case of
convulsions coinciding with a bad  position in 48,397 labors."   In cases of
eclampsia the head is almost ahvays the presenting  part; but, as Tyler
Smith remarks, the first attack does not come  on at the moment the head
presses upon  the neck or clears its orifice, but  rather Avhen it distends the
perineum, and  partially  dilates  the vulva.   It is then,  especially, that a
prompt termination of the labor puts an end  to the convulsive attack by
removing the pressure from the soft parts. 
ECLAMPSIA.
795
   All the unfortunate circumstances that may complicate the labor and
 require the introduction of the hand, whether before or after delivery, should
 be mentioned as capable of producing the same excitation ;  such are encysted
 placenta, its abnormal adhesions, its partial or complete retention,  the pres-
 ence of large clots, retroversion of the uterus, &c.
   B.  Intestinal Caned.—The irritation produced by distention of the intes-
 tinal  canal, and especially by the accumulation of large quantities of fecal
 matters, and the presence of Avorms or foreign bodies in the large intestine,
 is sometimes also the determining cause of eclampsia.
   Both  Merriman and  Chaussier have  insisted upon the influence of a
 saburral condition of the primae viae, which influence is, they say, sufficiently
 shoAvn by the state of the tongue, and  epigastric  pain Avhich the patient
 nearly ahvays complained of at the onset  of an attack.
   The presence  of indigestible food in the stomach appears, in some cases,
 to have been the cause of convulsions.   John Clarke relates the history  of
 several Avomen who Avere so affected after delivery, in consequence of having
 eaten largely of oysters.
   c Bladder.— Lastly, the same may be said  of irritation of the  Avails  of
 the bladder produced by its extreme distention with  urine.  The curious
 observation of Mauriceau is Avell knoAvn, and Dr. Vines mentions an exactly
 similar case.   In the latter, the convulsions which had for two days resisted
 the delivery and all the generally recommended means, ceased immediately
 upon  Avithdrawing from the bladder, by means of the catheter, five pints and
 a half of a turbid and highly ammoniacal urine.
   Numerous other predisposing causes have likeAvise been described, the in-
 fluence of Avhich, hoAvever, it must be acknowledged, is far more difficult  to
 appreciate; thus, for instance, M. Baudelocque enumerates in his thesis, a
 residence in large cities, the use of small  or tight garments, an over-succu-
 lent diet, the abuse of spirituous liquors, constipation, retention of the urine
 (pointed  out  by  Delamotte), sexual intercourse,  the  suppression  of  an
 habitual discharge, too much sleep, Avant  of exercise, the  frequentation of
 balls or plays, anger, jealousy, bickerings, disappointments, &c.   There can
 be no doubt that all these causes, by modifying or  disordering the circula-
 tion, may render it more active,  and thus facilitate a sanguineous determina-
 tion toAvards the brain ; but they should evidently be considered in the light
 of a secondary predisposition, Avhich  may be added to some one  of those
 mentioned above.
  Epilepsy has also been considered, though improperly,  as constituting  a
 predisposition  to eclampsia;  for, though the   two  diseases have  a close
 analogy, yet those pregnant Avomen Avho Avere epileptic before their gestation
 commenced, are less subject to attacks then than at any other time.  Indeed,
 some authors have supposed that pregnancy suspends the epileptic fits alto-
 gether ; but  this is not absolutely the case, for they only occur  then more
 seldom than usual.
  Dr. Tyler Smith relates a curious case of an epileptic woman who had an
attack immediately after Avhat she regarded as the fecundating intercourse,
and avIio  experienced  an entire suspension of  the  disease during  the re-
mainder of her pregnancy. 
796
DYSTOCIA.
  We would repeat, in terminating this etiological study of eclan psia, thai
the various determining causes exist very frequently Avithout  giving rise to
convulsions.  The reason  of this is, that they are of themselves  incapable
of producing them, and have no real influence except in cases presenting in
a greater or less degree the general or local  lesion which occasions albu-
minuria.
  A review of all the causes Avill enable us to explain their mode of action.
It is evident that all of them have a tendency to produce  an irritation of
the nervous centres. This irritation is direct, when due  to the immediate
contact of vitiated blood, and indirect, or  by reflex action, when  it folloAvs
the excitement of a distant organ, as the bladder, uterus, &c.  I am happy
to find  in the work of Scanzoni  a confirmation of these vievys, long since
proposed by me.   Setting out Avith these ideas, Scanzoni divides eclampsia
into, 1.  Reflex convulsion, proceeding from the peripheral extremities of the
irritated sensitive nerves; 2. Spinal convulsion, produced by direct irritation
of the spinal marroAV, Avhich irritation is transmitted to the peripheral ex-
tremities of the nerves;  3. Cerebral convulsion, when the irritation resides
in the brain, and  is transmitted to the spinal marrow.  The existence of this
latter form is doubtful, and, for our OAvn  part, we are much  disposed to
believe  that eclampsia always has its origin in spinal irritation.  It is a
fact, proved experimentally by  physiologists, that irritation  of the spinal
marrow, of the medulla oblongata, or of the tuberculae quadrigeminae, gives
rise  to  convulsions  only, Avhilst  irritation of any other part of the  brain
produces nothing of the kind.  It is true that cerebral lesions may destroy
voluntary motion, but involuntary contractions, the excess  and disorder of
which constitute eclampsia, are not affected by them in the least.   The lat-
ter may be  produced by irritation of the spinal marrow or of its nerves,
even Avhen the cerebrum and cerebellum have been completely destroyed.

  § 2.  Symptoms.
  Like  Madame Lachapelle, we shall  describe three orders of phenomena
in the  attack of  eclampsia, Avhich, under the triple aspect of diagnosis,
prognosis, and treatment, are  of great importance, namely, the precursory
symptoms, those which are manifested during the fits, and  those Avhich are
sometihies developed in  their intervals.
  A. Precursory Phenomena.— An attack of eclampsia scarcely ever appears
unexpectedly, as it is almost ahvays preceded by certain phenomena, which
enable us to foretell its  speedy invasion.  Chaussier even supposed these to
be so constantly  present, that, in  the  feAV exceptional  cases Avhere the ob-
servers  have not mentioned them, it was because they Avere of short  dura-
tion, and, therefore, either passed aAvay unperceived, or else Avere misunder-
stood.   This opinion is, however, rather too unqualified.   The precursory
symptoms are sometimes absent, and, as M. Wieger remarks, the compara-
tive frequency of the prodromes differs according to the periods  at which
the convulsions make their appearance.  Those Avhich come on before labor
are, he  says, preceded  by premonitory symptoms in  forty per cent, of the
cases;  those appearing  during labor or the delivery of the placenta, have
the  symptoms  in  thirty per cent.;  and  such as are delayed until after
delivery, in twenty per cent, of the cases. 
ECLAMPSIA.
797
   These precursory phenomena are variable in duration; thus, for some
days, though occasionally only for a feAV hours, before the invasion of the
puerperal epilepsy, the patients complain of agitation or malaise;  they are
easily excited, are impatient and irritable;  they experience a marked diffi-
culty in respiration;  and they suffer from an exceedingly poignant and
acute pain in the head, which, like the megrim, occupies but one-half of the
cranium, and  sometimes  is even still more concentrated, and appears fixed
upon one  coronal  boss, or some other equally circumscribed point.  This
pain in the head, which is one of the most important diagnostic signs, nearly
ahvays resists all the curative measures usually employed ; it is accompanied
with nausea, or even vomiting, by vertigo, dimness of vision, tinnitus aurium,
and sometimes by an acute pain in the epigastrium.  (Chaussier, Denman.)
   When these primary symptoms have lasted for some time, they acquire a
greater degree of intensity, and are often complicated Avith a more or less
marked  disorder  in  the  sensorial  and  intellectual  faculties.   The vision
becomes affected, the sight seeming to be obscured  by a  thick mist, and the
patient distinguishes objects less  clearly;  sometimes even, as in a  case
observed by Dr. Meigs, of Philadelphia,  she sees only one-half of an object
held before her.1  The hearing is likeAvise less distinct; the touch not so fine
and less delicate ;  the Avoman's countenance exhibits  an  unusual hebetude;
the expression is fixed, the lineaments immovable, and she appears sunk  in
a deep abstraction, from Avhich she can only be aroused with some difficulty ;
she scarcely comprehends  the questions addressed  to  her,  and very fre-
quently replies incoherently.   In a plethoric female,  the pulse is full, slow,
and hard, and the face is occasionally flushed and animated; on  the  con-
trary, Avhere the patient is affected with anasarca, particularly  if she hap-
pens to  be  of an irritable, nervous  constitution, the  pulse is small, hard, and
contracted, the face is pale and the skin cold, especially on the extremities;
and sometimes  there  is  a  slight chill, or  an imperfect horripilation.  In
addition to these, some Avomen experience pricking sensations and formica-
tions  in the limbs.
   When the eclampsia appears during labor, it is often preceded  by extreme
indocility and agitation;  the  uterine contractions  also  present for  a time
that peculiar character of continuity and irregularity which  has gained for
them the name of uterine tetanus.
   The patient laughs and weeps  alternately, and  speaks with  volubility.
A state of hebetude and stupor sometimes succeeds to this extreme agitation.

  [b. Phenomena  of the Attack.— After the premonitory symptoms just mentioned
have continued for a length  of time, and in a degree which are liable to great vari-
ation, the first paroxysm occurs, and sometimes very suddenly.  The  very faithful
picture of it drawn by  M. Prestat in his inaugural thesis, would lead one to sup-
pose that he was reading the description of an attack of epilepsy, so striking is the
resemblance of these affections to each other.  Dr. Soyre, to whom we  are indebted

  1 It seems  to me  that these  disorders of vision are not due,  as  hitherto  supposed,  to
cerebral  congestion preceding  the eclampsia,  but that, in at least  the  majority of
cases,  they are consequent upon the lesion producing the  albuminuria.  It is wel]
knowD, indeed, that,  disordered vision and even blindness are not uncommon occur
rences in Bright's disease. 
798
DYSTOCIA.
for excellent works  upon the disease, very properly,  therefore, in his inaugural
thesis, divided the attack of eclampsia into certain stages, as Dr. Beau had already
done for the paroxysm of epilepsy.  The only fault which we find with them both
is for making the coma one of the stages of the attack, whereas it is but the end of
it.  We shall, therefore, admit three stages in the paroxysm of eclampsia:  1. The
Btage of initiatory convulsions.   2.  The stage of tonic  convulsions.  3. The stage
of clonic convulsions.
  1. Stage of initiatory convulsions.— These  almost ahvays begin in the face, the
mUscles of which are affected with very limited  and very rapid  choreic motions,
readily perceptible through the  skin.  The eyelids wink  very rapidly, but  suffi-
ciently to show the globe of the eye, which rolls upward  and  downward several
times successively.   The strongly  contracted" muscles  of  the alae nasi dilate the
nostrils;  the mouth is partly open, and soon becomes distorted by the depression of
one of its corners.  The convulsions of the face are  always more  marked on one
side than on the other; finally, the  head  inclines in the  same  direction, and ap-
proaches  the shoulder.
  At the same time, the limbs, especially the arms, are  affected with convulsive
jerkings.  The forearms are violently pronated; the fists are closed, with the thumb
either bent into the palm, or extended and inserted between the forefinger and the
medius.  This stage rarely  lasts  longer than a minute.
  2. Stage of tonic convulsions.— Suddenly,  the  look  becomes completely fixed;
the countenance, taken as it were by surprise, and rendered immovable in the midst
of its  grimace, exhibits barely a  few limited fibrillary contractions.  The tongue ia
thrust out of the mouth, the masseters close the  jaws strongly, and the tongue ia
badly bitten, unless care has been taken to push  it in, or prevent the teeth  from
coming together.
  The limbs and the trunk  stiffen in the just described attitude; breathing is sus-
pended, and there is an instant of general immobility, when death seems impending.
This stage is very short, rarely lasting  over a few seconds.
  3. Stage of clonic  convulsions.— Relaxation  soon occurs, and  the  tonic spasm
subsides  to be succeeded by clonic convulsions, which appear  simultaneously in
various parts of the body, giving rise to shocks corresponding with alternate con-
traction and relaxation of the muscular system.
  The face, which had been drawn  to one side, returns to the median line; the head
vibrates from one side to the other. The eyelids open and close suddenly, with
rhythmic regularity.   The orbicular, canine, and zygomatic muscles of the lips are
jerking,  and the patient  seems to be chewing or endeavoring to mumble some
words.  Respiration  is imperfect and quickened.   The face is congested, swollen,
and acquires a bluish or livid hue.
  Air, mixed with saliva and blood from the wounded tongue, gives rise to a  bloody
foam, which fills the  mouth and  is discharged between the lips.  The  appearance
of the patient is then  truly  hideous.
  The convulsive movements of the limbs are generally quite limited in extent: if
the woman is lying on her back, she retains the position without  need of holding,
and it is only necessary to take care that she does not fall out of bed.
  The clonic convulsions occur twice, thrice, or even four times or more per second.
Though this stage of the attack is generally short, it is liable to be prolonged; cases
are noted in which it  lasted ten minutes,  and I know that  I have seen it last for
twenty minutes, by the watch.]

  The muscles of the hollow organs do not remain altogether indifferent to
the disorder in the external muscular  apparatus;  for the fecal matters, the
urine, and the contents of the  stomach, are often expelled by the  convulsive
contraction of the reservoirs in which they had accumulated. 
ECLAMPSIA.                           799
  The respiration is  interrupted, noisy, and affected by continual jerkings
 without any regular order; sometimes, indeed, as Madame Lachapelle has
 observed, it is wholly arrested by the spasmodic contraction of the diaphragm
 and other muscles of the thorax.
  According to Dr. Tyler Smith, the muscles of the larynx are contracted
 convulsively, so as to  obliterate the  glottis  almost completely;  hence the
 respiration is either suspended or noisy, and the inspiration short and quick;
 consequently, hematosis is either suspended or diminished.  This momentary
 asphyxia  explains satisfactorily the  bluish,  or even blackish color of the
 face and extremities, the SAvelling of the head  and neck, Avhich are gorged
 with  black blood, as also  the frightful  turgescence of the  skin, eyes, and
 tongue.  The carotids beat violently, and the jugulars stand out prominently.
 The secretion of the salivary glands is increased  by their congestion.   The
 jaAVS  are  closed forcibly, and in consequence of the approximation of the
 teeth, and the quantity of saliva in the mouth, the air escapes with a hissing
 noise, and by agitating the saliva, forms a  thick  foam, which is expelled
 continually from  the mouth.   This  foam is not unfrequently stained with
 blood from wounds produced in the tongue by the teeth.
  The spasm  of the pharynx  renders SAvalloAving  impossible, so that sub-
 stances placed upon the base of the tongue, remain there to the risk of pro-
 ducing asphyxia.  In a case of this kind, Dr. Simpson (of Stanford) excited
 deglutition by placing the substance  to be swallowed  in the upper part of
 the pharynx, and sprinkling the face with cold Avater.
  According to Dr. Smith, the muscular fibres of the  heart may  also parti-
 cipate in the general convulsion.  The extreme lividity and turgescence of
 the entire surface of the body are  sometimes  greater in eclampsia than in
 ordinary asphyxia, the entire body being in the condition in Avhich the head
 is found in persons Avho have been hung.   Dr.  Smith thinks that this state
 is attributable to the venous circulation;  may it  not  be asked, he  says,
 whether there is not a spasmodic contraction  of the  right auricle, giving rise
 to a congestion of the entire venous system from the vena cava to the capil-
 laries?  And is not this supposition confirmed by  the autopsy, exhibiting,
 as it does, the ventricles and  auricles  completely emptied of blood ?
  A very remarkable circumstance, and one which seems to me to proAre the
 uraemic nature of eclampsia, is the suspension for a longer or shorter time
 of the urinary secretion.  I  have had occasion, several times, to introduce
 the  catheter during the  attack, and have found the bladder quite strongly
 contracted, and entirely empty.  In the majority of cases, I have not been
 able to obtain more  than half a spoonful of urine, Avhilst  in others it was
 impossible to extract a drop.   It is Avell known that ischuria is one of the
 symptoms of  poisoning by uraemia.
  At  the commencement of the fit, the pulse is full and hard, subsequently
 becoming smaller and almost imperceptible;  the skin is hot and dry, and is
soon covered by a profuse perspiration. This transpiration usually coincides
with a diminution in  the  frequency and intensity of the  spasm, and an-
nounces its speedy termination.  While it lasts, the sensorial and intellectual
functions are Avholly abolished ; the patient is  conscious of neither sound nor
light; the sensibility is entirely lost, and  we  may pinch, incise, or burn the- 
800                           DYSTOCIA.
skin Avith impunity, and without her knowledge, and even without her re
collecting it after the fit.
  The effect of the convulsions upon  the contractility  of the uterus is
extremely variable.   During the attack, the uterus sometimes remains pas-
sive, astonished, as it Avere, at the  universal disorder;  whilst, on the other
hand, there are cases in Avhich, Avhether the eclampsia comes on during labor
or precedes it,  the contractions  continue  with  their normal regularity
Occasionally, also,  it seems  to  participate in the general irritation, and
expels the foetus very rapidly, even Avhen  the  slight dilatation of the neck
would appear to indicate that delivery was yet distant.  This rapid expul-
sion, of AA'hich the patient is entirely unconscious, may escape the attention
of the accoucheur, and in some instances the child has  died asphyxiated
between the mother's thighs, for Avant of the proper attentions.
  I think,  however, that these  rapid deliveries are far less frequent than
some accoucheurs imagine.   The idea of an earlier delivery than usual may
have  had its origin in a neglect to ascertain  the condition of the cervix,
which may have become  dilated Avithout  the consciousness of the female.
Whenever  I have been able to follow up  the  labor, the cervix has ahvays
appeared to me to dilate very slowly,  and has  often seemed to be contracted
spasmodically, as though it participated in the general convulsions.  The
expulsive stage is, I think,  shorter than usual, a fact readily accounted  for
by the energy of the uterine  contractions and the slight resistance of  the
perineum, the muscles of which are in a state of resolution during the coma.
  Although the fits do not accompany each pain, they nearly always come
on just at the commencement of one.  " This  appears to me to be so  mani-
fest and decided," says Dewees, " that I think  I could  tell what is going on
at the mouth of the uterus, without an examination per vaginam."  This,
hoAvever, is not ahvays the  case; for, under some unusual circumstances, the
contraction appears only when the convulsion has reached the loAver extremi-
ties.  Therefore, although  in  the  first case the uterine action appears to
determine the convulsive attack, in the second  it seems to be the consequence
of it.  It is possible that this difference may  furnish an explanation of  the
variable effect of eclampsia upon the termination  of labor.
  The cessation of  the  convulsive attack is never abrupt;  the movements
and spasms gradually become less violent; the respiration is less hurried
and more full; the face loses part of  its lividity ;  the muscles are only agi-
tated at intervals, and their action  resembles that which is  excited by
passing a brisk electric shock through them.
  In general, the first fit is of short duration,  and not very violent; but, in
most cases, the fits are repeated  frequently, and the sj7mptoms become more
and more frightful in proportion as they  are  reneAved ; the succeeding one,
say Merriman  and Velpeau, being often  heralded by an  uncommon sIoav-
ness in the pulse.   In the latter  paroxysms, Madame Lachapelle has re-
marked that the convulsive  shocks are less considerable, and sooner over
than  the earlier ones, but that the comatose symptoms are more grave and
persistent.   I do not regard this as correct, but it is true that the comatose
symptoms are more serious and persistent.
   The duration of  an attack is very variable.  The first fits are commonly 
ECLAMPSIA.                          801
the shortest, becoming more prolonged  as  they are reneAved.  At first, they
last from one to two minutes, and afterwards from three to four;  but they
rarely exceed six to eight minutes.   It is said that  they have lasted for a
quarter or half an hour, and even for a Avhole hour;  but those authors Avho
pretend to have knoAvn them to continue  for  several hours, have evidently
regarded both the convulsive and comatose periods as parts of the paroxysm.
The number and rapidity of the convulsions are equally variable; in nearly
all cases, there are tAvo or more, and  sometimes they have reached as high
as sixty.  In some instances, there is an interval of several hours, or half a
day, betAveen them ; while in  others, on  the contrary, only a few minutes
elapse before the return of the next.
   C. Interval.—The patient remains in a state  of complete prostration during
the intervals of the first three  or four paroxysms;  but  she soon comes to
herself, opens her eyes, and looks at  everything around Avith  astonishment;
she scarcely recognizes the persons  and  objects about her, and cannot  be
made to comprehend the distress and anxiety of her friends and family, for
she has no knowledge  of what took place Avhile the fit lasted;  but in a short
time her ideas become clearer, and  at  length she entirely recovers the use
of her faculties.  These lucid intervals are quite prolonged after the early
attacks; but,  as they are  reneAved, the  moments  of intelligence become
shorter and shorter during their intervals, and the Avoman ultimately sinks
into a state of profound coma or  apparent death; from which  she is only
aroused by the return  of fresh convulsive movements.
   This comatose state  presents all the characteristics of an intense cerebral
congestion, of Avhich  indeed it  certainly  is a consequence.   Even if it  be
supposed that during the convulsion the muscular fibres of the auricles pre-
sent no obstruction  to the return of the venous blood, the violent contraction
of the muscles of the neck certainly compresses the \reins there situated, and,
by preventing the return of  the  blood, gives rise to  cerebral congestion,
which produces the insensibility during the attack, and the sleep which fol-
Ioavs it.  The stupor is profound, the face injected, the respiration stertorous,
and the limbs are in a state of perfect flexibility ; but the sensibility, though
greatly blunted, is rarely lost altogether, for Avhen Ave pinch the  patient, or
rub her roughly, she shows signs of uneasiness, and groans very much like
individuals who are laboring under a severe concussion of the brain.  How-
ever, the torpor may be such that the sensibility is entirely lost; but even
then the female appears to be conscious of the paiu caused by the uterine
contraction,  for, Avhen  the latter comes on, she evinces by her countenance
and groans,  the sufferings she experiences.  The intellectual  faculties seem
to be  wholly abolished, the pupils are dilated and insensible.   In general,
the pulse is strong and developed.
   When this comatose state  is about passing off, it changes  into a somno-
lency, from Avhich the  Avoman may be aroused by  speaking to her; and the
sensorial faculties gradually  return.  AY hen  the torpor  is dissipated, she
complains of great  fatigue, and of a  feeling of painful Aveariness; then,  at
the end of a  variable period, this prostration gives Avay to great anxiety, the
prelude of a fresh attack.
       51 
802
DYSTOCIA.
   § 3. Termination of Eclampsia.
   An attack  of eclampsia may terminate either by recovery, ly death, or
by giving rise to some other disease.   AYhen the patient is likely to get well,
the paroxysms are usually feAV in number, of short duration, and occurring
after  long intervals.   During this latter period, the female recovers more or
less completely the use of her limbs, as also of her sensorial and  intellectual
faculties.
   AYhen there is to be no return of the fit, the intellectual  faculties are the
longer in regaining their normal condition as they have  been the more  dis-
ordered, or as they have been suspended for a greater period.   The memory
particularly is much weakened, sometimes even is  altogether destroyed, for
the patient not  only cannot recall Avhat took  place during the fit, but she
has likewise forgotten  the common  occurrences of the few days preceding
the invasion of the symptoms; and it is only restored by degrees, each hour
adding some facts to those of Avhich she had  previously recovered the recol-
lection.  It is singular that this defect of memory is often limited to isolated
words; thus some have  been knoAvn to forget entirely the names of their
nearest relatives;  others could  no longer recall the name of the street, or
the number of the house they occupied; and certain others again had  en-
tirely lost the memory of dates.
   Alphonse Leroy reports one instance in which a very singular aberration
of vision folloAved some convulsive phenomena, that held the  patient's  life
in jeopardy for several  days; all the objects that Avere brought  before her,
and all the surrounding persons, looked black.
   The sight and hearing likeAvise require a certain time for tne recovery of
their  perfect  integrity;  the woman's  general  condition  is thus gradually
ameliorated, and ultimately she regains her usual health.
   On  the contrary, Avhen  the  disease  is  about to  terminate by death,  the
convulsive attacks are observed to last for four, five, or six  minutes with
great intensity ;  they occur in rapid succession, and during the interval that
separates them, the female is sunk in  a torpor, from which she cannot be
aroused by any external irritants.   The period  at which  death takes  place
under such circumstances is very variable, though  in general it  is between
twelve and forty hours after the invasion of the first symptoms.   Sometimes,
hoAvever, the patient dies  at the outset of the  disease.   The head, says  M.
Depaul, began to distend the perineum and appear at the vulva, and  there
Avas nothing to  excite alarm,  Avhen I  suddenly observed a change in  the
patient's countenance, characterized by convulsive movements, and grimaces,
heralding eclampsia, and death folloAved immediately.
  The child Avas extracted alive by the forceps, but it died a few minutes
after with eclamptic convulsions.
  Death may  occur in the convulsive stage, or in that of the coma.  In  the
former case it is evidently  due to asphyxia, Avhich is itself produced by  the
paralysis, or rather by the permanent contraction of the muscles of the chest
and of the glottis ;1 in  the latter, it is  a result of the cerebral  congestion,
and sometimes even of a true apoplexy.
  1 This asphyxia might also result, according to Boer, as a consequence of the ob-
struction of the bronchial ramifications,  in  which a  considerable quantity of frothy
mucus sometimes accumulates. 
ECLAMPSIA.
803
   Finally, there is no reason why Ave should not admit, with  M. Aran, that
death may, in some cases of eclampsia, result from a sudden a rest of* the
movements of the heart.1
   Again, an attack may not be grave enough to end in death, and yet may
give rise to several very serious disorders.   For instance, Avhen the eclampsia
occurs in  the commencement of the labor, the violent  contractions of the
womb may cause  rupture of the organ, if the  os uteri  is not  sufficiently
dilated.   Again, it is possible that the disorders  in the circulation may occa-
sion a cerebral congestion;  and the consequent engorgement of the vessels
of the brain  may be such as to produce their rupture, Avhich  is folloAved  by
an apoplectic effusion, and, as a consequence, by hemiplegia.  In plethoric
women, this anatomical lesion might even be produced by the early parox-
ysms ; and it is probably in this Avay that the cases observed  and described
by M. Meniere, under the name of puerperal apoplexy, might be interpreted.
   A sanguineous determination may also  take  place toAvard  the lung, and
thus produce congestion of that organ.
   As a possible  consequence of the  congestive condition of the brain and its
membranes, Ave should also mention a state of irritation, Avhich occasions and
maintains for a longer or shorter time, a complete or  partial delirium, and
sometimes even, the symptoms of a true meningitis or meningo-encephalitis.
Of the seven eclamptic Avomen treated at  the  Obstetrical Clinic, Avhilst I
was on duty, four presented evident symptoms of meningitis after the coma
had entirely passed off; tAvo of them died, and exhibited the  anatomical
characters of meningitis at the autopsy.
   But independently of these unfavorable complications, which constitute so
many new diseases for  the physician to combat, there is another one Avhich
is less immediate, but not less rare, says Madame Lachapelle; that is puer-
peral peritonitis.
   In conclusion, certain cutaneous or intestinal inflammations  may result
in consequence of the energetic measures  employed  against the eclampsia.
Thus, the life of  the patient has sometimes been endangered by an  attack
of entero-colitis.   The sinapisms, also, Avhich are then crowded on the lower
extremities, are not felt by the  patient, and may be forgotten  in the general
agitation ; consequently, they remain  applied too long, and thus produce
erysipelas  and  severe vesications.   A lady, reported by M. Velpeau, was
attacked,  on  the second day of her  convalescence, by a violent  erysipelas
over the Avhole  leg, because the sinapisms applied there produced no effect
at first, and therefore Avere alloAved to remain on too long.
  1 The heart, says M. Aran, is a muscular organ, and as such is certainly liable to
have its innervation affected,  as also the properties with which it is endowed as a con-
tractile agent, that is to say, its irritability, motor power, and tenacity
  To whom, for example, is it not evident, that if the heart, which is sometimes known
to be lacerated by its own contractions, should be paralyzed by an interruption of
nervous action or by the  loss of some  of its muscular properties,  death would be
instantaneous ? Would it not be equally so, if, instead of ceasing to contract, it should
be atfected  with spasm, as  happens to some of the external muscles?  May it not lie
Bupposed thai several  convulsive neuroses, in which death sometimes  takes place sud-
denly, as epilepsy, eclampsia, spasm of  the glottis, &c, prove fatal less from deficient
haunatosis than from a complete and instantaneous cessation of the pulsations of the
heart? 
804
DYSTOCIA.
   § 4. Diagnosis.
   The minute detail into which we have entered in describing the s} mptoms
of eclampsia  might  possibly dispense with a return to its p incipal  char-
acters ;  but as there are  some affections that have a strong analogy to puer-
peral convulsions, we shall again bring  forward the signs by Avhich they can
be distinguished.
   AYhen considered as a whole, eclampsia is so easy to diagnosticate, and its
symptoms  are so well marked, that it  really seems  useless  to recapitulate
them ; but  it is composed of two widely  different stages, the paroxysmal and
the comatose, during either of which the physician may be called upon to
decide what is the nature of the  affection.  Thus, during the paroxysm, it
may  be  confounded  Avith  hysteria,  epilepsy, catalepsy, or tetanus; Avhile
apoplexy,  concussion of the  brain,  and the coma of drunkenness may be
mistaken for it in the comatose stage.
   HoAvever, in hysteria  there is sometimes an alteration, but never a total
abolition, of the intellectual poAvers; indeed, the sensorial faculties have an
unusual degree of delicacy and perfection ; there is no coma after the fit, and
the convulsive movements  are altogether different from eclampsia;  thus, the
limbs become forcibly flexed (instead of being extended,) and subsequently
writhe Avith violence; there is a continual tendency  to change the  position,
and  the  patient would certainly throw herself out of  bed if she were not
held  doAvn by  vigorous  arms.  Again,  an hysterical  paroxysm is nearly
ahvays preceded or accompanied by the sensation of a ball rising from the
hypogastrium toAvards the throat, Avhich gives rise to a feeling of suffocation
similar to that produced by strangulation.
  Deglutition  is very difficult or impossible, but the  muscles are much less
strongly contracted, and instead of that Avhistling respiration which indicates
constriction of the throat, there are loud cries, proving a free opening of the
larynx.   There is almost never frothing at the mouth as in eclampsia.   The
thumb, instead of being  flexed in the palm of the hand, is extended outside
of the other fingers, which are flexed.  Finally, hysteria generally appears
in the early months, whilst eclampsia  appertains more particularly to the
termination of pregnancy.
   But of all the convulsive affections, epilepsy is the most likely to be con-
founded Avith eclampsia.   It is unusual, hoAvever, for the patients to utter a
cry at the beginning of an attack of eclampsia, as is very common in  epilepsy.
This is the first point of difference as noted by Chailly and de Sailly, and
which I can confirm  from personal observation.  Succeeding the  epileptic
paroxysm there is little or  no coma,  Avhich is ahvays  present to a greater or
less  degree after puerperal  convulsions.  Still,  as epilepsy is sometimes
followed by a  profound coma, it will  be necessary to examine the urine,
which will  not usually be found to contain albumen as  it Avould in a case of
eclampsia.
   Moreover, in the latter disease, microscopic examination of deposits in the
urine Avithin tAventy-four hours after its evacuation, may detect the presence
of the cylinders of fibrin described by German authors, as well as blood and
mucus corpuscles'and epithelial cells from the ureters.
   It is well, however, to bear in mind that the same observation applies tc 
ECLAMPSIA.                          805
the presence of these cylindrical bodies in the urine as to the albumen and
blood, namely, that sometimes feAV or even none  are detected by the most
careful examination;  and the same thing has been observed  in all varieties
of Bright's disease.   It has been shoAvn  by A\reld, that the  occurrence of
these  exudations is  intermittent, and that, consequently, there are times
when  none are present in the kidneys.   This explains why some observers,
M. Blot, for example, have never met with them.
  The persistence of the convulsive rigidity of the limbs distinguishes tetanus
from every other disease.   Finally, catalepsy presents as an essential char-
acter the singular peculiarity, — that the extremities often preserve through-
out the Avhole fit the position Avhich  they happened to have at its commence-
ment, or any one Ave  can succeed in making them  assume during this con-
vulsive state.
  The comatose stage of eclampsia Avill be  distinguished from apoplexy by
the folloAving signs : it has been preceded by convulsive phenomena,  Avhich
is not the case in the latter  disease; all the extremities are in a state of
complete resolution, and they have entirely lost their sensibility and mobility;
and, most generally,  only hemiplegia results as a consequence of the cerebral
effusion.   It must, hoAvyvcr, be observed that, Avhen the eclamptic paroxysms
are frequently renewed, and the patient's  intelligence has been lost for some
time, the cerebral congestion, Avhich keeps  up the coma, may determine an
effusion into the substance  of the brain.   Hemiplegic phenomena then
appear at once, and it Avill be possible to detect, on the side  opposite to the
one where the effusion took  place,  a more complete loss of  sensibility and
mobility, though the limbs on the other side may be in a state of resolution.
The reader Avill understand that, if the previous history  were unknown, the
diagnosis Avould then be very obscure.   The  loss of intelligence is  ahvays
constant and total in  eclampsia, whilst this phenomenon may be Avanting in
apoplexy, or be limited to a simple obtuseness.
  In cases of concussion of the brain, the absence of all previous convul-
sions, together Avith the presence of the marks of a fall, or of a violent bloAV
on the head, Avill serve to make out the diagnosis.
   Lastly, the previous  history of the patient, the  ejection of the contents
of the stomach  mixed  Avith  a large quantity of alcoholic liquors, and the
vinous odor of the breath of intoxicated individuals, will enable us  to dis-
tinguish the coma of  drunkenness from that of eclampsia.

  § 5. Prognosis.
  Eclampsia is a very dangerous affection,  but Ave   cannot  agree with
Madame Lachapelle, Avho  states that one-half of  the women affected with
it are lost.   In  order  to appreciate this  conclusion from the practice of the
illustrious midwife, it is necessary to bear in  mind the  peculiar conditions
in Avhich  the patients at La Maternite  are placed.   After  consulting the
numerous cases  Avhich I have had occasion  to observe, I think I  might
safely say, that Avhen  the patients receive proper care in  due  time, the mor-
tality is hardly greater than one out of three and perhaps four.
  The prognosis varies, however, according to the cause that gave  rise to
the convulsions, to the stage of the puerperal condition  at Avhich they are
manifested, and to the particular progress of the symptoms. 
806
DYSTOCIA.
  Of all the various predisposing  causes, serous  plethora, or a partial or
general infiltration, says Madame  Lachapelle, must give rise to the most
unfavorable prognosis.   This proposition  noAV appears  to  us a great deal
too absolute.  General  infiltration  should doubtless be considered as pre-
disposing  to  eclampsia  much more than partial oedema; but AA'hen the dis-
ease has once appeared, the general or partial  infiltration adds nothing to
the gravity of the prognosis.   This results evidently from the observations
of MM. Blot,  Regnault,  and  Devilliers.   Thus, of four  patients Avith
eclampsia, observed by M.  Blot,  three  died, whilst all of  three  others
affected in the same way,  but free  from oedema, recovered.   So, also, MAI.
Regnault  and Devilliers, Avho had tAvo deaths for tAvo  non-infiltrated cases
of eclampsia, observed  but five deaths for nine cedematous cases, and three
others fell victims to later  complications  succeeding the eclampsia.  In
short, the patients Avith  eclampsia and albuminuria, Avithout oedema, give a
mortality of 7  out  of  15;  and  those with  oedema, a  mortality of  11
out of 51.
  As albuminuria is almost always  pre-existent  to eclampsia, it can have
no other  effect than is  referable to its  longer or shorter duration and its
quantity.   Albuminuria of very recent  date, or of «the  kind styled  transi-
tory, and yvhich gives only a slight cloud by the  use of reagents, will lead
to a much less unfavorable  prognosis than if it  had existed for several
months and  had  afforded a  copious deposit of albumen.  An old case of
albuminuria ahvays  supposes an advanced disease of the kidney, or else an
altered state of the  fluid.   The cases  observed  by MM. Devilliers and
Regnault, prove that death  then occurs most frequently either during the
coma, or as a  consequence of ulterior complications.  The folloAving table
of 36 cases, by Braun, leads to the same conclusion.
Albuminuria.	No. of Cases.	Mothers Cured.	Died.	
			In the Convulsions.	Of Complica-tions.
Very severe, .... Very considerable, . Considerable, .... Slight,......	3 7 14 8 4	1 3 9 7 4 ♦	3 4 0 0	0 1 1 1 0
  The convulsions that are developed in hysterical and epileptic patients,
or in Avomen of great nervous  susceptibility, and those Avhich succeed any
acute moral emotion, are less formidable than those Avhich have no relation
Avith the former  nervous state of the female.   Finally, the eclampsia that
can only be explained by the general alteration of the blood produced by
albuminuria, is much  more dangerous than that Avhose- appearance seems
connected Avith the irritation of some organ, as the uterus  bladder, intestine,
&c.; for in the latter case, sublata causa, tollitur effectus.
  As the depletion of the uterus is one of the most favorable conditions for
the cure of the paroxysms, it is evident  that,  other things  being  equal, 
ECLAMPSIA.
807
eclampsia is far more serious Avhen it comes on at the commencement of the
labor, than where it is not manifested until the dilatation of the parts is so
advanced as to render a spontaneous or an artificial delivery both  possible
and easy.   The convulsions are likewise more dangerous Avhen manifested
at an early period of the gestation; not  only because  the patient, in case
of recovery, is exposed to fresh attacks during the  remainder of this state,
but also because the complete obliteration of  the orifice, and the hardness
and length of the cervix, will render the depletion of the Avomb impossible.
It is unnecessary to add that, in this respect, primiparae Avill be much more
exposed than yvomen Avho  have previously borne children.  The truth of
this assertion has been questioned of latter time, but I am happy to find a
resume in  the  memoir of M. AATieger, Avhich  confirms  it fully.  Of sixty-
five  Avomen  at  different  stages of pregnancy, avIio were attacked  Avith
eclampsia, tAventy-five died, either during the attack, or in consequence of
subsequent complications.  That which takes place after the  delivery is the
least  unfavorable  of all; or rather such  is the opinion of  Duges; but I
believe with  Ramsbotham, that the prognosis Avould  then be much more
serious.   I have remarked, says the latter,  and here  again  I agree  AA'ith
him, that Avhen the  convulsions come on in  the last  stages of labor, and
continue after  the delivery, the woman  generally dies; but  if  they are
arrested by the delivery, they seldom return, and the gentle slumber Avhich
then succeeds is the signal of a prompt convalescence.
   The course and  intensity of the symptoms of a convulsive attack greatly
influence its termination:  thus, Avhen the paroxysms  are numerous  and
violent, and folloAv each other in quick succession, more particularly if the
comatose state  is prolonged during the whole interval  that separates them,
and Avhen the patient does not recover the  use of her sensorial and intel-
lectual faculties in this interval, the prognosis is exceedingly unfavorable,
for death most usually results.
   Again, it must not be supposed that all danger is over when the labor is
terminated and the convulsions have altogether disappeared ; for according
to Denman, Collins,  and others, the patients are then much exposed to con-
secutive abdominal inflammations, Avhich, as is  well knoAvn, often  compro-
mise their existence.
   After the complete cessation of the accidents, the albuminuria is generally
found to disappear rapidly, so that sometimes  no traces of it remain at the
expiration of four  or five days subsequent to delivery.
   This circumstance is a happy one, since it  justifies the expectation  of a
happy convalescence.  But if the  urine remains charged Avith  albumen for
ten or fifteen days  after the termination of the  eclampsia, a return of the
accidents is to be feared, as I once observed, on the fifteenth day;  or else it
may be dreaded lest  the alteration of the  secretion might be  due to a more
advanced  degeneration  of  the  kidney, Avhich of itself  would be  likely to
endanger the Avoman's life.
  If the  prognosis is grave as regards the mother, it is at least equally so
for the child, since it very  frequently dies during the convulsions that take
place  in the course of the gestation or at the commencement of parturition;
for the disorder created in the nuiternal circulation must necessarily affect 
808
DYSTOCIA.
that of the foetus.  The latter may be  affected with  fatal eclampsia in the
womb.  I have sometimes seen it present a contracted state of all the muscles
of the limbs, immediately after its expulsion; nor is it necessary to the pro-
duction  of the latter  condition, that the mother's convulsions should have
lasted for a long  time.  I saw (October, 1846) a highly infiltrated  primipa-
rous female, in whose case the complete dilatation of the  cervix and power-
ful expulsive pains gave promise of a speedy delivery,  notwithstanding a
slight contraction of the pelvis, suddenly seized Avith an attack of convul-
sions.  I  applied the forceps immediately, and  the child, Avhose heart Avas
beating a few minutes before, was  extracted Avithout difficulty.  It Avas dead,
and the upper and lower extremities, those of the right side especially, Avere
strongly contracted.  The biceps muscles Avere extremely  hard.  M. Prestat
mentions a nearly similar case.
  Although the  foetus may escape the dangers to which the  convulsions
expose it whilst  still Avithin the womb, it is  not yet entirely safe, for  it is
subject  to a sort  of  hereditary influence, during the  early part  of  its exist-
ence,  which renders  it liable to convulsions similar to those Avith which the
mother was affected.  Schmitt (of Paderborn) relates, that a woman in whose
case an attack of eclampsia assumed for more than three hours the appear-
ance  of decided  catalepsy, was delivered by the forceps of a living child.
At five o'clock of the next day, the latter presented symptoms of catalepsy
resembling precisely those of the mother, and died in spite of all that could
be done.
  But these are not the only dangers to Avhich eclampsia  exposes the child,
for it  is evident that version or the application of the forceps, Avhich is then
so often  necessary, always endangers its existence more or less.  Thus, of
fifty-one  children reported  by Merriman, thirty-four were  still-born, and
seventeen were born  alive; which  statement, unfavorable  as  it is, proves at
least  that, contrary to  the  opinion of many accoucheurs, the  child is not
always lost;  and  that Ave should  not regard  its  life as worthless  in those
cases  in Avhich the intervention of  art becomes requisite.
  NotAvithstanding the gravity of the general symptoms of eclampsia, its
effect  upon the progress of gestation is  not ahvays so disastrous, for it has
been knoAvn to continue in spite of long and frequent attacks.  Generally,
however, abortion or premature labor  is the result,  and  that, Avhether the
child  be living, or whether it has perished  in consequence of the violent
shocks experienced by the mother.
  HoAvever severe the attack may be, it  is very  unusual  for the Avoman to
die  undelivered,  unless the expulsion  of  the foetus be prevented  by  a
mechanical obstruction.   Still, sudden death has several  times been known
to take place, four cases of the kind being mentioned by M. \Yieger as hav-
ing occurred in the practice of German  accoucheurs.   The Cesarean opera-
tion Avas performed upon the bodies.

  § 6. Pathological Anatomy.
  Thus far, post-mortem examinations have throAvn no, light on the nature of
eclampsia, for most usually this disease leaves no appreciable  anatomical
lesion behind.  Often, indeed, there is  a little serosity found in the ven- 
ECLAMPSIA.     •                     809
tricles or arachnoid cavity, and  possibly a more or  less evident congestion
of the encephalic vessels;  and Avhen the affection has  terminated in apo-
plexy, the dissection has exhibited either an apoplectic  extravasation into
the cerebral substance, or  else a  free effusion on its surface.  But these are
evidently nothing more than secondary lesions, the effects, and not the  cause,
of the convulsions.
  In a Avoman Avho died from puerperal  epilepsy, M. Prestat found a little
body, of a stony consistence, and about as large as an ordinary pea,  in the
corpus  striatum of the right side; and, in another  case, M. Baudelocque
detected an ossification  of the dura mater.   But M. Prestat Avas  certainly
correct  in  regarding such  anatomical lesions as  mere  coincidences, for
nothing Avould Avarrant  the  conclusion that a relation  of cailse and  effect
exists between them and the convulsions.
  What Ave have stated in regard to the  almost uniform coincidence of
albuminuria Avith eclampsia, and to its common connection Avith lesions of
the kidneys, sufficiently indicate that the anatomical lesions are  hereafter
to be sought for in those organs.  For our  OAvn  part, Ave have never  failed
to do so for the past ten years, nor do Ave hesitate  at the present time to
consider albuminous nephritis  as  one  of the most  common lesions  after
puerperal convulsions.  As already stated, the kidneys  have almost univer-
sally presented the anatomical characters of nephritis, the  more or less
advanced degrees of which  appeared to  coincide with  the chronicity and
abundance of the albuminuria.
  Other observers, amongst whom I might mention MM.  Blot and Depaul,
state that usually they have met Avith no disease of the  kidney, and regard-
ing the  above-mentioned facts as altogether exceptional, insist that in the
majority of cases Bright's disease has no connection  AA'ith eclampsia.
  In the first place, I Avould call attention to  the fact, that I do not regard
Bright's disease as residing  in the  lesion  of  the kidney exclusively (page
401); and  that although the kidneys should present  nothing abnormal, the
alteration of the  urine is sufficient to prove its existence.  I might,  there-
fore, strictly pay no regard  to the facts mentioned by  my opponents; but
let us examine  Avhether, independently of the  opinion which I support, the
observations  of MAI. Blot and  Depaul are of  much  value.   They have
found nothing,  say they; but perhaps their  not having done so is their own
fault in not having examined sufficiently, and I have to acknoAvledge that
hitherto I  had committed the  same error.   AYorks recently published in
(iermany sIioav, in fact, that the  naked eye is entirely incompetent to  detect
anatomically the commencement of albuminous nephritis, and that the first
degrees  of renal alteration can be discovered only by the microscope.
  The nature of this  book does  not permit me to enter into the anatomical
and microscopic details found in  Frerichs' Avork; but the researches of  Avhich
I speak  evidently show the small value of observations  in Avhich the micro-
scope has  not been employed.   All negative  facts should, therefore,  be re-
garded for the moment as  having no existence, and more accurate observa-
tions are necessary to determine  Avhether or not there  are cases in Avhich the
lesions of the kidneys are altogether Avanting.
  Henceforth, therefore, attention  should be especially  directed to the kid-
neys. 
810                           DYSTOCIA.
  § 7. Nature of Eclampsia.
  As  a consequence of the labors of those modern pathologists Avho have
followed  the impulse given  by M. Rayer, eclampsia, which had been so
long classed Avith the  neuroses, that is to say, Avith diseases whpse nature is
entirely unknown, begins to  be better understood.   AYhoever shall have
read attentively what Ave have said of puerperal  albuminuria (page 492),
and of its relations with eclampsia (page 792), Avill perceive that we can no
longer withhold our opinion as respects the nature  of puerperal convulsions.
  In the  first place, let us return to what Ave regard as the fundamental fact,
which  must decide the whole question, namely, that eclamptic females are
almost ahvays affected Avith albuminuria.  Now, the  presence of albumen
in the urine during the puerperal state,  ahvays denotes a general alteration
of the urinary secretion.  This alteration, as stated (page (492), first con-
sists in a  modification of the elements of the blood, which is soon compli-
cated  Avith a lesion of the kidneys, constituting its anatomical expression,
as albuminuria and still later eclampsia are  its  symptomatic expression.
Eclampsia  is,  therefore, the  ultimate phenomenon  of  Bright's disease,
Avhether it be merely a general affection or more especially localized in the
kidneys.
  It is positively shown by clinical observation that a very close connection
exists between albuminuria and eclampsia.  It  becomes, then, a very impor-
tant matter to trace back this connection from the  latter to the former; and
here it is that the theory of uraemia comes in, as explained in another part
of this Avork, to Avhich we refer the reader.  (See  page 498.)  AYe confess,
hoAvever, that the pathological assumptions there taken are far from  being
firmly established, and that the true explanation   may be  yet unrevealed;
at all events, the fact remains that there does exist a relation of cause and
effect  betA\een  albuminuria and puerperal convulsions.
  MM. Blot, Depaul, and some others,  having  raised  several objections to
this opinion, Ave shall next endeay^or to appreciate their value.
  " 1.  As albumen is not discovered in the urine of all  pregnant women,
therefore eclampsia  is  not necessarily  connected Avith albuminuria and
Bright's disease."
  Supposing the observations  upon which this first  objection is based to
have been well made, and some of them, at least, seem to me deserving of
all confidence, they still do not prove incontestably Avhat is desired.   Albu-
men, indeed, is not found invariably in all individuals Avho, not being in
the puerperal  state, are  certainly affected Avith albuminous nephritis; al-
though very abundant at certain periods, it diminishes greatly at others, and
sometimes  even disappears entirely for a longer  or shorter time, but only
to return again  rather  later.  These same intermissions may also be met
with during pregnancy;  and we may readily imagine that unless the urine
of the same  Avoman who  afterwards Avas attacked Avith eclampsia, had been
examined frequently and through  a long period, it could not be concluded
that she was not albuminuric, especially if the albumen should appear dur-
ing the convulsive attack.
  Furthermore, facts have been observed by Mazoun, a Russian physician,
and referred to by M. Imbert-Goubeyre, Avhich appear to me to ansAver the 
ECLAMPSIA.
811
 objection still more completely.  Mazoun mentions three cases in which the
 autopsy disclosed,—once, the anatomical  type of the  second  degree  of
 Bright's  disease;  once, a lard-like condition of the kidney; and  once, the
 characters of the first degree of Bright's disease; yet, although the patients
 were observed daily for several weeks, albumen Avas never detected in their
 urine.   Unless Ave admit that the fatty kidneys  did not mark  a case  of
 Bright's disease, it must be alloAved that this disease may exist exceptionally
 Avithout albuminuria.   I myself Avitnessed a case  of the  same  character,
 which  was aftenvard published by my colleague  and friend, Dr. Fournier,
 in  his thesis for the Concours.   Noav, if this  is so,  Avhat can  be  concluded
 from those rare cases in Avhich the eclampsia was  neither preceded nor
 accompanied by albuminuria?
   " 2.  AYhen the  kidneys present  no alteration at  the autopsy, can it still
 be  said that the eclampsia Avas the consequence of albuminuria?"
   I have already replied to this objection affirmatively, if Ave  regard, as
 ahvays  should be  done, the general alteration of the fluids, and also if the
 microscope  has  not been  employed, for it  alone can noAV enable us to say
 that no real alteration exists.
   " 3.  The difficulty and rarity of the cures of Bright's disease are well
 knoAvn; how, then, if puerperal  albuminuria is due to the same cause, ex-
 plain the prompt  disappearance  of  the albumen  after  delivery, and the
 rapid recovery of  the patients ? "
   It is true that the albuminuria disappears quickly in a certain proportion
 of  cases ; but generally  in those cases  no eclampsia had taken place, or,  at
 least, the patients recovered.   Here,  as Avas stated, it is probable that the
 blood Avas but slightly altered, and that the active  or passive congestion  of
 the kidneys produced by the obstruction to the venous circulation, contrib-
 uted to  a certain extent  to  the production of  the  albuminuria.   AYe can
 then readily imagine that, one  of the  causes being removed by the delivery,
 the other might  be incapable of maintaining the functional disorder; but it
 is not  true to say that  in  other than  these favorable conditions, the albu-
 minuria ceases in  a feAV hours.   I have already quoted the statistics of M.
 Imbert-Goubeyre,  from Avhich it evidently folloAvs  that when the disease
 proves fatal, the albumen continues to the end ; and that in a  certain num-
 ber of  cases, AAdiich Avill  probably be found to increase Avhen the patients
 shall be followed  more carefully,  it  passes into the  chronic condition.  I
 might add Avith M. AYieger, that the  medium duration of the albuminuria
 in the non-fatal cases is from eight to ten days after delivery.
  We see, therefore, that these objections haA'e no  great force, and are not
 of a character to invalidate  the many good  reasons Avhich go to support our
 opinion.
  \Ye do not wish to deny absolutely the possible occurrence of  apparently
 eclamptic convulsions, in  the case of a Avoman in labor, Avho presents neither
 albuminuria nor any of the symptoms of Bright's disease.  On the contrary,
 Ave believe that in  some very rare eases, the  reflex irritation produced by an
 extremely painful  labor,  or  the violent congestion of the veins of the spinal
column, occasioned by the extreme  efforts  of the Avoman, may over-excite
the  spinal marrow and give rise  to  partial  or even general convulsions. 
812
DYSTOCIA.
 But Ave regard such cases as altogether exceptional, and would even be dis-
 posed to debar them from the title of eclampsia, and consider them as sim-
 ple convulsions, hysterical or otherwise, in their nature.  Such, at least, is
 the impression left upon us by the two cases of the kind Avhich have  come
 under our own observation ; and the reading of the published cases inclines
 me to believe that most of them were not instances of real eclampsia.

   § 8. Treatment.
   The management of eclampsia must  necessarily be divided into the pre-
 ventive and the curative treatment.
                         1. Preventive Treatment.
   AYe have dwelt sufficiently upon the  etiology of  eclampsia to  shoAV the
 importance which Ave  attach  to albuminuria, or, rather, to the disease  of
 Avhich it is the symptom.  The  presence of albumen  in the blood of a preg-
 nant  Avoman is the  indication  of a  marked predisposition on her part to
 puerperal  convulsions, and the best  preventive  treatment Avould  be  that
 Avhich Avould result in the most favorable alteration  in the condition of the
 blood, or in the amelioration of the renal affection Avhich is  the apparent
 cause  of the  albuminuria.   Unfortunately,  all the  therapeutic measures
 employed hitherto in other conditions than the puerperal,  have been  very
 unsatisfactory.  The tonic treatment, however, has seemed in  some cases to
 be sufficiently useful  to encourage new trials, especially during pregnancy,
 in Avhich, as Ave have seen, the diminution of the albumen  is attended  by a
 lessening in the amount of all the  solid principles of the blood.   I would,
 therefore, have no hesitation in  recommending the animal  diet and  the ad-
 ministration of iron, in cases of albuminuria complicating pregnancy.
  The recent investigations of  M. Mialhe, Avhich prove that  an excess of
 water in  the blood is one  of the most active causes  of albuminuria, are evi-
 dently calculated  to  confirm  us in the  therapeutic  course which we have
 recommended for a long time.
  But, as Ave have already observed,  convulsions almost never appear  in  a
pregnant woman Avith albuminuria, unless some accidental circumstance, so
to speak, should happen  to excite them.   They are usually connected  with
cerebro-spinal  congestions,  themselves  occasioned by  fortuitous  circum-
stances, Avith serous  plethora, or the mechanical  obstruction to Avhich the
venous circulation is subjected  during gestation and labor; therefore, the
first object should be to prevent this  congestion.   On this account it is that
 bleeding should have the precedence of all others as  a preventive measure.
It should be practised several times during the latter months of pregnancy
in such Avomen as may present  some of the  symptoms  of cerebral  conges-
tion ;l it might also  be practised with the  happiest  success in cedematous
  1 By way of showing the importance of venesection as a preventive measure, Dr.
Dewees relates the following  case: Mrs.----, pregnant with her first child, was seized
with frequent headaches towards the end of her gestation;  she neglected to be  bled,
and was attacked with  severe epileptic convulsions at the onset  of labor, from which,
however, she recovered.  During her second  pregnancy she was bled freely, and de-
livered without accident.  In the third and fifth, venesection was not resorted to, and
they were attended with convulsions; whilst, in the other gestations, she had recourse
to this remedy, and Avas safely confined. 
ECLAMPSIA.
813
 females, more particularly Avhen the precursory  phenomena  of eclampsia
 shall be manifested.   In the latter, we  should also resort to  the  measures
 calculated to diminish the volume of the parts  distended  by infiltration;
 such as derivatives to  the intestinal canal  and  urinary passages, the appli-
 cation of compresses steeped in cold Avater,  or some aromatic decoction, and
 to punctures with the lancet.  Nervous and irritable women, of a dry habit,
 will also be  benefited by a  moderate bleeding from the arm,  and by luke-
 warm baths, repeated  frequently during the  latter  months of pregnancy;
 and they should  avoid all acute moral emotions, &c, Avith the greatest pos-
 sible care.
   Reserve is called for in the use of diuretics, for, although they are useful
 in certain cases, they may, in others, affect  the progress of the disease unfa-
 vorably.  Generally speaking, when there  is no diminution in the amount
 of urine excreted, they should not  be employed, for the increased urination
 Avould augment the waste of albumen, and consequently the impoverishment
 of the blood.   AYhen, however, the patient passes but little  urine, it is im-
 portant to increase the  secretion, in order to prevent an admixture of the
 principles of the urine with the blood, and thus lessen the chances of uraemic
 intoxication.   The preparations of squill, digitalis, juniper, &c, may then
 be used Avith advantage.
   After venesection and purgatives have  been tried, Drs. Collins and  John-
 son highly extol  the use of  tartar emetic, administered in  such a way as to
 nauseate Avithout producing vomiting.   For this purpose, a tablespoonful of
 the folloAving mixture is given by the mouth every half hour:

      R.—Tartar emetic,    ......  gr. vj.
          Laudanum,    ......     gtt. xxx.
          Simple  syrup,    ......  fcjijss.
          Infusion of pennyroyal,      ....     f3HJ.
               F. M.
   The quantity of tartar emetic is  increased or diminished according to the
 intensity of the symptoms',  and  the imminence of the disease.  The same
 potion is also strongly recommended as a curative measure, after the invasion
 of the convulsive attack.
  [Although it cannot certainly be knoAvn that the paroxysms of eclampsia will
 cease immediately  upon delivery, it is nevertheless true that they then do very often
 diminish in frequency, and  at last subside altogether.  This fact explains the
 unanimous opinion of accoucheurs  that delivery is  a favorable event during an
 attack of convulsions.  The question,  therefore, arises, Avould it not be proper to
 induce premature labor, for the purpose of arresting  the albuminuria of pregnancy
 and  preventing a  possible attack of eclampsia?  The  question, when entertained,
 has almost ahvays been  decided in  the negative.  Cases,  in fact, are not wanting
 which go to prove that after proper treatment, especially bleeding, the albuminuria
 may  subside, and that convulsions even, after having occurred, may cease, allowing
 the pregnancy to continue its course, and end Avith  a  faA'orable delivery at term.
 Considerations of this character, together with the observation that women affected
 with  severe albuminuria have not been attacked with compulsions, intimate that the
question of premature labor, as a  preA'entive, is one  which should be  approached
 very  carefully.  Admitting all this, we still think that there are some exceptional
 cases in which premature labor, artificially induced, might be of advantage.  Let 
814
DYSTOCIA.
 us suppose, in the first place, that a woman eight months pregnant, affected with
 albuminuria, and threatened with eclampsia, should have labor to come on prema-
 turely and spontaneously.   It is very certain that the  latter circumstance Avould,
 by most accoucheurs, be regarded as favorable, and that nothing would be done to
 arrest it.  Conceding this,  we are  not very far  from  accepting the idea of the
 induction of premature labor.  It must not, however, be supposed that convulsions
 will  only occur when  the labor comes on, and that then their occurrence will be
 almost inevitable.  On the contrary, it often happens that the patient is attacked
 with eclampsia before the end of gestation, and the labor ensues ; in  which case the
 prognosis is the less unfavorable in proportion as the labor is the farther advanced.
  On all these accounts we  think that the induction of premature  labor in such
 cases ought not to be absolutely discarded, but would require as a justification for
 its proposal a conjunction of the following conditions: I, that the eighth month of
 gestation should be  fully accomplished, in order that the child might live without
 encountering too great risk ;  2, that the albuminuria should be severe, or the patient
 experience some precursory symptoms of the attack of convulsions ; 3, that it should
 be a  first pregnancy, or else that the patient should have had convulsions during a
 previous labor; 4, that medical treatment, especially bleeding, should have been
 proved to  be useless.  Under these  circumstances, premature labor, artificially in-
 duced, seems to me rational, and I do not hesitate to say that I Avould be disposed
 to have recourse to it unless  subsequent facts should prove the fallacy of my present
 opinion.]
  During parturition, the accoucheur should endeavor to modify or prevent
 the influence of the various causes  of dystocia; thus,  if the  contractions
 assume  the character of irregular, tetanic pains, he must attempt to restore
 them to their normal and regular type, by a resort to bathing, to the opiates,
 or belladonna, and to venesection ; for it is an ascertained fact that the exces-
 sive  agitation produced by these  pains is often the  forerunner of  eclampsia
in a  nervous and irritable woman.
  It Avere hardly necessary to call attention to  the favorable effect  that inha-
 lations of chloroform might have under these circumstances, both  by chang*
ing the character of the contractions, and diminishing the irritability of the
nervous centres.
  At the very commencement of the labor, the precaution should be taken
 to empty the bladder and  large intestine, and to relieve the stomach of indi-
gestible food, which might have an unfavorable effect, by vomiting.
  All these  measures are particularly indicated  when the patient under
care   had previously suffered from convulsions in  her former labors, for she
is by that very fact predisposed to a return of them.
  After the delivery, the accoucheur might  often prevent this accident by
carefully exploring the state of the womb subsequent to the expulsion of the
child and placenta;  and  by assuring himself that  it is Avell retracted, and
that  it contains no foreign bodies, such as coagula, or portions  of  the mem-
branes or placenta.

                          2. Curative Treatment.
  The curative treatment consists of the general measures that are applica-
ble in all cases, and of the special  means, Avhich necessarily vary according
to the period at Avhich the puerperal convulsions are manifested.
  A.   General Measures.—At the head of the list of curative means Ave must 
ECLAMPSIA.
815
place sanguineous emissions, which have been resorted to under every form.
To these, therefore, we must first have recourse; but, in the employment of
this  remedy, several  questions, that are important in a practical point of ,
view, are presented for solution.  Ought Ave to employ general  or local
bleeding?  And, if general, which vein is to be opened?  And what quan-
tity of blood should be drawn ?
  ['•After having tested myself," says M. Depaul, "and seen tested  by others, the
various modes of treatment recommended for eclampsia, I have no hesitation in
expressing as my conviction  that venesection  should  be  regarded as of primary
value.  The bleeding should, however, be carried  so far as to withdraw from the
patient, in the course of a few hours, thirty-two, forty-eight, or sixty-four ounces of
blood, according to circumstances and the effect produced."]

  In a large majority of cases, general venesection will first be  preferred;
and the revulsive application of leeches or cupping will only be resorted to
in those instances where the convulsions shall have folloAved a profuse hemor-
rhage.   Where free  bleeding has been  practised, and the coma continues,
notwithstanding, throughout  the Avhole  interval  betAveen the  fits, thus an-
nouncing an intense congestion about the encephalon, we might apply leeches
with advantage to the mastoid processes, or to the neck, and also, perhaps,
around the malleoli.
   Writers have sharply discussed the question as  to Avhat vessels should  be
opened; and arteriotomy in the temporal, bleeding in the arm or foot, and
opening the  jugular vein, have  been extolled in turn.  The advantages of
blood-letting are very nearly the same, Avhichever vessel be opened;  and,
consequently, as venesection in the arm is by far the most easy, and as Ave can
always obtain there as much blood  as may be deemed advisable, this is
 usually practised, and, as a general rule, should be preferred.
   It is very important that the  vein should be opened largely, and that the
 blood should Aoav in a full stream.   Should it dribble aAvay, or the jet be
 very small, the bleeding, Ramsbotham says, is almost  useless, and another
 vein had better be opened  at once.
   The quantity of blood to be draAvn A'aries according to the  patient's con-
 stitution, the violence of the  paroxysms, &c,  &c.; thus, in lymphatic  indi-
 viduals, Ave should, as  a general rule, be  satisfied Avith the  extraction of
 fourteen to eighteen ounces ;  and if the symptoms still continue after this,
 and it be deemed necessary to keep up  the sanguineous emission, it ought
 to be confined  to the application of fifteen, tAventy, or thirty leeches behind
 each ear.1
   In plethoric Avomen, after a copious bleeding of sixteen ounces, a second,
 of ten to fourteen ounces, might  be resorted to, tAvo or three hours aftenvards,
and perhaps even a third ;  but a fourth is rarely admissible,  and Ave would
preferably apply, instead,  either leeches to the mastoid processes or cups to
the back of the  neck.
   Bleeding has the double advantage of removing the congestion or irrita-
tion of the spinal marroAv, and of preventing at  the same time the cerebro-
  1 The reader will bear in mind that the leeches directed in the text are of the Euro-
pean variety,  whicn extract a much larger quantity of blood than our own. — Translator. 
816
DYSTOCIA.
spinal congestion, Avhich takes place during the fit, and which may produce
fatal disorders, or at least become indirectly the cause of a fresh attack.
  General bleeding,  even when carried so far as to weaken the patient
greatly, does not surely prevent congestion of  the brain or  even effusion;
for all these anatomical lesions have been observed in Avomen who died after
profuse bleeding by the lancet.   On the other hand, when  carried beyond
certain limits, it may become itself the occasion of a fresh excitement of the
spinal marrow7, as is  observed after  all great  hemorrhages, Avhich  almost
ahvays  end in convulsions.  The particular  object,  in applying leeches or
cups to the nucha or  behind the ears, is to supply the insufficiency of vene-
section, or to avoid any unfavorable effect which  the latter might possibly
have.
  Though the gravity of  the  symptoms,  and  the fear of congestions and
effusions  in the brain  and spinal marrow, may often call  for  bleeding, it
should  not be forgotten that  the impoverishment  of the blood of most
eclamptic patients contra-indicates a  too abundant loss of blood.   It  is
proper, therefore, to bleed  sufficiently to remove the congestions of the ner-
vous  centres or lungs, and to prevent  apoplectic effusions, but going too far
in this direction would involve the most deplorable consequences.
  Simultaneously yvith the venesection, it is advisable to produce a salutary
derivation to the intestinal canal and skin.

  [We have already mentioned, under the head of Preventive Treatment, that Drs.
Collins and Johnson had recommended the  use of large doses of tartar emetic.
When  given in the style of Rasori, Dr. Legroux has found it to have a good effect
even in cases of confirmed convulsions, and I had  the same experience in one severe
case.   Unfortunately, however, this favorable result does not always follow.]

  I think that, as a rule, emetics  ought not to  be given during  the  attack,
being  calculated to augment the  convulsive  movements and cerebral con-
gestion by the retchings they determine; still,  if there Avas  good reason for
supposing that the accidents Avere partially caused by the pressure of badly
digested food in the stomach, vomiting should be encouraged either mechan-
ically, by tickling the throat, or by the administration of an emetic.
   Purgatives are much to be preferred, especially when the large intestine
is filled with hardened fecal matters.
   If the patient recovers her intelligence during  the intervals, and she can
be induced to swallow, Ave might exhibit castor-oil by the mouth in the dose
of one or two ounces  ; or, still better, two grains of calomel every quarter of
an hour,  until  it produces a purgative effect.  If, on the contrary, she cannot
swallow,  a plan advised by Merriman might  be adopted ; that is, to put the
calomel mixed with  moist sugar in equal  proportions betAveen the lips and
alveolar  arches, or, if  possible, into the  mouth, and reneAV it until  several
stools are procured.^  If this latter measure be ineffectual, it will be requisite
to act on the lower part of the intestinal canal by administering injections,
rendered purgative by the addition of an ounce and a half or two ounces of
castor-oil, or of the miel mercuriale, and, if necessary, by incorporating with
it a feAV drops  of croton-oil.
   The fact that extreme distention of the bladder has occasionally appeared 
ECLAMPSIA
817
to be the determining cause of the attack, should ahvays lead us to ascertain
the condition of that viscus by percussion, and to use the catheter if it should
chance to be found distended.
   There are yet  some  other  measures  that  cannot be  relied on when em-
ployed alone ; but Avhich, nevertheless, are too important to ^ neglected.
AVe allude to sinapisms applied successively on the thighs, calvelof the legs,
and feet, to vesicatories, and to dry cups  placed on the back of the  neck,
and on the loAver  extremities.   I apply them,  says  M. Velpeau, to both
thighs and the nape of the neck, so that they may act whilst we are engaged
with the  blood-letting,  blisters, or leeches.
   They have appeared to  me, remarks M. Prestat,  particularly useful in
cedematous Avomen; only it is necessary to Avatch their effects for a feAV days
afterwards, lest their surface  becomes gangrenous.
   I place  an application  of the large  cups of Dr. Junod1 to the  loAver
extremities  in the  first class of revulsives, as being the most powerful and
prompt in their  action of any.  In a case of  eclampsia, that occurred five
hours after delivery, the symptoms lasted for thirteen hours; and the patient's
condition  became more and more dangerous, notAvithstanding the employ-
ment of all the measures just spoken of.   At the first application of these
cups, the  com'tilsive paroxysms disappeared ; at the second the coma became
less profound: and at the third, the  patient  regained  her  intelligence.  In
three other cases, the effect was not so rapid, although they appeared to have
a favorable influence.
   These cups are especially applicable Avhen, notAvithstanding large general
bleedings, the application of leeches or scarified cups  has  failed to remove
the symptoms.   Under these circumstances, they have the immense advan-
tage of opposing  the cause which seems to drive the fluids towards the brain,
by keeping a large  amount of blood in  the loAver extremities.
   Cold aspersions upon the face and  chest, and  tickling the nostrils, have
sometimes had the effect to render the inspirations more easy and perfect,
and thus defer  the attack of convulsions.   Harvey relates  the case of a
woman in  labor, Avho Avas aAvakened  from  a deep  coma by tickling the
interior of the nostrils.   Deninan  gives  the history of a lady Avhose every
pain Avas  attended  by a convulsion, until he put an end to the latter for the
rest of the labor, by sprinkling the face at the beginning of each contraction
by means of a feather dipped  in cold water.   Even if useless, the measure is
too innocent a one not  to be had recourse  to.
   Since the use of anaesthetics in obstetric practice, some accoucheurs have
thought  it  right to employ inhalations  in the  treatment of eclampsia.
Calculating upon the poAver of ether and chloroform to destroy the action
of the muscles of animal life, they hoped that  they might act in the same
way upon the involuntary and spasmodic  contractions resulting from  puer-
peral convulsions.
  Reasoning a priori, Ave Avere inclined to disapprove of their employment

  1 Tlie apparatus of  Dr. Junod consists of a large metallic boot, capable of receiving
the greater portion of a lower extremity.  The upper part of the boot is so adapted to
the limb as to prevent the ingress of air, and a partial or compile vacuum is obtained
by the use  of an air-pump.— Tlmslator.
      62 
818
DYSTOCIA.
in a disease so often complicated Avith congestion of the  brain, and  even
apoplexy, and were not, perhaps, free from prejudice, thus derived, in reading
and analyzing most of the published observations.  In the last edition, Ave,
therefore, proscribed  their use in the majority of cases, except when the
beginning oi the convulsion seemed due to some local irritation of an organ
Avhose extreme sensitiveness aAvakened the reflex action of the spinal nerves.
Other facts published by several colleagues as well as the result of personal
observation, have greatly changed our first opinion, so'that we  are noAV con-
vinced that when eclampsia comes on during either pregnancy or labor, and
the closure  or  undilatability of the  cervix makes  it  impossible to effect
delivery, or when the attacks, having resisted bleeding and  revulsives, are
very frequent, and by their steadily increasing severity threaten the lives of
both mother and child, then, we are convinced, the use of chloroform may
be of some service.   In two cases Ave found it to suspend the attacks  com-
pletely.  In one of these cases, tAvo bleedings, purgatives  by the mouth
and  rectum, &c, had been  employed Avithout advantage.   The cervix was
insufficiently dilated, and at 5 a. m. I used the chloroform, repeating the
inhalations at the beginning of each pain, and continuing them until 9 a.m.,
at Avhich time I was able to apply my forceps. Not a single attack occurred
during this  interval.  After delivery I thought it right to stop the  inhala-
tions, and the woman became partly sensible. Some fruitless attempts were
made to extract the placenta, and Avhen, an hour'after the birth of the child,
it Avas brought away,  another convulsion occurred. I immediately resumed
the chloroform, and the attack "Avas  not  repeated; short inhalations,  how-
ever, being made during the hour succeeding. Both mother and child came
out safely from  the  fearful  trial.  I might borrow similar  cases  from the
theses of M. Blot  and others, but will not  dAvell  further  upon this point,
reserving its more detailed treatment for the chapter devoted  especially to
the study of anaesthetics in obstetric practice.
  Such are  the measures that ought to be primarily employed; but there
are certain  others which, Avithout having the same efficacy, may hoAvever
prove very useful.  For instance, when the  intervals  between  the  attacks
last for an hour at least, and during all this time  the patient has recovered
her senses, it is advisable to place her in a lukewarm bath, and whilst she is
there, to  keep compresses, steeped in some iced liquid, constantly applied on
her head. This application of cold should  be kept up throughout theAvhole
duration of  the  attack; this measure has often seemed in our hands, says
Madame Lachapelle,  to second the venesection  beneficially.  It is particu-
larly useful when a febrile coma succeeds the eclamptic paroxysm; as also
when the occurrence of delirium announces  the commencement of a cerebral
fever.
  The antispasmodics recommended by M. Velpeau in the hysteric form of
eclampsia, that is to say, in the hysteria of pregnant women, appear to  me
useless in most cases  of puerperal  convulsions ;  and it Avould only be as a
preventive measure,  or else in a very slight attack, that  they  could  be
resorted  to Avith benefit;  besides Avhich, we should lose  precious'time  by
depending on them in these grave cases.
  Compression  of the tAvo primitive carotids, which has recently been pro- 
ECLAMPSIA.
819
posed a^ a remedy  for  most convulsive affections,  has been  successfully
practi.-ed in some cases of eclampsia; and hence it constitutes another meas-
ure to Avhich Ave might recur, Avithout, hoAvever, attaching  too much impor-
tance to its action, for  it  has failed  in  several  instances.   (Journal de
Trousseau,  Nov. 1840, p. 186.)
  In my estimation, the opiates ought to be wholly banished from the treat-
ment of a disease which  so often terminates in cerebral congestions, at least
whenever the condition of the patient is such as to allow of the abstraction
of blood;  but in the case of an anaemic female, or of one Avho  has already
been bled very freely, opium, by acting  as a sedative to the nervous centres,
might perhaps be productive of some advantage.
  During the paroxysm,  the necessary precautions must be taken to restrain
the patient's dangerous movements ; but it is not requisite to employ violence
for that purpose, as some persons advise; for we have elsewhere stated that
there is scarcely any tendency to change the position ; and it Avill be quite
sufficient to merely watch over her, without endeavoring to prevent the con-
vulsive movements, the intensity of Avhich might thereby be augmented.
  Particular care is  requisite to prevent the tongue from being bitten, since
it is very liable to be pushed beyond the alveolar arches, and often becomes
wounded by the convulsive contraction of the  masseter muscles.  To pre-
vent such  an  'accident, it  has been  advised to place some hard  body, the
handle of a spoon, for instance, betAveen the teeth, so as to  hold them apart;
but Madame  Lachapelle says  this is an almost infallible Avay of breaking
the incisors.  Gardicn directs a piece of cork- to be put between the molars
instead, as  it Avould not be attended with this inconvenience; but this might
escape  from the fingers, and be draAvn  doAvn, by an inspiratory movement,
into the opening of the  glottis, and  thus  suffocate the patient.   A much
more simple plan is  to push back the  tongue behind  the alveolar  arches
with the fingers  themselves, at the commencement of each fit; when, the
jaws being once closed, the tongue can  no  longer  protrude;  it may be con-
tused between  the teeth, but that is all.   Besides, this little operation may
easily be explained to the assistants, who perform it without difficulty, as
soon as they have overcome the chimerical fear of being bitten.
  [A still more  simple method has been,  for a long time, in use at the Hospital of
the Clinic.   It consists in stretching tight between the tAvo hands eight or ten inches
of the edge of a  towel,  and applying it upon the dorsum of the tongue, at the same
time pressing it  strongly back into the mouth.  The jaws are then free to close upon
the linen without inconvenience .to the patient or risk to the assistants.  When  the
paroxysm subsides, the towel may be removed.]
  B. Special Measures.—The course pointed out thus far might be considered
as the medical part of the treatment of eclampsia.
  But when, notwithstanding  the employment of these  means, the convul-
sions continue  and increase in violence, Avhat is to be done ?   The pregnant
condition being the first cause of eclampsia, it Avas natural to expect to find
the most effectual remedy in the evacuation of the uterus.   Such, indeed, is^
the opinion of almost all  practitioners, and it Avas also our  own, until within
a feAV years past.  Since, however, Ave have  so  often seen the  convulsions
continue for several days  after the spontaneous expulsion  or the extraction 
320                           DYSTOCIA.

of the foetus, we have far less confidence in the immediate results of the
cessation of pregnancy.   As we have  already said, the  principal cause of
eclampsia is  to be sought for in a general alteration of the economy;  noAV,
although this modification is due to the course of gestation  and sustained
thereby, it is impossible that it should  disappear immediately upon delivery.
It remains for a longer or shorter time, and the woman  returns but slowly
to the normal state of the unimpregnated condition.   Although lessened, it
may still  exert  its influence, as is proved by the occasional occurrence of
attacks several hours,  and sometimes even several days, after delivery.   To
empty the uterus  is, therefore, to attack but one of the remote  causes  of
eclampsia, by no  means the immediate one.   NotAvithstanding all these
limitations, Ave do not reject absolutely the  induction of premature labor,
but will state hereafter the circumstances under which we think that it Avould
be right to employ it.
   In order to explain  our view thoroughly, Ave  shall  examine  successively
the indications afforded  by severe eclampsia, according  to Avhether the con-
vulsions are  manifested  in the course of pregnancy, or  during parturition,
or subsequent to the delivery.
   1.  During the Gestation.— Prior to the seventh month, that is to say, be-
fore the period at which the foetus is viable, the treatment should be purely
medical.
   At a more advanced period two very different cases may present; that is,
either the uterine contractions are prematurely and spontaneously developed
under the influence of the general convulsions, or the womb remains entirely
apart from the general disorders produced by the eclampsia.  In the former
case the labor has commenced, and Ave shall treat below of the means to be
then  employed, upon which most accoucheurs are agreed; but, in the latter,
the proper course to folloAv is far from being so clearly marked out.  The
question naturally arises, what then is to be done, supposing the eclampsia
has resisted venesection, the intestinal  and cutaneous revulsives, etc.; and
supposing that the patient has arrived  at the  eighth or ninth month, and
the labor has not commenced, but still the convulsions continue and threaten
the mother's life ?
   [Induced labor and forcible delivery have both been recommended under  these
very serious circumstances.  In regard to the first, it may be said that the measures
commonly employed to excite uterine contraction, act too slowly to be used in cases
in which we suppose the life of the patient endangered by convulsions which have
already lasted for a long time, and against which all therapeutical resources have
been exhausted.
   Premature artificial  delivery has, therefore, had  but few partisans, because it
requires considerable time, whilst eclampsia pursues its course rapidly, so that its
termination  by recovery or death' will have  taken place before delivery can  be
effected.
   This  condemnation has not, however, been universal.  Chailly, Krause, and
many others have succeeded, and do not hesitate to advise it.  It is also fair to state
that we are now in possession of means  for bringing on labor very rapidly, (see
Premature Artificial Delivery,) which is a consideration that ought to incline the
balance in favor of active intervention.   Inasmuch as the chances of success  are
certainly very small, Ave think that induced labor ought to be reserved for cases in
which the disease progresses notwithstanding the use of copious bleeding and other
allied measures.] 
ECLAMPSIA.
821
   There are certain females who are subject during  pregnancy to repeated
 attacks of convulsions  at variable intervals, and in  whom, also, each fresh
 attack is more serious than the preceding.  The recurrence of these attacks
 every eight days or  tAvo Aveeks, compromises increasingly the life of both
 mother and child, and Ave might reasonably fear lest another  should  prove
 fatal to both individuals.  Noav, although Ave have rejected the provocation
 of labor during the attack itself, Ave think it proper  in the cases  just men-
 tioned, but  it should be practised only in the  intervals  of the convulsive
 paroxysms.
   Forcible delivery would seem likely, by emptying the  uterus at once, to
 afford some chance to the patient.
   But at a period still quite distant from term, the length of the  neck, and
 the resistance of its unsoftened internal  orifice, would render the forcible
 introduction of the hand very difficult, and the efforts required to penetrate
 within the womb are very likely to  excite, to irritate the organ, and conse-
 quently, to increase the general convulsions.
   These resistances, and the general  irritation which they produce, are  so
 great in most cases, that efforts have been  made to overcome them by making
 numerous incisions around  the  circumference  of the  cervix.   Doubtless,
 when the neck is effaced either by the progress of gestation or by premature
 contractions, these  incisions may be useful and harmless,  since they are
 practised upon the intra-vaginal portion of the neck only ; but in the eighth
 month, Avhilst the neck retains its entire length, the greatest difficulties are
 presented  at  the internal orifice and upper part of  the cervix.  To incise
 the external orifice, Avould remove only the least resistance, and I think that
 do surgeon Avould have the  temerity to  apply a cutting  instrument to the
 internal orifice. I have yet  no experience in such cases, but am convinced
 that when the incisions  have been  successful, it has been in cases  of far
 advanced  pregnancy, or Avhen  unobserved contractions had dilated the
 upper part of the cervix.  This, happily, is Avhat takes place in most cases
 of long-continued convulsions, but Avhich Ave exclude from  the supposed con-
 ditions.
   Admitting, however, that  a forcible introduction  of the hand, Avhether
 preparation  have been  made or not by  incisions, can be effected without
 much difficulty, it must not be supposed that the extraction  of the foetus is
 unaccompanied by danger.   AVe have supposed the uterus to  be inert; noAV,
 although the  irritation produced by the hand of the  accoucheur and the
 movements impressed upon  the foetus during its extraction, are calculated
 to excite contractions, is there not  cause to fear lest inertia  of the organ
 might result from this too rapid depletion, and become the source of  fresh
 accidents ?
  If, finally, after having overcome all these difficulties, Ave were sure that
 the eclampsia Avould cease, I  could understand bow such an operation might
 be undertaken ; but as experience proves the contrary, I think that during
 pregnancy, hoAvever severe the convulsive  attack may be, forcible delivery
ought not to be attempted.
  2.  During  L-'.bor. — The  prompt  termination of the labor  so  generally
advised, should rot, however, be practised except with a certain degree of 
822
DYSTOCIA.
reserve;  and for the sake of clearness in this recapitulation of the indica
tions*! Ave shall endeavor to solve the folloAving questions in order:
  AVhat  ought to be  done Avhen  the cervix is dilated or dilatable ?   And
what is the  proper course to pursue when it is neither sufficiently dilated
nor dilatable, to permit a prompt artificial termination of the labor?
  a.  The cervix is dilated or dilatable. — If the head has descended into the
excavation and distends the perineum, or presses strongly upon the circum-
ference of the uterine orifice, if but one or tAvo attacks have yet occurred,
and especially if there is reason for supposing that extreme  sensibility of
the cervix or of the soft  parts, may have had any agency in the production
of the eclampsia, the  forceps should be applied immediately.  It is  under
these circumstances, more particularly, that the immediate termination of
the labor prevents a recurrence of  the accidents.
  If the eclampsia is  slight, though it has lasted for a certain time, that is
to say, if the  convulsive  attacks  are moderate and the intervals betAveen
them long;  and if the woman regains her consciousness entirely during the
interval; if, under these  circumstances, the  labor is advanced, the dilata-
tion complete, and the head of the child has passed through the orifice and
descended  deeply into the excavation; if the  uterus contracts poAverfully,
and if the  perineum is not  too resisting, Ave  think it  right to Avait for the
expulsion to take place  naturally.
  But if, under the same conditions, the pains are feeble, distant, and  in-
efficacious, or if the contractions are energetic, but the convulsions are fre-
quent and  prolonged, Avith  profound  coma  during  the interval of the
paroxysms, we believe that  the mother  and infant should be immediately
relieved  from the dangers that threaten  them, by the  application of the
forceps.
   When, so far from  having cleared the os uteri, the head is still retained
above the  superior  strait, especially if the membranes are still intact, the
pelvic version would in  general  appear preferable to an application of the
forceps.  (See Forceps.)   AVe say that the version would  appear in general
not ahvays preferable, for Ave know this is  at times  impracticable, even
where the  head is  still above the abdominal strait.  The almost total dis-
charge of the amniotic  liquid, and  the violent contractions of the uterus,
which often participates in the general convulsions, and the violent  irritation
that the organ has to support during the introduction of the hand and the
evolution of the  foetus, sufficiently  explain our reserve, as well as the prefer-
ence that Ave accord to the forceps  in this particular case.
   Should the face present, and be well down in the excavation, Ave Avould like-
Avise apply the forceps;  but, on the contrary, we should  have recourse to
the pelvic version if it were  yet  above the superior strait, or even  when
engaged in this strait, if it happened to be in a mento-posterior  position.
In  the presentations of  the  pelvic extremity, it  is advisable  to hasten  the
termination of the labor by drawing judiciously and carefully on this ex-
tremity.  In  the presentations of the trunk, the feet  are  to  be brought
doAvn; for Ave Avould only have recourse to the cephalic in  preference  to  the
pelvic version, Avhen the  pelvis is greatly contracted; and when the cephalic
version is resorted to,  it must evidently be folioAved by a prompt application
of  the forceps, and if  these should fail, of the cephalotribe. 
ECLAMPSIA.
823
   b.  What is to  be  done when the cervex is neither dilated nor dilatable f —
 If the membranes are  not  broken, and  more  particularly if  the uterus
 appears to be greatly distended by a large quantity of Avater, they should be
 ruptured, and a discharge of the liquid and a partial depletion of the organ
 be facilitated, by pushing up the presenting part Avith the finger ; for such a
 rupture has  often proved sufficient to diminish the frequency and intensity
 of the convulsive paroxysms, and has justified  the  accoucheur in Avaiting
 for the complete dilatation of  the  cervix.  But if the  distention of  the
 Avomb is  not so  far  from normal, Ave think that the interest of the foetus
 demands  that the membranes should be respected, and spontaneous dilata-
 tion aAvaited; when  this dilatation  progresses too sloAvly, the ointment, or,
 still better, the extract of belladonna should  be  employed, and be smeared
 over both the internal and external  portions of the orifice.
   But, supposing the eclampsia is  more serious, the coma  still continues,
 and the convulsions have not been alleviated by the rupture of the mem-
 branes ; and, moreover, the os uteri is  not yet dilated, or else is so convul-
 sively contracted as to prevent an introduction of the hand  or instruments,
 are avc, under such unfavorable circumstances, to abandon  the delivery to
 nature, as some  accoucheurs advise?   Or, on  the contrary, ought Ave to
 penetrate forcibly into  the  uterine  cavity, by opening a route by violence,
 or a cutting instrument?
   At the  commencement, or even during the first four or five hours of labor,
 these extreme measures doubtless should  not be resorted to; but when the
 convulsions persist,  notwithstanding the employment of the most rational
 means; Avhen ten, twenty, or thirty hours have elapsed since the onset of the
 symptoms; when the Avoman's life is compromised by the duration and the
 constantly increasing intensity of the paroxysms, our only hope is in a
 depletion  of the  uterus; a forced delivery then appears  to us the  sole
 resource, and authorized by the  interest of the child even more than by that
 of the mother.
   Two plans have been proposed for effecting this object, namely, a forcible
 introduction  of the hand into the Avomb, and the division of the cervix by
 the aid of a cutting instrument.   AAre shall hereafter revert  to the mode of
 operating in  both cases, Avhen  describing the difficulties that may  be met
 with  in making  the pelvic version; and will therefore  only remark here
 that,  by the  length of time  it demands, by the  excitement and  irritation
 thereby produced (all of which  are assuredly calculated to increase the  con-
 vulsions), and by the lacerations to which it gives rise, hoAvever carefully it
 may be performed, the  forcible  introduction of the hand into the Avomb is
 very dangerous and ought to be rejected; and  that, unless  there is a very
 feeble resistance  at  the orifice to be overcome, repeated incisions,  made at
 dh-ers points  of the circumference of the neck, ought, in our opinion, to be
 decidedly  preferred.
  But, Avhatever  operative process  be employed, the resistance from the os
 uteri being once overcome, the labor Avill be  terminated  by an application
 of the forceps, or by the pelvic evolution, according as the conditions shall
 be found more or less favorable to the practice of the one or the other opera-
 tion ;  which conditions will be carefully detailed when we shall treat of ver-
eion and the forceps. 
824
DYSTOCIA.
   Inasmuch as the expectation, recommended by  us  Avhen  the  cervix  is
neither dilated  nor dilatable, except in cases of  imminent danger to the
mother, is opposed  to the generally received opinion, it becomes necessary
to defend it.  Although regarding in a general Avay the termination of the
labor as a favorable condition, Ave are far from according to it the happy
effect claimed by some authors in its favor.
   In no case, indeed, in AA'hich  the eclampsia had existed for a long  time
before we yvere called to the patient, have we ever  found the termination of
the labor to put an end to the symptoms, and very rarely did it ever lessen
their intensity.   The convulsions  continued after delivery Avith the same
frequency and violence as before.  In three cases only have Ave knoAvn them
to cease after the application of the forceps; but  here it must be said, that
having witnessed the commencement of the eclampsia, Ave were enabled to
extract the foetus immediately after the first attack.
   If, therefore, we regard only the interest of the mother, Ave think that the
intervention of art is justifiable only when the dilatation of the cervix ren-
ders it easy and but moderately irritating to  the maternal organs ; but if the
foetus is living, its life is seriously endangered by a too long continuance in
the cavity of the uterus, especially after the rupture of the membranes; and
since the termination of the labor, Avhen prudently effected, does not sensibly
increase the dangers to Avhich the Avoman is exposed, Ave think that the child
should be extracted as early as possible.
   3. After  the Delivery.—The  only special indication, presented by  the
eclampsia after the child's expulsion, is to extract the after-birth  and all the
coagula, together Avith any portions of the membranes that may have been
retained in the uterus ; and to remove the sanious matters and  detritus by
detergent injections thrown up into its cavity.
   But if the introduction of the hand should prove too difficult and painful,
it should be withheld;  for the retention  of the foreign body would be much
less  irritating, and consequently less painful,  than ill-timed attempts at
introduction.
                       CHAPTER  XIII.

       OF  CERTAIN  DISEASES THAT MAY COMPLICATE  LABOR.

  Independents f  of the various  accidents just studied, Avhich have  a
special  relation to pregnancy and  parturition, there are yet some other
affections whose existence at the time of labor may render the  delivery
dangerous,  difficult, or perhaps altogether impossible, without the interven-
tion of art.   Thus,  hemoptysis, hematemesis,  or  an aneurismal tumor;
asthma, syncope, the presence of a hernia, or the loss of strength in a woman
who is enfeebled by some  chronic disease, traumatic emphysema, or fracture
of the sternum, may individually complicate  the  delivery; and, therefore,
they claim  the particular  attention of the accoucheur.
  A. Hemoptysis; Hematemesis. — AYhen  the patient under care happens to
be affected  with hemoptysis or hematemesis, and the  hemorrhage is incon- 
             DISEASES  THAT  MAY  COMPLICATE  LABOR.         825

 siderable, there is nothing to be done ; but if it does not abate, or if it suddenly
 augments in quantity during the pains of child-birth, we must endeavor to
 remove the patient from the danger that  threatens her, by terminating the
 labor as soon as the dilatation or the dilatability of the os uteri will permit,
 by an immediate application of the forceps or the pelvic version, according
 to the particular conditions in Avhich the parts of the child and those of the
 mother shall be found.
   b. Aneurismal Tumor.—The  same indications for treatment also present
 where the patient has a moderate-sized aneurism, more especially if it occu-
 pies one of the large vessels of the abdomen and chest.  In fact, the reader
 must foresee hoAv greatly the tumor Avould  be exposed to rupture, during the
 violent strainings to Avhich the Avoman involuntarily gives  Avay during the
 second stage of labor.
   Chronic diseases of the heart, Avhether consisting in an hypertrophy of the
 organ, or simply in alteration of the valves or contraction of the orifices, are
 but too often,  as M. Aran has recently demonstrated, the cause of sudden
 death, not to call for some special attention during labor.   It would seem
 to me very  imprudent to allow the  expulsive stage to continue too long in
 such cases,  and I should think it right to terminate the labor artificially as
 soon as possible.1
   c. Asthma.—The same course is to be pursued in all  cases where any
 considerable obstacle to the  respiration is found  to exist;  as happens in
 asthmatic  persons and in Avomen of small  stature, in whom the uterus is so
 enormously distended as to press up the diaphragm and lungs toAvards the
 upper part  of the chest, and in Avhom  the respiratory functions have, on this
 account, been disordered during  the latter  months  of pregnancy.
   i). Hernia. — AVhere a  hernia exists, every one must understand, says
 Desormeaux, Avhat disastrous  consequences might result from  the violent

  1  I was requested to  assist, at the autopsy of a female, forty years of age, who died
 suddenly during labor.  She was the mother of  three children.
  For seven years past, her respiration had been very difficult, and she coughed habit-
 ually.  Both the dvspnwa and cough had increased of late, and the sputa were some-
 times streaked with blood ;  a few hours  after the membranes were ruptured, and
 during a pain, whilst resting one hand on the edge of a bed and the other on the arm
 of an assistant, she fell dead without  uttering a cry.  At the examination, about three
 pints of serum were found in both pleurse ;  the  lungs were healthy, hut compressed;
 a considerable amount of fluid was also contained in the pericardium.
  On another occasion, one of my pupils requested my attendance at the autopsy of a
 woman  twenty-eight years of age, who died  suddenly, immediately after tlie delivery
 of her fourth child.  For three or four years past she had suffered from violent palpi-
 tations, and the slightest exertion, especially going up stairs, even slowly, put her very
 much out of breath; she coughed continually, and now and then spat a little blood.
 The labor was easy and rapid ;  she did not appear fatigued, and inquired the sex of
 her  child.  Whilst the  accoucheur was tying  the cord, he remarked a few convulsive
 movements, but hardly  had time to run to her. before she  was dead.
  The uterus  was firmly contracted. The abdominal viscera were healthy, as also were
 the lungs, though the latter were engorged with  blood; the heart was small, and very
flaccid;  the mitral valve was much thickened, and the auriculo-ventricular opening would
barely admit the extremt'y of the little finger.  There were hardly five ounces of serum in
the peritoneal cavity.   (Francis Ramsbotham, Obst. Med.  Surg., p. 608.) 
826
DYSTOCIA.
throes of the latter stages of labor;  and how much these tumorj must then
be exposed to an increase of size, and how liable they are to become strangu-
lated.  The accoucheur  ought to prevent these accidents, by reducing the
hernia as soon as possible, if it is reducible; endeavoring to return it during
the interval betAveen the  pains; and, when the contraction comes on, he will
make a strong compression over the  hernial opening by his fingers, or, still
better, Avith a convex pad, to prevent its  coming doAvn.   But if it  is  irre-
ducible, he should apply a convex pad, or merely support the tumor with the
palm of his hand, so as to prevent the expulsion of neAV parts during the pain.
Finally, if,  notwithstanding  all these precautions (which the accoucheur
ought to attend to-himself, unless he  has  an assistant  upon Avhom he can
rely,) the hernia becomes strangulated, he  should immediately terminate
the labor, as in the foregoing cases.
  e. Syncope.— There are certain very delicate or very irritable females Avho
are apt to fall into  a state of syncope from the occurrence of the most trivial
pain. In such cases, where the faintings are dependent either on a restricted
diet, on a previous hemorrhage, or on some former  disease, it is necessary to
keep up the patient's  strength by some light nutritive articles of diet,  such
as broth, and by a little generous Avine or cordial.   If these measures prove
to be insufficient, and the SAvoonings are renewed so often as to threaten her
existence, Ave must terminate the labor.   HoAvever, this measure  is not to
be prematurely resorted to, for these syncopes may  be owing to some trifling
cause or nervous condition, without there being that extreme debility, Avhich
alone, says Gardien, can  authorize this ultimate step to be taken.   Desor-
meaux says, I have seen such faintings reneAved at every pain, in a woman
who Avas pregnant with twins; and they lasted throughout the interval from
one pain to  another, so that the patient was  only aroused from that state
by the effect of, and  during the time of? the contractions; nevertheless, the
labor terminated  spontaneously and happily for both the mother  and
children.
  Baudelocque gives the history of a woman who died  during  labor aftei
repeated  syncopes; but the autopsy proved  that  these latter, as also the
vomitings and diarrhoea that accompanied them, had been produced, not by
the labor, but by the  presence of a calculus, about the size of a small  nut,
in the gall bladder.  It is really very difficult to accept such an explanation
as this, especially as  so many examples of quite  as sudden death  are on
record, of which no other explanation can  be given than  such as  attaches to
the phenomena of  the labor itself.
  Dr. Davis relates a much more extraordinary case of the kind :  A  poor
Avoman had been five hours  in  labor at the.Charity Hospital;  the mem-
branes Avere ruptured, and a large quantity of the  waters escaped, but from
that moment the patient became excessively feeble; experiencing an urgent
desire to empty the bowels, she seated herself on the vessel, and made some
straining efforts, when she fainted away ; the attendants immediately placed
her in a horizontal position,  and they had scarcely time to get her into bed
before she died.  Nothing whatever was detected at the autopsical examina-
tion that could  give a clue to the cause of this  sudden death.
  f  Exhaustion.— AVhen the patients are exhausted by an antecedent dis- 
DISEASES  THAT  MAY  COMPLICATE  LABOR.         827
ease,  Avhether  acute  or chronic, and Avhen  frequent and long-continued
vomiting has affected nutrition  greatly, and  diminished  the  strength con-
siderably, I should think it prudent not tc alloAV the expulsive stage to con-
tinue longer than an hour or two.   The efforts required  to terminate the
second stage, might,  in some cases, exhaust  the remaining strength, and
bring on immediately after delivery a rapidly fatal collapse.
  To the cases already known I  might add another.  The young Avife of a
medical  friend had been affected with such  obstinate vomiting during the
last three months of her pregnancy as to be  unable to retain anything on
her stomach.  A constant febrile  movement  Avas the consequence, accom-
panied by nocturnal  paroxysms and extreme AAasting and debility.   She
finally reached the term of her painful pregnancy.   The  labor lasted ten
hours in all, and the expulsive  stage,  during Avhich  I  Avas obliged to be
absent, four hours.  Immediately after  the spontaneous termination of the
labor, the unfortunate lady fainted, and although hemorrhage was prevented
by the favorable  contraction of the uterus, she expired in three-quarters of
an hour,  notAvithstanding the internal and external employment of the most
powerful tonics.

  [g. Pulmonary and Subcutaneous Emphysema.— In consequence of the forcible
compression of the air contained in the respiratory organs during the violent efforts
of labor, rupture of the air-passages  sometimes, though  rarely, occurs, and gives
rise to emphysema.
  An article upon  the subject by M. Depaul lies before us whilst writing, and we
shall use  it, as also the more recent production by Dr. de Soyre.
  Should the rupture occur in the larynx or trachea, the emphysematous swelling
will appear in the neck, to Avhich it  is sometimes restricted,  though at  others il
invades both the face and the head.   Still more rarely, it spreads to the  body,
where it occasionally acquires  an enormous size.   When limited in extent, the em-
physema is, so to speak, attended with no inconvenience, but when  it invades the
body and  the limbs, may occasion  oppression  and threaten suffocation.   I  have,
however,  no case  to  report  of  death occurring under these  circumstances, for
recovery gradually takes place by absorption of the air.
  When the pulmonary vesicles give way, it is, doubtless, possible for the emphy-
sema to reach the mediastinum, and from  thence  spread to the neck, but the air
may  also  diffuse itself  through the intervesicular,  interlobular, and  subpleural
cellular tissue, and thus  invade both lungs, without, however, passing beyond them.
In such a case, emphysema may prove rapidly fatal, as shown by a remarkable
instance published  by 31. Depaul.   The patient in question had never during life
a single symptom to excite a suspicion of the existence of  the  slightest lesion of
the respiratory organs.  During the greater part of her second labor, the breathing
was easy and free, but the latter stages were rendered difficult by deformity of the
inferior strait and  large size of the head of the child.  During the powerful ex-
pulsive efforts to which the patient gave Avay, her respiration suddenly became
short and difficult, and  the  pulse small and extremely rapid.   31. Depaul imme-
diately delivered her by the forceps, but the symptoms grew worse until ended by
death, forty-six hours after delivery.  The autopsy revealed  emphysema of the
cellular tissue of both lungs.
  Emphysema usually demands  no  special treatment; should  the air invade the
body and  impede respiration, punctures  should be made with a lancet, or even in-
cisions through the skin.  As in all cases it is to be apprehended that the affection
will continue to spread,  should the labor be prolonged, delivery should be hastened
by the use of the forceps. 
828
DYSTOCIA.
  h. Fractures of the Sternum.— It is possible for the sternum to be fractured by
muscular effort during labor.  Chaussier saAv two cases of the kind, both occurring
during the first labors of women of from twenty-four to twenty-five years of age.
At the moment the fracture took place, both the patients had the head thrown back
as far as  possible, at the same time drawing strongly with the arms and pressing
with the feet.  These fractures  are simple, transverse,  and  separate the sternum
into two pieces.   The symptoms are, first, sharp pain at the  point of fracture;  and
one of Chaussier's patients heard at the same time a crack which caused her to
exclaim that she  had probably broken  something  in her breast.  With this there
is sometimes abnormal mobility, and occasionally even crepitation. The diagnosis
is, however, often far from easy.   In one of Chaussier's cases, the fracture was not
discovered until the tenth day.  The treatment  is simply a bandage applied around
the chest to prevent motion.]
                        CHAPTER XIV.

        DYSTOCIA OCCASIONED  BY  THE FCETAL  APPENDAGES.

  The membranes which form the walls of the ovum, the  umbilical cord,
the placenta, and the amniotic fluid, may all, through some departure from
the normal  condition, give rise to dystocia.  Thus, unusual strength of the
membranes  may retard labor and necessitate their artificial rupture.   (See
p. 396.)   On the other hand, they may be too thin  or tender, and thus dis-
pose to a premature discharge of  the  waters, Avhich  is not desirable.   (See
p. 296.)   Excess of amniotic fluid  forms one of the true diseases of preg-
nancy (see p. 541), and sometimes causes the  labor  to be very tedious (see
p. 607).   Finally, by its insertion upon the neck of the uterus, the placenta
is but too often the  cause  of alarming hemorrhage.   (See p. 754, et seq.)
All these causes of difficult labor, very different as they are seen to be, have
already been studied in the various articles referred to, and w ill receive no
further attention; but to complete the subject of dystocia occasioned by the
foetal appendages, we have, lastly, to treat of prolapsus  and shortness of the
umbilical cord.
                            ARTICLE  I.
                PROLAPSUS, OR  FALLING OF  THE  CORD.
  The descent  of  the cord  is quite a rare accident, since Madame  Lacha-  "
pelle states that she met with it but forty-one times in fifteen thousand six
hundred and fifty-tAvo labors ; but it is probable, as she appears to think her-
self, that there has been an error in the registers, for the statements given
by other observers show a much larger proportion.   I shall  only bring for-
Avard  the account of Michaelis,  who  says that he  had  detected fifty-four
cases  of filling of the cord in two thousand and four hundred labors; and
a summary, by Dr. Churchill, of  ninety thousand nine hundred and eighty-
three labors, in which  there Avere three hundred and tAventy-tAvo cases of
prolapsus, or one in two hundred  and  eighty-two, nearly.   (Rigby.)
  The falling  of  the cord  is most  frequently observed  in vertex  pre-
sentations, Avhich  circumstance is readily explained  by the comparative
rarity of the others.  But, in proportion to the relative numbers, it  is more 
DYSTOCIA  OCCASIONED BY  THE FCETAL  APPENDAGES.   829
  frequent in breech presentations, and far more so in those of the trunk.  In
  thirty-three cases of labor at term accompanied by this accident, Mauriceau
  observed seventeen presentations of the vertex, one of the  face, one of the
  feet, nine of  the hand  or arm, three of one hand and  one foot, one of the
  breech  and one hand, and one of the  head and  one  hand.  In  sixteen
  thousand six hundred and fifty-tAvo  deliveries, Dr.  Collins has met Avith
  ninety-seven  cases  of prolapsus, namely, twelve  times  in tAvin pregnancies
  (and in seven  of these twelve the prolapsed cord belonged to the second
  child); nine times in footling  presentations;  twice  in those of the breech;
  four times Avith  the shoulder; seven times when an escape of the hand com-
  plicated a head presentation; seven Avith a  dead and  putrefied foetus; and
  lastly, in three cases  the  delivery took place before term; that is, twice at
  seven and once at eight months;  and the others were  simple vertex pre-
  sentations.
    Certain  authors have  endeavored to draAV a line of  distinction between
  the  prolapsus or presentation and the falling,  properly so called; desig-
  nating,  under the former title, those cases in which the cord, though found
  in the  uterine  orifice, is  still  retained in the amniotic sac, on Avhose loAver
  part it  lies ;  and, under the latter, those cases only in which it hangs doAvn
  in the vagina, or even protrudes beyond the vulva, after the  rupture of the
  membranes ;  but such a distinction is puerile, as it can  only serve to desig-
  nate two degrees of the same accident.
    a. The causes that  may be considered as predisposing to a prolapsus are:
  the unusual length of the cord itself, a large amount of Avater, deformities
  of the pelvis, an obliquity of the Avomb, and
  those malpositions of the child which prevent            Fl(J-112-
  the presenting part from engaging readily
  in the superior strait  and  excavation.   The
  attachment of the placenta  near the os uteri
  also predisposes to a prolapsus, by keeping
  the cord just  at the  uterine orifice.   A\rith
  regard  to the determining  causes, Ave must
  place in the  first rank a  sudden rupture of
  the membranes, and  the  rapid escape of a
  large quantity  of Avater, Avhich  generally
  SAveeps  along Avith it a  fold  of the  cord.
'  Consequently, when  the neck  of the Avomb
  is almost effaced, the bag  of Avaters very
  prominent, and the head not engaged in the
       ,•        __ ,„+. „„„/,i,,,H„ mrrvirl  ynv>    The rigtit posterior occipito-iliac posi-
  excavation, we  must carefully avoid  rup-  tioD) ^^ by a falli/g of the cord
  turing the membranes during a pain, for the
  gush of liquid, which then  escapes with considerable force, nearly  always
  carries along a loop of the  cord, which thus precedes the  presenting part.
  I Martin, of Lyons, Comptes Rendus, page 13.)   To these causes, let us further
  add  the descent of a hand or a foot, which seems to act as a guide, as  it
  were, for the  cord, and to open the way for it.
   B. The signs  Avhereby this accident can be recognized, vary according to
  whether the membranes are ruptured or are still  intact.   In the latter case.
 
830
DYSTOCIA.
the diagnosis is quite difficult; nevertheless, Ave can often detect something
like a soft, small cord, through the portion of the membranes covering the
os uteri, and slipping aAvay before the least pressure, but the true nature of
which  can only be determined by the rapid pulsations in it.  The rapidity
of these, Avhich Madame Lachapelle  aptly compares to  the  ticking  of a
watch, can  alone  enable us to distinguish them from some other pulsations
produced  by certain  arteries  that  occasionally ramify in the  substance of
the neck, and Avhich  are synchronous with the mother's pulse.   This error
would  be more difficult to avoid,  should  the finger, when  applied on the
membranes, encounter one of  the arterial  ramifications of the cord, Avhich,
as in the cases described  by Benckiser (see Umbilical Cord), may spread
out on the membranes before entering into the proper tissue of the placenta.
The size and the mobility of  the prolapsed cord would also aid in making
out the diagnosis.   On the other hand, the thickness and the spongy  con-
dition of the membranes, the inequalities they occasionally present, and the
folds of the child's scalp, might perhaps lead us to suspect a falling of the
cord, if the clearly ascertained absence of pulsation did not promptly rectify
the mistake.  But after the rupture of the membranes all the difficulty dis-
appears, for then the  cord  hangs down in the vagina,  and often escapes
beyond the vulva,  and therefore may  ahvays be readily explored.
  The tAvo portions of the prolapsed fold are not uniform in their relations
with each  other;  most generally, they touch, or are  simply approximated
together;  and sometimes they are separated by the Avhole thickness of the
presenting part.  Nor is the fold  more regular in its length ; at times it  only
embraces the head, holding it like a sling;  while  at others  it appears ex-
ternally betAveen the Avoman's  thighs, though  most  usually it  is lodged in
the vagina,  or at least only reaches the exterior in the latter  stages of the
labor.   It has, in some very rare instances, been knoAvn to go up again, and
thus become reduced spontaneously.  (Guillemot.)  As a general rule, it is
situated just in front  of one of the sacro-iliac symphyses,  or behind the ilio-
pectineal eminence.
  A prolapsus, therefore, can  always be detected; but it is much more  diffi-
cult, though at the same time  it is highly important to determine, after the
exploration, Avhether  the child is living or not.  A momentary disappear-
ance of the pulsations is not a sufficient sign ; for it not unfrequently  hap-
pens that the throbbing ceases in it during the pain, because the cord is  then
strongly compressed,  but it reappears again  as soon as  the  pain is over.
This Avant of circulation in the vessels of the cord may continue for five or
ten minutes, and  it has  even  been knoAvn to last for a quarter of an hour,
Avithout necessarily terminating in death.  It is therefore during the interval
alone that  any researches of  this nature should  be made, and  the child's
death can only be  determined  Avith  certainty Avhen this exploration, repeated
several times under like conditions, shall have ahvays furnished a negative
result.  A cold, soft, Avithered, and greenish cord  doubtless belongs, in  most
cases, to a dead child, but this is not ahvays true;  and,  on the other hand,
as  death  may result very promptly from compression of the cord, the latter
may still be Avarm and fresh,  though  the foetus be dead.
   [Per contra, one might fancy that he detected pulsations in the cord, even though
the foetus had been  long dead.   This is due to the fact that the finger in contact 
      DYSTOCIA  OCCASIONED BY THE  FCETAL  APPENDAGES.   831

with the cord sometimes perceives very clearly  an  undulation of the blood within
it which distends its vessels and  raises the finger.  It will, however, soon be ob-
served that the  phenomenon is coincident with the beginning of a  pain, and is
caused by the reflux of blood then expelled from the placenta.  There is, conse-
quently, no occasion for mistaking this undulatory motion for the true foetal pulsa-
tion.]

  c Prognosis.— The falling of the cord is only serious as regards the foetus;
but to it the danger is  imminent, since  death itself may result in conse-
quence in the course of a feAV minutes.  Thus, in three hundred and  fifty-
five cases  collected by  Churchill, two hundred and twenty  children,  or
nearly two-thirds, died; though it  is  worthy of remark that  in many  of
these  cases, the mothers were  not transported  to the hospital  until  some
time  after the descent of the cord, and when its  pulsations had entirely
ceased.
  The compression of the cord, and the consequent interruption of the  foeto-
placental  circulation, is the principal if not the only cause of death ; though
certain  authors, among whom I  can  enumerate Velpeau and Guillemot,
suppose that, when  the  cord protrudes beyond  the vulva, the  blood  may
lose its fluidity in  consequence of being chilled by the external temperature,
perhaps may even coagulate, and  that the  delay in the circulation thereby
produced, combining its influence Avith that of a slight pressure, completely
interrupts the current which, up to that moment, had only  been retarded;
Delamotte, Baudelocque, and Madame Lachapelle,  do not admit this effect
of the cold.   " For I have  seen," says this illustrious  midwife, " the  cord
hang  out of the vulva for several hours together Avithout the foetus suffering
therefrom in any wise, because there  was no compression ; and this, in  some
of the cases, notwithstanding the patients  had come a  greater or less dis-
tance, either on foot or in some vehicle, from their residences to our hospital."
  But Avhatever vieAV may be adopted, it is  still to a compression of the cord
that Ave must attribute the greatest share  in the production of the child's
death;  and  under this aspect, its  position, Avhen  prolapsed,  Avill greatly
modify the prognosis.  The points Avhere it is least exposed to compression are
just in front of the sacro-iliac symphyses;  and, as M. Naegele has justly  re-
marked, the frequency of the vertex positions in which the  occipito-frontal
diameter corresponds to the left oblique one of the pelvis, renders the danger
in general much less if the fold of the cord happens to be placed behind and
to the left.
  The influence of this compression has been variously interpreted.  Accord-
ing to some, the child Avill die from apoplexy in consequence of an excess
of blood, Avhich continues to  arrive by the vein, but can no longer return to
the placenta through the umbilical arteries; agreeably to others, the circu-
lation Avill be free in the arteries, the vein alone being obliterated, and then
the foetus will die  from anaemia or syncope.   But it is only necessary  to ex-
amine the  intertAvining exhibited by the vessels of the cord, to become con-
vinced that this partial compression  cannot exist except as an  accidental
circumstance, and that,  as a general rule, the current must be interrupted
in all three vessels at the same time.   The most plausible opinion, and  we
believe the only one admissible, is that asphyxia is the sole cause of death : 
832                           DYSTOCIA.
for, as we have elseAvhere stated, the placenta is the only organ of hematosi?
for the child up to the moment Avhen  the pulmonary respiration is estab-
lished;  and, therefore, if the circulation in the cord is interrupted  by any
compression before birth, the blood of the foetus can no longer derive the
elements necessary for its renovation by its mediate contact with that of the
mother  in the placenta; and from that moment the child finds itself placed
in the same conditions as an adult deprived of respirable air, and, like him,
dies asphyxiated.
  In most cases, it is  not until after the membranes are ruptured that the
descent of the cord exposes it to a sufficient degree of compression to com-
promise the infant's life.   Indeed, if we might judge from some observations
of Madame Lachapelle, the pressure which  it  undergoes is  never great
enough  to obliterate the umbilical vessels, so long  as the head is not engaged
in the superior strait.   For our own part, Ave are  inclined to believe that the
simple pressure of the head on the cord may  be  so considerable as to inter-
rupt the foeto-placental circulation, even before the discharge of the amniotic
waters.   D'Outrepont relates two cases Avhich confirm this view;  and the
numerous instances in AA'hich Ave find the meconium mixed in large quanti-
ties with the liquor amnii at the time of the rupture of the membranes, can
only be explained, in  our estimation,  by a  momentary compression  of the
umbilical cord.
  d. Treatment.—As regards the treatment, the delivery might be  left to
the powers of nature: 1, Avhenever there is  a  certainty that the child is
dead ; 2, Avhen, though the  infant be living, the  membranes  are only rup-
tured as the head becomes firmly engaged in the excavation, and when, from
the fact of the contractions  being energetic, there is every reason to hope
that they  alone will be sufficient to terminate the labor promptly; which, in
fact, usually occurs  in women  who have a  non-resistant perineum, from
having  previously borne children;  and, 3, Avhere the head is small, the pel-
vis large,  and the cord situated in front of one of the sacro-iliac symphyses;
for then it is only necessary to return the cord into the vagina to protect it
from  contact  Avith the air.   But,  notwithstanding  these  favorable  condi-
tions, it Avill still be  necessary to watch  the  state of the  cord  attentively,
and to apply the forceps as soon as the pulsations are found to grow  weaker
or to become intermittent.
  Under all other circumstances, the intervention of art will be indispen-
sable.   Thus, where the presentation is such as to render a natural delivery
impossible, or, even if possible, Avhere  the expulsion of the foetus Avould re-
quire a  long and painful labor, the forceps should be applied or the pelvic
version  be resorted to without delay.  The former operation will be the only
one practicable in a vertex or face presentation, supposing  both to be firmly
engaged in the excavation, and that the previous  attempts at reduction had
proved  ineffectual.   It is generally thought that turning by the feet should
be preferred Avhenever the part is not too strongly engaged.
  In a presentation of the breech, the operator ought to search  for the feet,
if the presenting part be still above the superior strait, or bring down the
groins with the blunt  hook,  if it has descended into the excavation.
  In a presentation of the vertex or face, where  these parts have not as yet 
     DYSTOCIA  OCCASIONED  BY  THE   FCETAL APPENDAGES.  833

engaged  in  the excavation, Ave should  first  endeavor  to  reduce the cord.
Several plans have been recommended for this reduction; but  the manual
method, the oldest of all, is still entitled to the preference, notwithstanding
the great number of instruments that have  been proposed for the purpose.
The operator can ahvays proceed Avith  greater facility behind, and on the
sides of the pelvis, close to the sacro-iliac symphysis; the right hand will be
used Avhen the cord is to the left, and the left one if it is at the  mother's
right.  AVhere the  loop is small,  it will only be necessary to push it up  by
the middle;  but in the contrary case, it is to be  gathered up and pressed
back little by little, just as the taxis is usually performed in the reduction
of hernia.  But merely pushing the cord back  into the uterus will not  be
sufficient to  protect it, and  it must be carried up above the superior strait,
and the band retained in the vagina during several contractions  to prevent
it from falling doAvn.  Some accoucheurs, fearing that it could not be  kept
in position, notwithstanding this plan, have directed the introduction of the
whole  hand  into the womb, with a vieAv of placing the cord on  one  of the
child's limbs;  though this  precaution is useless in most cases, it  Avould cer-
tainly  be preferable to the pelvic version, says M. Guillemot, where there is
a slight contraction of the pelvis.
  [It is very certain that the cord has a great tendency to fall back again, unless it
be passed in very deeply ; so that we should not  hesitate to carry the hand up to
the fundus of the womb for  the purpose of leaving the prolapsed portion in that
part of the organ.  At any rate, this  practice has proved  very successful at the
hospital of the Clinique.  It  would, hoAvever, be useless to endeavor to pass the
cord around one of the limbs  of the child; all that is  necessary being to keep it in
position for a short time, until the hand is expelled,  so to speak, by a contraction
which compresses the parts and retains the cord in its new situation.]

  But the instrumental method must be attempted, where the smallness of
the external parts, or an undilated os uteri, &c,  render the introduction of
the hand very difficult  or  impracticable.  Some  of the various instruments
proposed for this purpose might then be used; perhaps M. Dudan's, recom-
mended by M.  Guillemot,  is one of the simplest and best:  He takes a gum-
elastic (male) catheter, of  the size No. 9, armed with its stylet, and having
a piece of narrow ribbon introduced into the  last eye of the catheter, Avhich
is retained there by the extremity of the stylet; the ribbon is next attached
to the umbilical cord, Avithout draAving it too  tight.  If the loop of the latter
is short, it is applied  near the middle,  but if long, the cord is  to be  first
doubled up;  being  thus secured, the extremity of the instrument  carrying
the cord is then directed along the hand that had previously been introduced
into the vagina, and placed within the  uterine  cavity.  The  hand in the
vagina assists the return of the cord by preventing it from slipping  from the
noose of the ribbon.
  When the reduction is completed, we  must Avait until the head becomes
engaged,  before Avithdrawing the instrument;  then the stylet is first removed
and aftenvards the catheter.
  [In a case of this kind  I used another manoeuvre, which proved A'ery successful.
The patient was a young woman in her first labor, which had made little progress.
dilatation  being incomplete, when the waters were discharged, carrying with them
      63 
834
DYSTOCIA.
 a fold of the cord.   The head  presented, and the dilatation was  too imperfect  to
 think of carrying the cord with  the  hand to the fundus of the uterus.   I made
 several attempts to  return the prolapsed loop  in  the same way that one  tries  to
 reduce a hernia, and to  get it  above the head ; but it ahvays slipped down again.
 To prevent it  from  being compressed, I passed my entire  hand  into the vagina,
 slipped two fingersinto the orifice between the head and the margin of the superior
 strait, and thus kept them alongside of the cord Avhich they protected, and of whose
 pulsations they were cognizant.   3fy fingers, therefore, had to bear the pressure at
 each pain ; fortunately, the labor progressed rapidly, and dilatation was completed
 in about an hour.  I then withdrew the hand, applied the forceps quickly,  and de-
 livered a living child.]
  Where the reduction  proves to be impossible, the  pelvic version, if the
 head is  high  up,  and the forceps, if it  is already engaged, are the only
 resources left us.  But Avhenever  version is  resorted  to, it  is necessary to
 carry up the cord into the uterus, Avhilst searching after the feet (Boer),  lest
 it be compressed either by the  arm of the accoucheur, or somewhat later by
 the hips and the trunk of the child.

                            ARTICLE  II.
                       OF SHORTNESS OF  THE CORD.
  The cord  may be very short naturally;  and, as  elseAvhere stated, it  has
 been knoAvn not to exceed four or five inches  in  length ; but such cases are
 very rare; most generally its brevity is accidental, that is, results from  the
 numerous  turns made around the body, limbs,  or neck  of the child.  The
 formation of these circular loops  is favored by an unusual length of the cord.
  The latter, in a case reported by Baudelocque, measured fifty-nine  inches,
 and made seven folds around the  infant's neck; and Schneider saw a cord
 that measured three  and a quarter yards (three metres), and  made six turns
 on the neck.   Nothing is more common than  to* find children whose bodies
 and necks are encircled by two or three of these folds.
  An accidental shortening of the cord may render the  labor difficult, either
 by retarding its progress, or by making it absolutely impossible, or by caus-
 ing the death of the foetus.   This  latter  circumstance may result from  the
 constriction undergone by the vessels of the neck, Avhen the cord is   tightly
 wound around  this part; or it may be owing to an interruption of  the  cir-
 culation in the umbilical vessels, produced solely from the stricture of  the
 cord itself, where it  closely encircles a limb;1 again, these tAvo causes may
 act simultaneously, and determine the child's death  much more speedily.
  1  This constriction is sometimes exceedingly great, and authors have certainly erred
 in denying that it could ever be such as to strangle the faetus.  Besides, it is not only
 at the time of labor, and as a consequence of the tractions produced by the expulsory
 efforts of the womb, that an effect of this kind is observed, but  these turns may  alsc
 form during the pregnancy, and  their constriction may then be extensive enough to
 occasion death.  Thus,  M. Monod met  with a foetus upon whose limbs they had  left
very deep marks, not merely in the soft parts,  but even on  the  bones themselves.   The
infa  t's neck often exhibits undoubted  traces of them,  and in one case examined by
 M. Tnxil, there were three circular folds around the neck, which was so diminished
 in size that its diameter did not exceed two or three lines (four millimetres).   It is to
 such circular turns that M. Montgomery refers those spontaneous amputatior s, which
 M. Richer and some others  have supposed were dependent on a gangrene of the part. 
       DYSTOCIA OCCASIONED BY  THE FCETAL  APPENDAGES.  83£

  These turns of the cord around some part of the body are of quite common
Dccurrence.   Mayer states, in his inaugural thesis, that out of 3,587 deliveries
which  took place between 1828 and 1841, they  were present in  685 cases.
Five hundred and sixty-four of the children were born alive, seventy-two
were in a state  of asphyxia,  but recovered  under proper treatment, and
forty-nine were dead.   In 18 of the  latter cases, hoAvever, the death could
not be regarded as due to the Avrapping of the cord.

  [Mr. C. Devilliers, Avho wrote a very complete  paper  upon shortness of the um-
bilical  cord, thinks that a short cord may be known to exist at the commencement
of labor by the following signs: " Continuance of the fundus of the womb  high up
in the epigastric region until the orifice is widely dilated, even though  the pelvis
be well formed, the child normal as regards position and size, the waters in medium
quantity, and the lower segment of the  uterus altered as is usual during gestation.
  "Agitation of the foetus  followed almost immediately by permanent diminution
of its motions at a period  not very remote  from  the term of gestation, when the
shortening is accidental; slight motion  during a part of gestation, especially near
its close, when the shortness is natural and  simple; a diminution and difficulty in
the movements which coincides with the preceding  symptoms."   (Devilliers, Paris,
1862.)]
  Generally, the delay in the  labor, caused by the shortness of the  cord, is
not usually manifested until the stage of expulsion, properly so called, begins;
and then,  as M. Guillemot justly remarks, the  attendant phenomena Avill
vary according to the point of attachment of the placenta.  AVIien inserted
at the  fundus, it, like the wall to Avhich it is attached, seems to descend at
each contraction, and approach  the  os uteri, but after the pain it retreats
with the fundus to its original elevation.   In ordinary cases, the  hand can
detect  this fact by being  merely placed over the uterine tumor; but  Avhen a
very short cord is forcibly stretched betAveen the placenta and some part of the
child's body, a particular phenomenon can be recognized by the touch ; thai
is, the  finger, Avhen applied on the head, finds it advancing during the pain,
and retreating as soon as it is over, because at this moment  the  fundus of
the Avomb, Avhich  had  been depressed  by the contraction, regains  its primi-
tive position, and draAA's after it the placenta, cord, and foetus.   But this sign
will evidently be wanting where the after-birth  is attached  to the lateral
parts of the uterus.
  We  have  met with  a  case in AA'hich  the  unusual  shortness of the cord,
which  Avas only nine inches in length, certainly detained the head above the
superior strait for fifteen  hours after  the rupture of the ovum  and the entire
dilatation of the os  uteri;  and  Ave can  affirm  that,  notAvithstanding the
closest attention, Ave Avere  unable to discover any of the signs given by former
authors ; though  it is true that the rapidity in the delivery of the after-birth,
after the child's expulsion, did not permit us to ascertain at what point the
placenta Avas inserted.
  Before the membranes are ruptured, this phenomenon might be confounded
with the successive elevation and descent of the  head  that takes place  in
nearly  every  case of labor.  But to  avoid such  an error, it Avill suffice  to
remark, that the ascent of the head then takes place during the contraction,
pad it only falls back after the pain is over; being just the contrary of Avhat 
836                           DYSTOCIA.
occurs when the cord is dragged upon.   Finally, in ordinary cases, av hen the
head engages at the perineal strait, it is found to project during the contrac-
tion, and to retreat immediately after it from the  reaction of the perineum,
Avhich, after having been forcibly distended during the pain, retracts strongly,
and thereby presses it back into the vagina.   But, as  Delamotte and Guille-
mot  have  remarked, Avhenever these movements  of  progression and repul-
sion merely depend on  the elasticity of the perineum, " they are only present:
1.  When the head engages at the inferior strait, and  then they are the less
evident as  the pains  are more rapid  and more energetic;  Avhile, on the con-
trary, they commence  much  sooner Avhen dependent on  a short  cord, and
become more sensible as the head approaches the vulva, because the tension
on the cord is then  increased; besides Avhich, they are persistent, Avhatever
may be the strength of the contractions, and are  the more marked  as the
latter become stronger.
  " 2. On  the other  hand, when the placenta is attached to the lateral Avails
of the Avomb, these  movements are very obscure,  and the diagnosis  is quite
difficult.   In  both cases, the  shortness of the cord is accompanied by pain,
which is felt at the point of attachment of the placenta, particularly in the
latter moments of the  parturition; this pain is a sensation of dragging, or
tearing, Avhich commonly coincides with the movements of progression and
repulsion;  and Avhich  might be compared to those felt by the patient when
an attempt is  made to remove the after-birth, before its complete separation."
(Guillemot.)   Sometimes, says M. Devilliers, there is  a sudden repression or
suspension of the contraction of the womb just Avhen it ought to be strongest.
  According to M. Naegele, Sen., these  circular turns may be discovered by
auscultation during  pregnancy or labor, by the existence  of a belloAvs mur-
mur accompanying the foetal  pulsations.  I agree Avith  M. Danyau in the
opinion, that further research is required to establish the absolute value of
this  neAV means of diagnosis.   (See Bellows Murmur.)
  The reader will iioav understand that a shortening  of the cord may retard
the progress of the head, Avhether it be still  at the  superior strait, or whether
it has cleared the excavation  and is on the  point of engaging at the inferior
strait.  AYe ought to add that even the shoulders may be arrested, and the
delivery of the trunk be prevented after the complete disengagement of the
head, by the circular turns Avhich are occasionally made  around the  child's
neck by too short a cord.  AVe Avere Avitnesses to a case of this  kind, that
occurred at the Clinique, in 1838, AA-here a division  of the cord, Avhich was
not made until two hours after the escape of the head, could alone effect a
termination of the labor : the foetus was born dead.  Delamotte (page 305)
furnishes an instance precisely similar to this.
  The intervention of art is therefore sometimes necessary, although it often
happens that  the trunk is delivered  spontaneously.   HoAvever, the mechan-
ism  is not  the same  in cases of natural and of accidental  shortening; for, in
those of normal brevity, the  head  may remain  applied against  the vulva
after its disengagement, Avithout much  inconvenience, and the extra-uterine
respiration may be  established and kept up.   In a short time,  the Avomb
gradually  contracts  on the parts of the  child that  it still contains, and, being
itself ft  reed along by  the bearing-doAvn efforts of the patient, it sinks intc 
      DYSTOCIA OCCASIONED BY THE  FCETAL APPENDAGES.   831

the vagina, and, by  thus  approaching the  vulvar orifice, may easily force
the trunk to the exterior.   Occasionally, this descent of the womb  does not
occur at all, or else  is not sufficient to permit the  escape of the child; and
then a rupture of the cord, or a detachment of the placenta, can alone en-
able the uterine efforts to complete the delivery.  Thus, in a  case  of the
kind reported by  Malgouyre, the discharge of the Avaters, the delivery of the
child, and the expulsion of the after-birth, all occurred simultaneously : and
the folloAving instance is related  by Dr. Rigby.  After two  or three hours
of severe pains, the foetus was suddenly expelled, and  the cord  Avas broken
at about tAvo inches from the umbilicus, so that, Avhen the midwife attempted
to deliver the after-birth, she could not  find the other end of the cord; but,
having introduced her hand into the womb, she felt and extracted  the pla-
centa ; and  it Avas then discovered that the cord  had  been lacerated at its
point of insertion.
   In labors complicated by an accidental shortening of the cord, the child's
head passes beyond the vagina, and retains its position there until a reneAval
of the pain; and Avhen the latter comes on, the head  is observed to pass to
the sides of the vulva, whilst the shoulders, back, and breech  successively
disengage.   This expulsion is sometimes effected so rapidly that it is difficult
to follow it; but, if it be delayed in the least, a prompt intervention is re-
quisite, for, as elseAvhere stated, the  compression  made by the folds around
the neck may  speedily prove fatal to the child.
   In breecn presentations, the labor  usually  terminates in the  following
manner, Avhen abandoned to itself; the  nates, after having been forced down
 to the vulva by the uterine contractions, turn up toAvard  the side Avhere the
 cord is situated, and then the trunk descends, becoming flexed on itself in
 the passage; so that, by the time the head reaches the excavation,  the body
 of the child forms a curve, Avhose concavity corresponds very nearly to the
symphysis pubis.
   Independently of the  delay that  it may cause in the progress of parturi-
tion, and the consequent danger to the  foetus, a shortening of the cord may
produce  other  and serious accidents to the mother.   It is to  this circum-
stance particularly, that Ave must in most cases attribute  the rupture of the
cord, and the premature separation of the placenta, points to Avhich Ave shall
return Avhen treating of uterine hemorrhage.  The danger of these accidents
will vary greatly  with the period of their occurrence; thus, at the commence-
ment of labor, the bleeding thereby occasioned might  seriously compromise
the  lives  of both mother  and  child, if the resources of our  art Avere not
promptly interposed.  But if they do not occur until  the moment Avhen the
head is ready  to clear the vulvar orifice, they  may rather be considered in
a favorable light, for, as Ave  have just seen, this is one of the means that
nature employs for  terminating the delivery.
   Again, if the cord and  the adhesions of the placenta should obstinately
resist, it is possible  that an inversion, or at least a depression of the uterus,
might be the immediate consequence of the child's expulsion.  The  inversion
occurs toAvards  the end of the  labor, Avhen  the distention  of  the parts
obliges  the Woman to bear  doAvn;  and  as she  still continues  to strain,
after the cessation of all uterine contractions, the relaxed womb yield5' the 
838
DYSTOCIA.
more readily to the action of the abdominal muscles, which tend to depress
its fundus, because the short  umbilical  cord  drags the uterine wall, where
the placenta is attached, in the same direction.
   Treatment.—The disastrous consequences that may result from a shorten-
ing of the cord present different indications for treatment, according to the
stage of the labor at Avhich its existence is detected.   AVhen the membranes
are still unbroken, if the os uteri be freely dilated, the contractions energetic,
and there, is every reason to suppose, from  the signs  before given, that a
dragging on the cord is the cause of the delay, they should be ruptured at
once; for, after the waters have escaped, the uterus Avill contract, its fundus
will approach the cervix, and the cord, being no longer dragged upon, will
permit the head to descend into the excavation.  If the head  be  at the in-
ferior strait, at  the  time Avhen  the alternate  movements of elevation and
descent begin to manifest themselves during  and  after the contraction, the
forceps should be applied.  But where  the head has only the  resistance of
the soft parts to overcome, Ave must be content Avith preventing it  from re-
mounting in the excavation after each pain, as much as  possible; for  that
purpose Ave must apply the hand strongly on  the perineum, and Avhile  sup-
porting it, favor the escape of the head  by pressing it  up in such a Avay as
to aid its process of extension or disengagement.  It would also be advisable
to have the hypogastrium compressed at the same time  by an assistant, in
order to prevent the uterus from ascending during the interval betAveen the
pains.   Lastly, after  the head is  delivered, the accoucheur should imme-
diately loosen the turns of the cord around the neck, and slip them over it;
and Avhere these folds are so tight as to resist the tractions made Avith  that
object, they should be divided, but it is not requisite to  apply the ligature
to the umbilical extremity of the cord at once.  In most cases, indeed, it is
necessary to allow this to bleed a little after the birth, in order  to relieve the
apoplectic state of the  foetus; for, by  applying the ligature  too soon, Ave1
would  be deprived of this resource.  Nevertheless, where the expulsion is
unusually delayed, the foetal  end of the cord, knoAvn by the  jets of blood
which issue from it, will  have to be slightly pinched betAveen the two fingers
to prevent hemorrhage.
   Dragging of the cord entAvined  around the trunk or  limbs is not at all
unfrequent in natural labors by the breech, and when pelvic version  has
been effected.  It is  to  be remedied by making moderate tractions on its
placental extremity, and if these are not sufficient, it should be divided, and
the labor terminated as speedily as possible.   The  same  precepts are appli-
cable in all cases Avhere the brevity  of the cord is natural; and if the
accoucheur is obliged  to carry his hand up into the womb to  ascertain the
nature of the obstacle, he should take  advantage of the occasion  to  effect
pelvic version, and to draw down the child until the base of its chest appears
at the vulva; then the  cord is to be cut and  tied, or else compressed  Avith
the fingers, and  the extraction of the foetus completed at once.
   It is advisable to introduce the hand again into  the uterus after the pla-
centa is delivered, to ascertain that the fundus of the  o' gan is neither de-
pressed nor inverted. 
DYSTOCIA  DUE  TO  THE  FCETUS.
839
                         [CHAPTER  XV.

                   OF DYSTOCIA DUE TO THE FCETUS.

  In order that delivery should be effected spontaneously and without danger, it is
Dot only necessary that the mother should be well formed  and the labor uncompli-
cated by any of the accidents Avhich have been already studied, but the size of the
foetus and the conformation of the different parts should have a proper relation with
the canal to  be traversed.   It ought also to present by one of the extremities of its
long axis, which should be properly situated in regard to the pelvis.  The foetus at
full term may also be diseased, or so deformed as to have its size sensibly increased.
  In the present chapter, therefore, we have to  consider the  indications arising
from unusual size, Avrong  presentations and positions, diseases and monstrosities
of the foetus.

                              ARTICLE  I.

                       UNUSUAL SIZE OF THE  FCETUS.

  Whether the pelvis be contracted or the size of the foetus greater than usual, the
relative proportions required for an easy delivery nc longer  exist, and the labor is
difficult.
  Very rarely does the size of the foetus exceed a certain limit and render delivery
impossible.
  The first chapter, hoAvever, of Duges' paper is devoted to cases of this kind, though
he has met with very few in his own practice.   One instance of the kind has been
already mentioned in the  present work.   (See p. 216.)
  There can be no doubt  that labor may be rendered longer and more painful by
unusual size of the child;  still, if all the other conditions  are favorable, deli\'ery
will most probably be effected by the unaided efforts of nature.  " It is more  par
ticularly Avhen  it becomes necessary to turn a very large child that the greatest
difficulties are liable to be encountered, and that especial  care  should be  taken  to
avoid the crossing of the arms back  of the neck, to turn  the face first toward
one  of the  sides of the pelvis  and then  toward the sacrum,  and also  to depress
the chin so as  to bring the sub-occipito-bregmatic and bi-parietal diameters parallel
to those of the pelvic canal and of the external genital organs."  (Duges.)
  The  unusual size may not be general, but confined to some one part of the foetus ;
therefore, to complete what has been already said, Ave shall treat briefly of unusual
Bize  of the head and shoulders.
   Unusual  Size of the Head. — To this cause of dystocia, our colleague and friend,
Dr. Joulin, Adjunct Professor of the Faculty of Medicine, at Paris, devoted a long
chapter of  his thesis  for the  Concours.   According to  him, the Germans admit
that trouble may be due to the size of the head alone, besides which they also call
attention to  a peculiarity  of the ossification, little  known in  France, which adds to
the difficulty of the situation ; viz., the development of ossa Avormiana in the fonta-
nelles,  causing their solidification.
  It is very  hard to determine Avhat ought to be done in cases of this  kind ; it is
almost impossible to become aware of the size of the child whilst it is still within
tin- womb, so that the practitioner who finds the progress of the case arrested in an
apparently  Avell-formed pelvis, will very probably decide  upon  active interference
before the true cause of the delay is detected, and apply the forceps  or cephalotribe,,
lu-cordin"- to the amount of difficulty Avhich the size of the head shall present to its
extraction.   (Joulin.)
   Unumal  Size of the Shoulders. — Labor may also be  rendered  difficult  by too. 
840                             DYSTOCIA.

great length of the bi-acromial diameter.  This cause of dystocia, which had beei
suspected for a long time, was made by Levret, under the title of impaction of tht
shoulders, the subject of very remarkable researches which, of themselves, ought
to have prevented its falling into oblivion.   In  our own time it has  been again
asserted and placed beyond doubt by M. Jacquemier, who wrote an excellent paper
upon it.   It Avere hardly necessary to say that we have to do loss with the size of
the shoulders proper than with that of the chest; still, on account of their situation
and  projection, the shoulders  are  included in the impeding part.  The shoulders
and upper part of the chest, says  M. Jacquemier, being  retained at the entrance
of the pelvis after having obstructed the passage of the  head through  the external
genital parts, again hinder the passage of the trunk after they haA'e got to the bot-
tom of the pelvic cavity.  But it may also happen that Avhen the hindrance to the
exit of the head occasioned by the presence of the  shoulders at the entrance of the
pelvis  has been  at last  overcome, the  remainder of the body shall pass Avithout
trouble.  Still, the opposite may occur, and  the difficulty occasioned by the shoul-
ders only declare itself after the head has  been born.
  I might add three cases of my own to those mentioned by M. Jacquemier, having
been called  upon to terminate the delivery under the following circumstances:  in
all the head had been born, but although traction was used, it was found impossible
to extract the trunk. My OAvn efforts were  more successful, though I must acknowl-
edge that I had to employ considerable force.
  It is important to recognize this cause of dystocia and overcome it quickly, inas-
much as it leads rapidly to the death of the child.  When the shoulders, continues '
M. Jacquemier, are arrested at the superior strait and  thus keep the head at the
bottom of the cavity of  the pelvis, or when  they are more or less engaged in the
 nferior strait, as the difficulty is due to the size'of the chest  rather than to the
sosition of the shoulders, there is no indication for endeaA'oring to alter  the position
af the latter, but the forceps should be applied. If this instrument prove ineffectual,
what is next to be done?   As soon as the foetus has ceased to live, or its chances of
life are rendered highly  improbable, the  mother's life ought not to be endangered
by too long expectation.   Craniotomy should be performed, followed  by cephalo-
tripsy ; in short, the size of the head ought to be so lessened as to enable the ac-
coucheur to pass  his hand deeply,  seize the arms of the child and bring them down,
after which, by draAving upon them, the trunk can be delivered.
  When the great size of the shoulders arrests delivery only sifter the head has
been born, what ought to be done ?   At first it would seem  reasonable to  draw
somewhat upon the  head, and although it might answer in simple cases, it would
be useless provided the difficulty were considerable.   Indeed, there is  risk of tear-
ing off the head, for it has often been  done.   Therefore it were much better to Avork
two fingers into one of the axillae and draw the shoulders down; but if necessary,
there should be no hesitation in  seizing  the root of the arm with the entire hand,
for thus only can it exert its full power.
  Tractions upon the  axillae are a step in  the process  which consists in the succes-
sive disengagement of the arms, followed by tractions  upon them in order to deliver
the trunk.   This latter method is preferred  by M. Jacquemier as being the most
efficacious, because it has the advantage not onhy of affording a solid bearing, but
of removing from the chest the thickness  of the arms and the abrupt  projections
formed by the stumps of the shoulders.  (Jacquemier.)] 
DYSTOCIA  DUE  TO THE  FCETUS.               841
                          ARTICLE  II.
[RREGULAR OR COMPLICATED PRESENTATIONS AND POSITIONS : ANOMALIES
                    IN  THE MECHANISM OF LABOR.
  The ancients applied the term  malposition to all those cases in Avhich the
top of the head did not correspond to the os uteri.   But, as we have already
demonstrated, the labor nearly ahvays  terminates favorably, both for the
mother and child, in the presentations of the face and breech, though it is a
little more  difficult than usual;  and  experience has even proved that it is
barely possible in those of the trunk.  Nevertheless the first three presenta-
tions offer certain anomalies and  irregularities, that may at times render the
labor difficult, and  require the intervention of art; for, although the presen-
tations of the vertex, face, and breech are usually free and regular, yet they
may be irregular or inclined.  But these last so rarely constitute an obstacle
to the spontaneous  termination of the labor, that  Ave  have not  hesitated to
include  them in the.  description, heretofore  given, of the  mechanism of
natural  labor.   In fact, the  only modification they determine in this mech-
anism is that the  head,  in  clearing the  superior strait  or traversing the
excavation, undergoes a movement of correction, Avhereby the occipito-frontal
or the sub-occipito-bregmatic circumference becomes parallel to the plane
of the strait.   But this movement is necessary ;  for, if the head exhibits its
normal size, the delivery is only possible under that condition,1 and, Avhen it
does not take place, the resources of art are indispensable.   Certain anoma-
lies, capable of interfering with the expulsion, may also take place  in the
movements of the  head.  AVe must  noAV ascertain Avhat are the indications
for treatment presented in these particular cases.

   § 1.  Inclined Positions  of the Vertex : Anomalies in the Mech-
anism of Labor.
   Under this title Ave include all those posi-             Fia-113,
tions that have been described by Baude-
locque as the positions of the sides of the
head, of the  ears, the  temples,  and  the
occiput;  the  former of Avhich is recognized
by the presence of  an  ear, the angle of the
jaw, or by the parietal protuberance; Avhile
a presentation of the occiput  is detected by
the triangular form of the posterior fonta-
nelle, by  the lambdoid sutures, and  the
vicinity of the neck.
   In general, Avhen an inclination of  this
kind is  detected at the onset of labor, or
shortly after  the  membranes are ruptured,
there is nothing to be done;  for  it  is Avell
known that,  in far  the greater number of  The left occipito-iiiao position, strongly in-
                  .   P         ,             clined on its posterior parietal region.
cases, the  conversion is effected sponta-
  1 However, we have known this conversion of an inclined vertex position into a free
)ne to occur at the inferior strait in a woman with her first child;  the head was placed
 
842
DYSTOCIA.
neously; but, if the head still retains  its primitive  posit on for fi  e, six
seven, or eight hours after the discharge of the waters, and  its descent is
thereby impeded, we must attempt an artificial correction.   It is possible to
accomplish  this with the  hand alone, Avhich is  ahvays  to  be tried  before
resorting to an introduction of the lever or forceps; and it is unnecessary to
add that any obliquity of the uterus, should it exist, must first be remedied.
As a general rule, that hand should be used whose palmar face Avould grasp
the vertex the most readily; and, Avhen introduced into the womb (see Ver-
sion), it grasps the occiput so as to draw upon it, after having first removed
it from  the iliac fossa;  Avhilst  considerable  pressure is made with the other
hand  over the hypogastric  region, in order to  force the head to descend.
When the correction cannot be effected by the hand alone, most accoucheurs
recommend the employment of the  lever;  but  Ave should  decidedly prefer
having  recourse to the forceps, the blades of Avhich would  act at first as a
lever in rectifying  the head, and then, by their  traction, the labor could be
terminated almost  immediately.   Because, where seven or eight hours have
been spent  (according to our precept) in the vain hope that the poAvers of
nature Avould  be adequate to rectify the inclination; and where the operator
has unsuccessfully  attempted to produce  the correction by his  hand alone,
it  must  be evident that an early termination of the labor is  indicated in the
double interest of the mother and child ; and that, consequently, the forceps
should be preferred in such cases to the lever.
   The attempt to seize the head properly with the forceps and bring it doAvn
into the excavation, does not  always succeed, in which  case  the  difficulty
may be overcome  by turning;  at least, I found it to answer in two cases of
failure  by the forceps.   I think, also, that I should  be disposed  to have
recourse to it immediately, when the uterus Avas but slightly contracted, and
still contained a considerabla amount of water.
   The occipito-posterior positions which  are not converted naturally into
anterior or pubic ones, may also allow of the spontaneous disengagement of
the head, though, as we  have already stated, they sometimes present insur-
mountable  obstacles to the termination of the labor.   AVe repeat that we
have  but little confidence in efforts  made with  the fingers to produce this
movement of  rotation, and that the application of the forceps seems to us
the most useful means that can be employed.   (See Forceps.)
   It is important to observe that the continuance of the occiput posteriorly
sometimes prevents the  engagement of the  head, which remains, long after
the membranes are ruptured,  above the  superior strait, and  that,  notwith-
standing the contractions are  poAVerful.    In such cases, the posterior fonta-
nelle  is hidden by the  swelling of the  scalp, and in order to diagnose the
position, it is  necessary to carry the  finger upward and in front, Avhen the
anterior fontanelle will be  discovered.   At each contraction, the  vertex

in the left anterior occipito-iliac position, and was at the same time inclined on the
right parietal region.  In descending into the pelvis, it retained this position, so that,
when it had  reached the floor of the excavation, we detected the ear;  but it became
rectified, after several strong pains, and cleared the inferior strait immediately after
having undergone  the movement  of correction.  The head was small, although the
foetus was at full term 
DYSTOCIA  DUE  TO THE  FCETUS.
.843
Btrikes the horizontal branch of the pubis, and  the  presentation then tends
to become converted into one of the nucha, so called by the old accoucheurs.
I have noticed this  anomaly more especially in the left occipito-posterior
positions, and have  ahvays been obliged to use the  forceps; quite poAverful
efforts are usually required to extract the head.
   The vertex positions, even when not inclined, sometimes present anomalies
in their mechanism.   Thus the movement of rotation, Avhich  in  the trans-
verse positions is calculated to bring the occiput under the pubic  arch, is
occasionally delayed for a long time, and thereby greatly retards the labor.
When this delay is dependent  on the feebleness of  the uterine contractions,
an application of the forceps is the best  remedy.   But, according to many
authors,  it may also  be owing to Avhat  Levret called the wedging-in of the
shoulders; that is, the latter then present their long bis-acromial diameter
to the smallest one of the  superior strait, and thus  become firmly engaged
or wedged there, in such a Avay that they cannot descend  any further, and
therefore arrest the  progress of the head.  This wedging of the shoulders,
which can scarcely  occur without a slight contraction of the  abdominal
strait, has been  detected  by Levret, by Delamotte, by Ruysch, et als., and
its occasional  occurrence  is admitted  by Desormeaux and  Duges; conse-
quently it should be regarded as being possible.  (See p. 840.)   This cause
of dystocia Avould scarcely ever be suspected during the  labor, unless atten-
tion Avere drawn to it by the mobility of the head in the excavation (Fried) ;
this is the only sign that Avould be likely to arouse attention, Avhere a normal
conformation of the inferior strait has been ascertained,  and where the con-
tractions  are  strong and sustained.  Under such circumstances,  Levret
advises (and  Desormeaux seems to approve the counsel) the  patient to be
placed on her elboAvs and knees, Avith her head declining, Avith a vieAv of
removing the Aveight of the child's shoulders from the mother's parts;  and
then the  accoucheur should slip his hand along betAveen the head and the
pelvic Avails, seize  the  shoulder that is locked at the sacro-vertebral  angle,
draw  it to one side and change  its position.  Although the performance of
this manoeuvre is attended Avith difficulty, yet it is the only one practicable
if the foetus  be living; but Avhere it is dead, he ought to diminish the head
by craniotomy, so as to open a  more ready passage up to the shoulders.
   Supposing  this  diagnosis to be Avell  made out, it Avould seem proper to
folloAv the recommendation of Desormeaux;  but the fact  is, it is  so very
difficult that, as M. Jacquemier judiciously remarks, the use of the forceps,
though in reality irrational, is perhaps the only  remaining resource.
   The rotation of the head, in virtue of  Avhich  the occiput gets under the
symphysis pubis, may likewise  be rendered difficult, or  even Avholly impos-
sible,  by  the size of the sero-sanguinolent  tumor of  the scalp, that is ahvays
formed when the head  remains in the excavation  for  sometime;  for, by
engaging  itself in the void of the pubic  arch, this  tumor may render the
movement of  rotation  absolutely  impossible.   (Tarnier.)   Of course, the
forceps must then be applied.
  Direct occipito-pubic or occipito-sacral positions are very rare,  though
certainly it is a mistake to deny their existence. AAre have  already stated
that the occiput may be in relation with  any point of the superior strait. 
844
DYSTOCIA
In the immense majority of cases these direct positions are con/erted, after
the labor begins, into the diagonal ones; for the convexity of the forehead
in the occipito-pubic positions, and that of the occiput in the occipito-sacrai
ones, having to glide over the sacro-vertebral angle, are almost ahvays turned
either to the left or to the right.
  In some cases, hoAvever, the primitive positions continue, and  the labor
terminates in nearly the usual manner.  It occasionally happens that if the
head is large, and the pelvis but moderately developed, though Avell formed,
the former is arrested at the superior strait, and impacted, as it Avere, by the
two extremities of its occipito-frontal diameter.  In such cases, the applica-
tion of the forceps is the only resource.

  § 2. Inclined Positions of the Pelvis : Anomalies  in the Mech-
anism  of Labor.
  Sometimes one hip, at others the lumbar region, or the  loAver part of the  /
abdomen, according to the direction  of the inclination, may engage first at
the upper strait; particularly Avhere the uterine obliquity is well marked.
A\re must, therefore, correct  this obliquity, which is the original cause of the
anomaly; then, if that is not sufficient to replace the breech in a' horizontal
position,  the feet are to be sought after and brought doAvn, or else one of the
groins  be acted on by hooking a forefinger into it.   (See Mechanism of
Labor in Breech Presentations.)

  § 3.  Inclined Positions of the Face : Anomalies in the Mech-
anism  of Labor.
  The face positions may likewise be irregular; that is, it may happen either
that only one cheek engages, in consequence of a lateral inclination, or else
that the head, being but little extended, the forehead  is found at the centre
of the superior strait; or, on the other hand, this extension being carried to
an extreme, that the chin and the front of  the neck are alone accessible to
the finger; but in all these,  as in the preceding cases, nature herself is gen-
erally able to accomplish the delivery.  The instances in which the forehead
is first placed  at the centre  of the upper strait  are quite frequent; but the
extension being completed at the moment Avhen  it engages the excavation,
the face then becomes completely horizontal.   (See Mechanism of Labor by
the Face.) The same is true of the malar positions, the correction of which,
like that of the parietal positions of the vertex, is effected  during the period
of descent.  In those rare cases Avhere  the  inclination resists the poAver of
the uterine contractions, the correction Avith the hand at first, then, in case
of failure, the application of the  forceps, if  the head is  engaged  and im-
movable, or the pelvic version, if it be high up and can easily be displaced,
appear to us the proper measures.
  The spontaneous  reduction, just alluded to, as the most ordinary termina-
tion of the frontal  or malar positions, is much more difficult in the  cases
where the chin, in consequence of the excessive extension of the head, has a
tendency to engage first, and approach the centre of the  excavation.   For
then according to the observation  of Madame Lachapelle, the head not only
presents unfavorable diameters, but the body likeAvise shoAvs a disposition tc- 
DYSTOCIA  DUE  TO THE  FCETUS.              845
descend along with the face; though at the same time it presses the latter
back from the passage, and thus creates an obstacle to its escape, Avhile the
contraction transmitted by the spine rather tends to augment than to correct
the inclination.  Under such circumstances, Ave can trust less to the poAvers
of nature, and therefore must endeavor to change  the position  by a resort
to pelvic version.
   These lateral  inclinations are usually primitive, and, as Ave have already
stated, are  reduced spontaneously into  correct positions.  But it  may also
happen that a position Avhich is entirely regular at the beginning  of labor,
may become converted  into an inclined  one, AA'hich nothing  can restore.
Thus, Dr. Birnhaum, of Bonn, mentions a case of right tranverse mento-
iliac position, of the most regular kind, Avhich became converted into a left
anterior  occipito-iliac  one, strongly inclined upon  the right parietal  bone.
The labor had to be terminated  by the forceps.
   It is well knoAvn  that a spontaneous delivery in  face positions requires
that they should be converted into mento-pubic ones; but this process  of
rotation, which is easily effected in  the mento-anterior varieties, that is to
say, in the cases Avhere the chin Avas primitively in relation Avith some part
of the anterior half of the  pelvis, is much more difficult in the mento-pos-
terior positions, and sometimes  even it does not take  place at all.  And it
must be  acknoAvledged that an unreduced engagement of the face, and its
want of tendency to reduction,  constitute one of the most serious difficulties
met Avith in the obstetrical art.
   Noav, Avith a vieAV of more  clearly specifying  the A'arious indications for
treatment that may  present under such circumstances, Ave AviU suppose four
different cases of face positions,  namely:
   1st. A woman has been  in labor for a considerable time, the membranes
are ruptured, and five or  six hours, or even  more, have elapsed  since  the
waters escaped, during all  which period the uterine contractions have been
very strong; a good conformation of the  pelvis, and a complete dilatation
of, and no resistance from, the os uteri are recognized by the touch, and yet
the presenting part still remains high up and does not engage in the excava-
tion ; but, in  searching for the  causes  that retain this part at the superior
strait, under so many favorable  circumstances, it is found that the face pre-
sents  in a mento-posterior position.  Here there would be reason to  conclude,
in my estimation, that  the delay in  the  labor is dependent  on  the non-
reduction of the mento-posterior position into an anterior one; and, there-
fore, I think that an attempt should be made to convert the face position
into  one  of the vertex.  This could be done by introducing that hand Avhose
palmar face embraces the  vertex  most readily; Avhich Avould be  the right
one Avhen the chin is directed backAvards and to the right side,  and the  left
in the opposite case; then, after having  grasped the head Avith the Avhole
hand, endeavor  to  push it up above the  superior  strait, and, if successful,
surround the vertex Avith the palmar  face of the four fingers, and flex the
head on the chest, Avhen, the position of the face being converted  into  one
of the vertex, the uterine contractions will accomplish the rest.
   I am  now convinced  that this  manoeuvre Avill  rarely prove successful,
therefore it should be  attempted very carefully, and  pelvic version substi-
tuted  for it Avithout much delay. 
346
DVSTOCIA.
  2d. If, to the mento-posterior position just described, Avhether the face be
engaged  or be still above the abdominal strait, any accident  whatever be
joined that demands a prompt termination of the labor, it is evident that the
pelvic version is the only operation that could be resorted to Avith a prospect
of advantage.
  3d. If the mento-posterior position is coincident AA'ith a moderate contrac-
tion of the pelvis, most authors advise the conversion of the facial position
into  one of the  vertex, and  then the application  of the  forceps upon the
flexed cephalic extremity.   It seems to  us, that this previous cephalic ver-
sion Avould prove very difficult, if attempted long after the membranes  are
ruptured, and Ave should give preference to turning by the feet.  AA7e shall
have occasion hereafter to settle this question when we come to discuss the
rise of the forceps in cases of contracted  pelvis.  (See Forceps.)
  The application of the forceps on the face in the mento-posterior positions,
seems to  us an  extreme measure, Avhich  should only be employed Avhen
nothing else can be done, as in the next  variety.
  4th. Lastly, there are  some unfortunate cases Avhere it is impossible to
push up the presenting part, either because the head has cleared the cervix
uteri, or because the strong contraction  of the Avomb renders every attempt
abortive; and, therefore, both the pelvic and the cephalic versions are alto-
gether out of the question.   The accoucheur must  then  necessarily have
recourse  to instruments.  The lever, the common forceps, the crotchet, and
the embryotomy forceps have all been proposed in turn ;  but before resort-
ing to the latter, the first should always be tried.
  In certain cases, the lever has proved very useful, and,  where applied on
the A'ertex or occiput,  has occasionally depressed  this part, and  thus con-
verted a face presentation into  one  of  the vertex.   It is oftentimes more
easily managed than the  forceps Avhen the head is high  up, OAving to  the
difficulty  of  getting the second blade of the latter to the proper height and
position ;  and I may  mention that it proved very serviceable  in a case to
Avhich I was called  by Dr. Fournier, Avhere  the head had engaged in  the
excavation,  in the right mento-posterior position, and  could neither be
pushed up nor advantageously grasped by the forceps.
  I believe that, in common Avith many practitioners, I have erred in pro-
scribing this instrument almost altogether from practice; for the lever, in
my opinion, may render very important  aid in those posterior positions that
approach a transverse character; and in Avhich, from being still high up, an
application of the forceps is exceedingly difficult.   (See Lever.)
  As -to  the  forceps,  though proscribed  by Madame  Lachapelle, in  the
cases under consideration, it may be  tried as a last  resource, being  far
better than  embryotomy Avhen the  child is living; but to be successful,
it is necessary that the operator should be Avell versed in the movements
that  are to be given to the  head by the instrument.  Thus, supposing  the
blades are properly applied  on the sides of the head (and the  difficulty of
this  is well knoAvn), should  we attempt to bring the chin  round in front
(Smellie) ? or Avould it be better, leaving the chin  posteriorly, to endeavor
to depress the forehead and  occiput,  and then to  disengage these parts first
'jnder the pubis  ?   Relying on the cases published by former authors, I do 
DYSTOCIA  DUE  TO  THE  FCETUS.                847
 not hesitate to decide in fiu'or of the last manoeuvre ;  for every practitioner
 must acknoAvledge that the rotation of the chin fonvards exposes the child
 to very great dangers from the extent of the movement in the atloido-axoid
 articulation, and the tAvo favorable cases reported by M. P. Dubois, which
 he himself considers as exceptions, cannot make us overlook  all  those in
 which this excessive rotation has cost the child's life.1
   I am Avilling  noAV to be less exclusive, for M. Blot's facts, besides some
 others,  haA'e convinced  me that artificial rotation of the chin in front  may
 sometimes be accomplished Avithout necessarily compromising the life of the
 child.  AVe may be  content, indeed, to bring the chin up to the ischio-pubic
 ramus, in which case, if it Avere a sacro-iliac position, the  rotation Avould
 hardly  exceed a quarter of a circle; and if it Avere at first a mento-sacral
 position, Ave might hope that the uterine contractions AA'ould cause the body
 to folloAv the rotation given to the  head by the forceps, and tAvisting of the
 neck be thus avoided.
   AVe shall see hereafter hoAv far the modifications of the process to  be
 employed, recommended by  MM. Champion, Baumers, and Danyau,  are
 capable of facilitating this rotary movement.
   If it be found  impossible to rotate the head, what should be done next ?
 Grounding  myself on  the  observations  of Smellie (t. xi. p. 570), of Meza
 (Acta Regia: Societatis Med. Hauniensis, t. xi. p. 379), and of Siebold (Sie-
 bold's Journal, ann.  1830, p. 209),  I think that one  might, after  having ap-
 plied the blades as accurately  as  possible on the sides of the  head, draAV
 directly dowmvards and backwards, Avith a  vieAV  of depressing the vertex.
   I am Avell aAvare of the objections to this  mode of procedure,  and that it
 may  be  said  that, during the  movement of flexion, which you  impress  on
 the head, the long occipito-mental diameter must necessarily pass one of the
 diameters of the excavation, thereby often creating an insurmountable  ob-
 stacle to the  delivery.   I do  not  deny the force of this objection, and  am
 Avilling to confess that  in theory it is  not altogether  satisfactory;  still, of

  1 I have had occasion to  prove very evidently the danger attendant on this extreme
 rotary movement.
  In July, 1845, I had charge of a case of right mento-sacro-iliac position in a primi-
 parous female, and the continuance  of which rendered delivery  impossible, and re-
 quired the intervention of art.  After  fruitlessly endeavoring tc  press up the head,
 we were obliged to use the forceps, the child being still alive.   Having  applied the
 blades upon the sides of the head, we endeavored  to bring down the Vertex, but it was
 impossible.  Neither was one of the  branches of the forceps applied as a lever upon
 the vertex more successful.  We thought it right, before having recourse to embry-
 otomy, to endeavor to turn the chin in front; therefore, replacing both blades of the
 forceps, we turned the head so as to make the chin correspond with the right, extrem-
 ity of  the transverse diameter, and next, after a slight rearrangement of the blades,
 behind the right acetabulum.  The face was then in the lower third of the excavation,
 and the vulva being partially opened  by the  instrument, we saw distinctly motions of
 the lips and tongue of the  foetus.   The  rotation was then completed, and when  once
 the chin came in front, the head  was disengaged by the usual flexion.   Though the
 heart of the foetus still beat feeoly, it  could not be  restored to life by long-continued
and well-directed efforts.
  I am convinced that the'death of the  foetus was in this  case  simply due to the ex-
treme  t .voting of the neck. 
848
DYSTOCIA.
what consequence is the theoretical impossibility, Avhere positive facts bear-
ing on this  point can be adduced, and some of Avhich I have just quoted?
But the someAvhat  material authority of facts is not the only one I might
invoke;  for does  not our reason tell us that, Avhen any of those cases (for-
tunately very rare) are  presented  in  practice, Avhich seem beyond the pale
of all theoretical notions, and in Avhich the practitioner  is constrained to do
Avhat he can, not Avhat he Avould, the Avisest course  is to follow as closely as
possible the route traced out by nature ?   Noav, has it not often happened
that the labor terminated alone, in the mento-posterior  positions of the face,
and yet the chin has remained behind throughout?  And Avhat  has  been
the mechanism under  such circumstances ?   By  consulting the published
cases, Ave shall find that the uterine contraction Avas incapable of depressing
the chin, and has seemed to transfer its action to the occiput; and then the
forehead, the vertex, and the  occipital extremity, by  slipping behind the
symphysis pubis, have successively appeared at the centre of the pubic arch.
It is not, therefore, logical to recommend  an attempt to impress the same
movement of flexion on the head, in the  hope that the tractions by the  in-
strument, coming to the aid  of the expulsory efforts of  the  Avomb, would
succeed in accomplishing Avhat these latter alone could never effect.
   AVhat Ave have stated respecting the impossibility of spontaneous conver-
sion in direct mento-sacral  positions, and  of its natural explanation in the
diagonal mento-posterior positions, finds here its practical  application.  The
consequence  is, that  if the  chin Avere  turned  directly  toward  the anterior
face of  the sacrum, AA7e  should, before flexing the head  Avith the forceps, im-
press upon it a slight rotary movement, Avhich would bring the chin to one
of the sacro-iliac symphyses, preferably toward the right, in order to avoid
compressing the rectum, Avhich is situated to the left,
   My own experience, as well  as that of  others, has so much  changed my
view in regard to this point of  practice, that I willingly admit having been
hitherto too exclusive.   I believe, therefore, that both methods  may succeed
in some  cases, and it being  impossible to determine a priori in Avhich one or
the other will be more successful, it Avere prudent to try them successively.
   It should, therefore,  be well  understood that accoucheurs of the present
day, draAving encouragement from the successful issue  in certain cases of a
recent date, are of opinion  that the first effort  should be to bring the chin
under the symphysis pubis.
   Again, there  are  some unfortunate cases  in Avhich, after having vainly
attempted all the different manoeuvres just referred to, craniotomy becomes
our only resource.1
  1 I have quite  recently witnessed a case  of this  nature  with  Dr. Letannelet, who
requested my attendance on a young lady in her first labor.  I saw her at eight o'clock
in the evening, and detected,  as my- learned associate  had previously done, a right
mento-posterior position (the frontal variety): the head had been firmly engaged since
three o'clock in the aftern.oon,  and from that hour had not advanced a single line.  At
eleven, as no change had taken place either in  its position or  elevation, we attempted
unsuccessfully to push it up   Both M. Letannelet and myself tried the lever and  the
forceps in vain; but before resorting to craniotomy, which was then deemed indispen-
sable, we requested M.  Dubois to see  the patient.   He arrived at one  o'clock in  the
morning, and  reneAV id  the attempts that we had before made, without any  better sue- 
DYSTOCIA  DUE  TO  THE  FCETUS.
849
  Do not the supposititious cases just given (which could easily be sustained
from the facts reported by authors), by rendering us  acquainted with the
various difficulties that may be encountered in these cases, lead us to adopt.
for the mento-posterior position, the rules  heretofore laid down by Baude-
locque, Gardieu, and others, for all face  positions?   And  though,  in the
present  state of our science, the mento-anterior  positions should be  aban-
doned to nature, yet  does the same rule hold  good Avith  regard  to the
mento-posterior ones?  In a Avord, if this last position  be clearly recognized
before or shortly after the membranes are ruptured, should Ave not, prior to
the engagement of the face, and Avhile the head is still  movable, endeavor
to convert  it into a  vertex position, and thus prevent the difficulties that
might subsequently arise ?  If I  had to decide under such circumstances, I
would certainly resolve the question in the affirmative.

  § 4.  Presentation of the Trunk.
  A natural delivery in trunk presentations is a very unusual occurrence,
and one upon  Avhich  the accoucheur should  never rely.   It is therefore an
absolute rule in practice to attempt to bring one extremity of the foetus to
the superior strait as soon as possible, by resorting either to the pelvic or
the  cephalic version.  (For the divisions,  causes,  and diagnosis of this
mechanism, see Natural Labor, page 368, et  seq.; and for the indications,
the chapter devoted to Version.)

  § 5.  Complicated  Presentations.
  Under the title' of " fallings"  (procidentias), Madame Lachapelle has
described the untimely  descent  of any part whatever of the child,  which
cannot of itself constitute a particular position on account of its smallness or
mobility, but Avhich, hoAvever, might complicate the presentation of a more
extended region.  Thus,  the  umbilical  cord,  the  feet, or the hands, may
individually or  collectively come doAvn at the same  time as the head or
breech.   This complication will  be very readily detected  by the touch, and
therefore it is unnecessary to enumerate the peculiar signs that distinguish
each of these parts.
  AVe  have  already spoken of a falling of the cord,  and of the means of
remedying it.  Again, in those cases Avhere one hand  has slipped under the
head or breech,  the  labor  may terminate alone if  the  pelvis is Avell formed
and the contractions are strong and continued ;  and hence we should delay
all operations.   Even the presence of both hands on the  lateral parts of the
head has not ahvays proved an insurmountable obstacle  to the spontaneous
termination of the labor,  for all these parts have occasionally been expelled
together;  but if the passage be  someAvhat contracted and  the  soft  parts
resistant, it would be advisable to terminate  the delivery artificially by the
application of the forceps or by version, according to whether the head  has or

cess, and craniotomy was then decided upon; but as the woman had great need of
rest, and the necessary instruments were not at hand, the operation was deferred until
eight o'clock a. m., when  it was accomplished with much difficulty; for, notwithstand-
ing his dexterity, M. Dubois had the greatest  trouble in extracting the head with th«
embryotomy  forceps.
      5-i 
850
DYSTOCIA.
has not cleared the superior strait; and to bring down the feet ii. the breech
presentations.   This latter plan should also be followed if one f\©t instead
of the hand, or if both a foot and a hand accompany the head.  Neverthe-
less, before resorting to an artificial delivery, the accoucheur should ahvays
endeavor to push back the hand or foot into the uterus and get it above the
head.   Most frequently, it Avill only be necessary to sustain it  there during
the pain, Avhich urges on the  head, to find the latter descending alone and
arriving  at the inferior  strait, and  then the labor  may be abandoned to
nature.   AVe must  remark, hoAvever, that a foot is far more difficult to
return than the hand, and that in  consequence of its volume it often consti-
tutes  an  obstacle which  cannot be surmounted by the ordinary resources;
wherefore,  craniotomy is sometimes indispensable, as several recorded  obser-
vations fully prove.
  A descent of the foot has hitherto only been observed, I  believe, in the
presentations of the flexed  cephalic extremity; but I have had an opportu-
nity of meeting Avith it in a, face presentation ; and the rarity of the circum-
stance, together Avith the difficulties that attend the delivery, induces me to
narrate it here in detail:
  I Avas suddenly aroused on the 4th of November, 1842, at five o'clock in
the morning,  by M. X----, a pork butcher in the  Rue du  Cadran, Avho
came  to request my attendance on his wife, Avho had  been in labor for two
days previously, under the care of Dr. Lome, her physician and accoucheur
Having arrived at the bedside of the patient, I learned the state of the case
from my worthy associate, after Avhich I proceeded to an examination per
vaginam.  Bt.it before stating its result, I must here transcribe a short account
of the case, sent me by M. Lome himself, Avho gives the detail, much better
than I could  (from simple recollection), of Avhat he learned of this Avoman's
previous history, as also an account of Avhat occurred during the labor.  He
says:
   " I  was summoned to the Rue du Cadran,  No. 7, on the 2d of November,
1842, at  six o'clock in the evening, to attend Madame X----in her con-
finement.  I  ascertained from the patient that she had had  seven children,
and from  her account the  former labors had  terminated in the following
manner,  namely:
   " 1. First child:  a long and painful labor of three days' duration ; presen-
tation of the  cephalic extremity;  the labor Avas natural, but the infant died
a feAV days after its birth.
   " 2. Second and third child: presentation of the pelvic extremity; delivery
spontaneous,  or by  the aid of simple tractions; both children dead.
   " 3. Fourth child: the uterine  contractions disappeared  for tAventy-four
hours after the rupture of the bag of Avaters; expulsion of the child during
the accoucheur's absence.
   " 4. Fifth and sixth child:  presentation of the cephalic extremity ; labor
long and painful; delivery natural.  One of these infants lived a feAV months.
   " 5. Seventh child: shoulder presentation and a descent of the arm.   M.
P. Dubois, having been called in consultation, ascertained the child's  death,
and performed embryotomy.  After the parturition  there was an inflamma
tion of one or more of the abdominal organs. 
DYSTOCIA  DUE  TO  THE  FCETUS.
851
  " Madame X----is thirty-two  years of age, is  of mediun height and
Banguineous temperament, and exhibits  all the evidences of tood  health.
Notiiing in her external organization Avould lead us to suspect the existence
of any deformity of the pelvis, and the  normal pregnancy seemed to be at
its regular term.  The preceding night she experienced some pains, which
passed off in the  morning, but again reappeared at six o'clock in the evening.
I examined her,  soon after my arrival, and found the os uteri dilated to the
size of a five-franc piece;  I readily distinguished the  bag of Avaters, Aviiich
was  relaxed  in  the intervals, but Avas  tense, and  protruded through  the
uterine orifice during the pain ; but I could recognize no part Avhatever of
the foetus.  At midnight the amniotic sac projected into the vagina like a
stuffed pudding, and  descended nearly to the vulva, Avhen it soon ruptured
spontaneously and permitted  the  escape of more than two pounds of the
waters.   But still I could touch  no part of the child, even after the  dis-
charge of the Avaters, at any  height within the reach of my finger.  Now,
however, the  scene suddenly changed;  for the  pains, that  Avere hitherto
strong, died aAvay; and as the patient assured me that the uterine contrac-
tions had been thus suspended for tAventy-four hours in a former labor (the
fourth^, and  aftenvards regained  a sufficient degree of force to  effect the
delivery, I had her replaced in bed.
   " I found the  Avoman in the same condition at eight o'clock in the morn-
ing of the next day, the 3d of November ; some pains were perceptible in the
left groin and flank, but the parts of the foetus Avere still inaccessible. ....
No notable change occurred in the course of the day.  Nine p.m. — I recog-
nized the  left leg and foot lying across the os uteri at the superior s'.rait;
the pains Avere very strong, though they had not the characters of the expul-
sive  ones.
   " Nov. 4th,  the pains Avere stronger, but the labor did  not advance.  As
the os uteri Avas  sufficiently dilated, I concluded to search  after the secmd
foot, but it proved to  be rigid, and Avould scarcely permit the hand to enter.
I found a hard and rounded -tumor just above  the foot first detected, Avhich
I suspected to be the head.  But after making some vain attempts to push
it up, and to find the  right foot, I  sent for M. Cazeaux."
   Having  received this history of the case, I proceeded to an examination
of the state of the parts.  I  found  a foot  at the  upper portion of  the  vagina,
Avhich  proved to be the left one,  Avith  its heel directed  backwards, and a
little to the right; then, by passing  my  finger  behind the symphysis pubis,
I detected a A'oluminous  tumor, Avhich was pressed  so  forcibly again.-.t the
anterior arch of the pelvis,  that I could  not insinuate the finger between it
and  the  pubic symphysis;  at first, I thought  it Avas formed by the right
buttock,  and I diagnosticated  a right posterior position of the breech, with
the left limb doubled  up on the anterior part of the belly, and the other, on
the contrary, stretched out  along the abdominal and thoracic plane of the
child.  The contractions again became strong and  energetic, but, notAvith-
standing the complete  dilatation of the cervix, the presenting part did not
engage.   AVhile  searching for  the cause of this delay, I carefully examined
the pelvis,  and detected a  considerable  prominence of the sacro-vertebral
angle, whereby the  antero-posterior diameter Avas  reduced  to three inches 
852
DYSTOCIA.
 and one-eighth at the most.  I then resolved to draAv on the foot, but, -to n y
 great surprise, these tractive efforts proved  Avhollv ineffectual.   By again
 placing  my hand on the tumor, that I had originally taken for the anterior
 buttock, I found it to be harder and much more voluminous than I  had at
 first supposed, and I recognized it as the head,_ surmounted by a large and
 soft tumor, or caput succedaneum.   I tried in vain to find the  sutures and
 fontanelles;  but, by gently slipping the fingers betAveen this tumor and the
                               leg belonging to the presenting foot, I felt
                               a  very irregular surface,  and  soon after
                               recognized distinctly the eyes  and eyelids,
                               and then the other signs of a face presenta-
                               tion.   ItAvas, in fact, an irregular  presen-
                               tation of the  face, in  Avhich the  chin Avas
                               directed backAA^ards  and  to the left,  and
                               someAvhat  engaged at the superior strait (a
                               left mento-iliac position, and the head not
                               completely extended:  or, in other  words,
                               Baudelocque's fourth  position of the fore-
                               head).  To sum up, I Avas in attendance on a
                               woman whose sacro-pubic diameter was but
                               three  inches and one-eighth at  the outside,
 The left posterior mento-iliac position com-  an(J whose  foetus wag presenting in an irreff-
   plicated by a descent of the left foot.                        r       °         b
                               ular or frontal variety of the left posterior
 mento-iliac position, and  this complicated by a  descent of the left foot;
 besides Avhich, the Avaters had been entirely evacuated for thirty-two hours,
 and the uterus was strongly retracted.   I Avas not discouraged, hoAvever, by
 all these difficulties; my first thought Avas to push up the foot that  had
 become engaged under .the head, but all  such efforts  proved abortive; I
 then applied (though not  Avithout some trouble) a fillet on the foot, and
 endeavored to press back the head, Avhile drawing at the same time on the
 fillet; but this was equally unsuccessful, for the head Avas firmly sustained
 by the poAverful contractions of the Avomb, and did not move.  As the child
 was still  alive, I next decided on the application of the forceps.   The intro-
 duction of the blades and their articulation were effected both Avithout diffi-
 culty and Avithout much suffering  to the patient, and  they were placed on
 the sides of tlie  pelvis ;  but, notAvithstanding the  most poAverful  tractions,
 Avhich were kept up for half an hour, I could not  make  the head advance
 in the least degree.  After resting for a feAV  moments, I AvithdreAV the instru-
 ment in order to reapply it, and this time I Avas fortunate enough to place
 the blades directly on the sides of the head ; I then communicated to the
 handles a slight rotary movement, so as to get the face in a transverse posi-
 tion.  But all proved ineffectual, for I drew Avith all my force, and  M. Lome
succeeded me; both of us exhausted our strength to no purpose, and I then
 withdreAv the forceps, and permitted the Avoman to rest for an hour.  Having
 decided on a  resort to craniotomy, if a third  application should be equally
unsuccessful, I  reqilested  my associate to go during  this  interval  after
Smellie's  scissors, and the  embryotomy forceps.   An  hour afterwards the
 comrro*  forceps Avere again introduced and easily applied, and tractions on 
DYSTOCIA  DUE  TO  THE  FCETUS.
858
 the foetus were or.ee more made by M. Lome and myself for half an hour
 Avithout any better success.
   Being then fully convinced of the impossibility of a natural delivery, and
 of the impotence of our efforts;  as also that, notAvithstanding the existence
 of the heart's  pulsations, the unusual  delay in the labor (thirty-two hours
 after the amniotic sac Avas ruptured), and  the compressions  made by the
 instrument,  must have necessarily compromised or  even  destroyed*  the
 viability of the foetus,  and having only to choose betAveen a bloody opera-
 tion on the mother or a mutilation of the  child, I resolved on the perform-
 ance of embryotomy.   Smellie's scissors, covered  at their points  by a little
 pellet of Avax,  Avere guided along the palmar surface of my left  hand, and
 directed perpendicularly on the head, Avhere  they had to penetrate through
 the soft parts to the depth of nearly an inch before meeting with anv resist-
 ance from the bony vault; I  then rotated  them,  and they entered  into the
 substance of the brain  Avithout difficulty;  I next  opened the blades in two
 different directions, so as to make a crucial incision, the radii of Avhich Avere
 about half an inch in length ; then penetrating still deeper into the cerebral
 substance, I Avorked the scissors in various directions so  as to break up the
 brain.   The male  and then  the female blade of the  embryotomy forceps
 Avere next introduced, and locked Avithout any trouble, as also without pain
 to the patient.   The articular part touched the vulva.  By aid of the vice,
 I next closed the instrument, leaving only a space of about one inch betAveen
 the ends of the handles, and tractions Avere then made; but I soon found the
 blades slipping.   It Avas  necessary to begin  the  operation aneAv, and  the
 same accident  occurred again.   The third time  the  slipping commenced,
 and  I only succeeded in arresting it by suspending the tractions, and closing
 the forceps more firmly, Avhen the head was finally extracted ; but the chest
 was  arrested at the superior strait, and considerable efforts Avere still neces-
 sary for the extraction  of the rest of the trunk.  The delivery of the after-
 birth, being immediately effected, presented no particular difficulty.
   In'u case of twin  labor, the particulars of Avhich were communicated to
 me by Dr. Leflem, of Pontrieux, the second child presented in a mento-pubic
 position, complicated Avith procidentia of the right foot and right hand, the
 heel of the foot being  turned toAvard the oubis.   It is true, that since an
 attempt to  turn  had been made by a midwife, it  is  impossible to  know
 Avhether these  situations  of the  hand  and  foot Avere  spontaneous, or the
 result of aAvkward manipulations.  HoAvever this may be, M.  Leflem found
 it impossible either to push up the head or to use the forceps with advan-
 tage.  Not having the  proper instruments for performing embryotomy  at
 hand, he Avas obliged to leave the patient for a few hours, and on his return
 he found that she had expired.
   It  is possible that, if, after having discovered the impossibility of turning
 occasioned  by the contraction  of  the  uterus, bleeding to syncope  had been
 practised, or if the state of the patient did not alloAV of this, large doses of
 opiates or anaesthetics had  been  administered, the patient might have been
delivered.
  The unfolding of the Ioaaw limbs in the positions of the pelvic extremity,
and the. stretching out of the arms in that of the shoulder, are merely con- 
854
DYSTOCIA.
comitauts of the principal  presentation, and should not be looked up^ n as
an unfavorable complication.  The extension of the arm, or the presentation
of the hand or arm of certain authors, has been considered  by them as one
of the gravest complications of labor; but it has already been shoAvn, in the
article on Spontaneous Evolution, that a descent of the arm rather favored
this latter  process than otherwise; and Ave shall hereafter see that it is only
from circumstances foreign  to the presence of the arm itself,  that the version
is at times rendered  more difficult.  (See Pelvic Version.)

                           ARTICLE III.
                        DISEASES OF  THE FCETUS.
  The diseases of the child, to  be mentioned  in this connection, are  those
which, by sensibly augmenting the size of one of its parts, create an obstacle
to its passage through the  pelvic canal.  AVe have, therefore,  to treat of
hydrocephalus, hydrothorax, ascites, and  the  accidental tumors that  may
have been  developed on various portions of its body, during the intra-uterine
life.

  § 1.  Hydrocephalus.
   Under this term are included all the  dropsies of the head, and all the
effusions or infiltrations of serum within or exterior to the cranium.
  Hydrocephalus has  been  described by authors as external or internal,
according to the seat of the effusion ; placing under the former  variety all
the serous or sero-sanguinolent infiltrations that are found beneath the scalp
or pericranium.   This latter affection has never hitherto been considerable
enough to constitute an insurmountable obstacle to parturition.   In fact, it
is usually associated Avith a  state of general oedema that destroys the foetus
at an earlier period of gestation; and, consequently, its expulsion is effected
Avithout difficulty, whatever may be the thickness  of  the  scalp.   I saw a
seven months1  child, at  La Clinique, in 1838, in Avhom this part was a
finger's breadth in thickness, and the mother also Avas quite cedema'tous;
the labor terminated Avithout difficulty.  Desormeaux speaks of two very
similar  cases.
  I do not know that the records of science furnish a single case of external
hydrocephalus formed by a  true collection of fluid, yet I have seen tAvo cases
of this  kind of effusion.   The subject Avill be referred to, presently, in greater
detail.
  Hydrocephalus internus,  the only variety  requiring a particular descrip-
tion, is such a rare disease,  that Madame Lachapelle observed  but fifteen
cases of it  in forty-three thousand five hundred and fifty-five labors.
  In the estimation of pathologists, this is always a grave  affection, on ac-
count of the  danger to Avhich it exposes  the  ebild after birth  ; but more
particularly so, in the eyes of the accoucheur,  from the difficulties thereby
entailed on the labor itself.   Moreover, these difficulties and dangers vary
with the quantity of liquid  effused into the cranium ; because, where this is
inconsiderable, the delivery is still  possible, OAving to the flexibility and the
softness of  the head,  the Avails of Avhich are nearly all membranous; so that,
Dy gradually moulding itself to the passage, the head becomes  lengthened 
DYSTOCIA  DUE  TO  THE  FCETUS.
855
out, and the labor is either terminated by the poAvers of nature alone, or else
is effected Avithout much difficulty by the application of the forceps, or by
the pelvic version; but Avhere  the  Avater exists in great  abundance, the
dimensions of the head exceed those of the diameters of the  pelvis1 so much
that the delivery is absolutely impossible, unless the fluids be evacuated by
an artificial puncture, or  by a spontaneous rupture of  the sutures, or fonta-
nelles.
   The folloAving, according to Duges, are the signs  AA'hereby a dropsy of the
head  may be recognized during the parturition : the finger falls upon a large
and slightly convex surface, Avhich covers every part of the superior strait
without engaging, and has  a variable consistence  at different points; for,
although hard and resistant while the pain  lasts, it is, on the contrary, soft
and fluctuating in some places during the interval between the contractions.
Then, by passing the index regularly over  it,  the accoucheur can recognize
pieces of bone separated by membranous interspaces, or soft commissures, as
broad as the finger;  and, at times, the  fontanelles, equal in extent to the
holloAv of the hand.   If the child has presented by some other part than the
vertex, and the head is only  accessible to the  touch by its base, the separa-
tion of the bones detected by  the finger will  be much less, though  it is often.
easily appreciable.   Finally, if the dropsy  be  inconsiderable,  the  same
characters will be observed, though they are less evident; and  besides, the
head  being then  more  convex, and  not  so  soft, Avill engage better in the
pelvic excavation.
   The diagnosis is sometimes rendered difficult by the elevation of the head;
but when the la.tter is ascertained to  be presenting, and the pelvis found to
be Avell formed, the presence of the pulsations of  the foetal heart on a level
Avith,  or even above the umbilicus, may excite  a suspicion of hydrocephalus.
(Blot.)
   According to Duges, the  signs  furnished  by the  touch are not  ahvays to
be met Avith, and I have seen  tAvo cases in which they Avere entirely wanting.
These tAvo cases, which, if my investigations are to be relied on,  are unique,
present instances of hydrocephalus with  double  effusion, viz., intra-cranian
and extra-cranian.
   A well-formed woman Avho had  once  been safely delivered was  again in
labor under the care of Dr. Bassereau.  Thirty-six  hours had elapsed when
the Doctor called me in consultation. By this time the neck was completely
dilated and the membranes ruptured, but the pains which  were for a long
time  powerful  had gradually lessened,  so  that the labor Avas almost  sus-
pended.
   I discovered at the  superior strait a large and  soft  tumor, offering none
of the characters of the head, but suggesting rather a presentation of the
breech.   During the contractions it became tense and elastic, but Avas devoid

  1 In  a case reported by Wrisberg, the child's head was  ten  and a half inches long,
and thirty-two  inches  in circumference.   Meckel has  the skull of a hydrocephalic
infant  whose transverse diameter is sixteen and a half  inches, and  its height taken
from the occipital foramen to the vertex, measures sixteen  inches ; and Burns gives a
case of hydrocephalus, where the  circumference of the head amounted to twenty-three'
inches. 
856
DYSTOCIA.
of bony resistance.   Upon introducing  the  entire hand Avithin  the vagina
and  grasping  the  tumor, I was able, by making  unequal pressure upon
various points of its surface, to  perceive here and there a sense of fluctua-
tion, and I knew that I had  to  deal Avith the head covered by a sac con-
taining fluid.  I then remembered having ten years before met Avith a similar
state of things, and confidently diagnosed external hydrocephalus coincident,
doubtless, Avith effusion Avithin the cranium.
  Nothing yvas revealed by auscultation.   The child had  ceased to live.
An incision, one-eighth of an inch in length, Avas then made upon the top of
the tumor, and about a glassful of liquid escaped.  The soft and fluctuating
tumor disappeared and the scalp alone remained betAveen  my fingers and
the bones of the head.
  The forceps  Avere applied,  but without effect, and three-quarters  of an
hour afterwards I decided to make  another  puncture; this time a quart of
liquid escaped, and shortly after the head  engaged, and delivery Avas spon-
taneously accomplished.
  Ten years before, I was called by Dr. Saint Ange to a woman who had
been in labor thirty-six hours, and in Avhose case various stimulants, amongst
them, ergot, had been vainly employed.  At  the commencement of the labor
my confrere had detected a vertex presentation, but feeling a large and soft
tumor, I at first thought of a presentation of the breech.  During an interval
between  the  pains I pressed  suddenly upon the tumor, and clearly dis-
tinguished the resisting surface of the bones of the head.
  The forceps were twice applied in vain, Avhen a puncture Avas made, giving
issue to two glassfuls of liquid.  The forceps Avere applied once more, and  a
dead child easily brought away.
  The sutures Avere large, and Avithin the cranium there Avas a collection of
fluid Avhich escaped upon an incision being  made through a suture.   There
was, therefore, in this case, both  internal and external hydrocephalus.
  It Avere unnecessary to say hoAv  greatly  this  anomaly  must  modify the
diagnostic signs pointed out  by authors.   Nothing  but a sudden pressure
upon the tumor, dispersing the  extra-cranian fluid, will  enable us  to  feel
the bones of the head.
  Hoav, next, are the two collections of fluid to be explained?   1. It may
be supposed that both are formed separately, one by pressing aAvay the sub-
cutaneous cellular tissue, and the other taking place in the intra-cranian
cavities.  This, hoAvever, is hardly  probable; but, 2. It is possible that be-
fore labor the internal hydrocephalus alone  was  present, and that under the
influence of the various kinds  of pressure undergone by the head, necessarily
unequal and partial as they must be from the very form and dimensions of
the pelvis, it is possible, that under these circumstances a fissure might occur
somewhere in a suture or fontanelle, alloAving the liquid to pass from Avithin
outAvardly and to form a tumor upon the external surface of the cranium.
  The latter theory  receives confirmation from  the fact that, in the second
case, M. Martin Saint Ange had  no difficulty in detecting the  head early in
the labor, Avhilst at a later period I discovered it Avith difficulty, masked as
it was by a soft and fluctuating  tumor.  But, supposing  a  communication
between the tAvo collections, hoAv explain Avhy the evacuation of the first wa« 
DYSTOCIA  DUE  TO  THE FCETUS.
857
not folloAved by the emptying of the latter? Iioav account for the necessity
of a double  puncture in the first case and the persistence of the internal
hydrocephalus in the second, even Avhen the  head was subjected to strong
compression by  the forceps ?   The  faqt merits  further  examination ;  but
hoAvever  the mode of its formation be explained, it is  not less curious as
respects both diagnosis and operative indications.
  The indications  for treatment  presented by this affection  vary with its
extent, and according to Avhether the child is living or dead.  Besides Avhich,
as Duges justly remarks, the physician must not only base his determination
on  the size of the head, but also on  its  flexibility and its inclination to
engage in the excavation.
  AVhen the cranium is  of moderate  size, is soft, reducible,  and, from the
influence of the  strong,  energetic contractions of  the Avomb,  gradually ap-
proaches the inferior strait, Ave should temporize, and be satisfied with favor-
ing a spontaneous termination of the labor  by the employment of the proper
means.   But if the delivery is delayed, and the pains are Aveakened or use-
lessly spent against insurmountable  obstacles, the forceps should be at once
applied.   Nevertheless, the pressure and tractions on the head  ought to be
sIoav and gradual, with the vieAv of preventing  rupture, which  can  ahvays
be avoided by proceeding Avith gentleness, and remembering that the instru-
ment is liable to  slip.
   Breech and trunk presentations are  much  more common when the foetus
is hydrocephalic, as shoAvn by statistics furnished by Scanzoni; of 152 cases,
30  presenting some other part than  the head, or 1 in 5.   Noav, under these
circumstances, it is evident that the difficulties will  not be felt until after
the spontaneous exit or the artificial extraction  of a great part or even the
totality of the  trunk, for then  it is that the occipito-frontal  circumference
considerably enlarged engages in the superior strait.
   The pelvic version would doubtless be resorted to in presentations of the
trunk;  but if the  operator has been fortunate  enough  to detect the large
size of the head before searching after the  feet, he should, in my opinion,
endeavor to bring the cephalic extremity to the superior strait.
   When the size of the head is such that  a  spontaneous delivery is Avholly
impossible, and the application  of the forceps  or the pelvic version is not
practicable, there is no  other resource  for saving the 'mother  than to punc-
ture the cranial vault, which  alone  can afford an outlet to the serum  accu-
mulated in its cavity.   This  operation may  be  performed Avith  the trocar,
the bistouiy, or Avith  any pointed knife Avhatever, after having taken the
precaution to envelop its blade Avith tape, so  as  to leave only the point un-
covered.   This  simple  puncture of the  membranous intervals is always
preferable to the mutilation of the child. For, although the sudden collapse
of  the brain, Avhich usually follows the  evacuation of the  liquid,  nearly
ahvays occasions the death  of the foetus, still  the latter may possibly survive
such an operation ;  since a  puncture of this kind made after birth has occa-
sionally been folloAved by a complete  cure.  Smellie's  and  Stein's scissors
should, therefore, be proscribed  in  these  cases, and we  ought  to decide on
plunging them  into an intact  brain only, Avhen  the opening made Avith  a
6iualler instrument has  not been free  enough to permit the  escape of the 
858
DYSTOCIA.
 liquid.   It may happen, in cases  of double hydrocephalus, that when tlie
 external fluid has been evacuated  through a puncture, the labor may tei rui-
 nate either spontaneously or by the  use of the forceps.  Should it be other-
 Avise, another puncture through the  sutures or fontanelles will  evidently be
 called for.  In  no  case is a bloody operation on  the  female permissible,
 because the life of the infant is then too seriously compromised, by the mere
 fact of hydrocephalus, to think of sparing it  at the expense of that of the
 mother.
   AVhere the child is  dead, cephalotomy Avould appear to us preferable, un-
 less some serious difficulties in its performance Avere likely to be met Avith.
   If cephalotomy  be decided  upon in cases of pelvic  presentation, some
 difficulty may be experienced in perforating the cranium.   Though  it is
 often possible to pass the instrument through the arch of the palate, I Avould
 prefer repeating Avhat I have already done in a case to Avhich I had been
 called in consultation by M. Ducros, namely, to introduce the blunt hook
 into the orbit, and enter the cranium through  the optic foramen.  This pro-
 cess had been before recommended by M. Dujardin in a note addressed to
 the Academy of Medicine in  1851, but it  is evidently practicable only when
 the child is dead.
   [Hydrocephalus becomes a more serious matter  when the breech  presents, inas-
.much as the true nature of the case is liable to escape detection.  Again, supposing
 the diagnosis made out, perforation of the cranium is performed Avith difficulty, on
 account of  its  being accessible  only by its base.   In a  case  of this  kind  another
 course mi<>;h.t be pursued, viz., to open the spinal canal by an incision betAveen the
 Bpinous processes of the vertebrae, and through the passage thus made introduce a
 gum-elastic catheter provided with its wire.  This is to be pushed into the cranium
 until it meets the water, which  may then be  discharged.  The head will collapse
 immediately, and no further difficulty be found in its extraction.  In my thesis for
 the Concours, I  reported several cases  in which this operation was successful.
 (Tarnier, These de Concours, 1860.) J

   § 2. Hydrothorax and  Ascites ; Retention  of  Urine.
   Ascites is even more rare than hydrocephalus, though it is met with some-
 Avhat oftener than hydrothorax.  The signs indicative of dropsy of the chest
 are, a considerable enlargement of the thorax, a widening of the intercostal
 spaces, and an evident fluctuation  in these enlarged  intervals.   On the con-
 trary, the  extraordinary size of the belly, the  distention of its walls, and
 the fluctuation detected there, characterize ascites.  The foetus, being retained
 by the amplitude of one or the other of these  cavities, is arrested in its pro-
 gress through the pelvis, and the  accoucheur finds the excavation filled up
 by a large, soft, and  fluctuating tumor.  In some cases of extreme distention
 of the abdomen, the walls of this cavity have been found  to yield,  so that
 a  great part of the tumor remained above the superior strait, Avhilst  the rest
 of the trunk  gradually descended  into the excavation;  and Avhen one por-
 tion of the abdomen had reached the exterior, the liquid gravitated tOAvards
 this point, Avhere the resistance Avas less, the  portion remaining internally
 progressively diminished  in  volume, and the labor terminated naturally.
 Frank speaks of a dropsical child that presented by the breech, in Avhoni a
 quantity of the sei^m had escaped from the abdomen into the scrotum ; and 
DYSTOCIA  DUE  TO THE  FCETUS.
859
 an evacuation of all the liquid Avas secured by making an incision into this
 part, Avhich course should be repeated, if a similar case were to occur.  But
 when the aqueous  tumor  of the  chest  or  abdomen is  large enough to be
 arrested by one of the straits, we should have recourse to puncture with the
 trocar.
   A peculiarity which might readily be mistaken for ascites, consists  in the
 accumulation of a large amount of urine in the bladder of the foetus.
   AVhen treating of the secretions of the foetus, it Avas stated (see p. 237)
 that a certain amount of urine Avas doubtless secreted during its intra-uterine
 existence, and we mentioned in support of the opinion, some instances in
 which obliteration of the urethra had given rise to enormous distention, and
 even rupture of the bladder.  In  a case communicated  to the Academy of
 Medicine by M. Depaul, the bladder Avas so distended as to prove an insur-
 mountable obstacle to the extraction of  the foetus.
   [This  case, conjoined with two similar ones, supplied M. Depaul with the material
 for an excellent paper, published in the Gazette Hebdomadaire of I860.  The  Pro-
 fessor thinks that retention of urine has often been mistaken for ascites, which,
 according to him, is very rare. For  further particulars the  reader is  referred to
 the paper above mentioned.]
   AVhether  aAvare of the true  cause of  the difficulty, or hesitating between
 ascites  or extreme distention  of the bladder, it is evident that if properly
 directed tractions are ineffectual, an  evacuation of the fluid is the only
 resource in either case.  We  would merely  add, in accordance Avith M.
 Depaul, that since  the permeability of  the urethra may sometimes  be re-
 established  after birth, it  is strictly indicated to perform  the puncture as
 carefully as it Avould be done in the adult.   The insertion of the cord would
 be a  sure guide in choosing the most favorable point.
   In a case observed  by M. Moreau, ascites and considerable distention of
 the bladder existed simultaneously.  The first puncture, though it discharged
 ■d large  amount of peritoneal fluid, did not enable the extraction to be made,
 and a second one was necessary to eyracuate the urine contained in the blad-
 der.   The delivery of the child was  effected Avithout difficulty immediately
 afterward.

  § 3. Emphysematous Condition  of the  Foetus.
  Merriman  has remarked that, when  the foetus had  been dead for some
 time, a large quantity of gas may be created in consequence of the putre-
 faction it has undergone ; thereby greatly augmenting the volume and  the
 distention of the belly, and consequently retarding the expulsion.   " I have
 known," says he, "two instances of rupture of the vagina, arising from the
 rashness of midAvives, Avho forcibly  dragged the children, enormously swelled
 with  putrid air, into the world.   In one  case, the  vagina  Avas  torn com-
pletely through.  Both the Avomen died in a few hours.  Had the bellies of
the children been punctured, to give  vent to the air, these fatal occurrences
 would have been avoided."  (Synopsis.)
  M. Depaul has recently published a case, in which not only was  a  large
quantity of gas developed in the abdominal  and thoracic  cavities, but the
limlis of the child Avere  so  greatly infiltrated as to  present nearly7 double 
800                           DYSTOCIA.
 their natural size.   After extracting the head by the forceps, it was deemed
 necessary to apply the cephalotribe forceps, and~close them Avith such force
 as to reduce the size of the trunk considerably, and at the same time obtain
 a firm hold for traction.  AVhilst proceeding thus, a large amount of exceed-
 ingly fetid gas escaped Avith a report, and very strong tractions were required
 to disengage the chest and deliver the child.  The uterus in contracting ex-
 pelled a similar kind of gas.
   Supposing  the diagnosis to be Avell  established, Ave agree with Merriman
 in the opinion that a previous puncture of the abdomen and chest Avould
 certainly have facilitated the use of the cephalotribe, or perhaps have even
 rendered its employment unnecessary.

   § 4. Tumors of  Various Kinds.
   The tumors, of  divers sorts, with Avhich the foetus may be affected  at the
 time of birth, and the size of Avhich is occasionally so great as to impede its
 spontaneous  expulsion, are not susceptible  of  being included under any
 general head, and  the measures to be employed vary for each.  AA^here they
 are pediculated, it not unfrequently happens that the pedicle  is broken,
 either by the influence of the expulsory efforts of the womb, or the tractions
 made by the  accoucheur.  AVhen their induration is not very great,  Ihey
 temporarily disappear, at times, from  being  compressed between  the foetal
 surface and  the uterine parietes, or the osseous Avails of the pelvis.   The
 proper course is to remove them, AA'hen accessible, or to discharge their con-
 tents  by means of a puncture where they contain a liquid.   But, unfortu-
 nately, we can seldom even suspect their existence until the labor is already
 so far advanced that it  is hardly possible to act.  If their volume be  exces-
 sive, the  child's death will nearly ahvays result from the delay and difficulty
 in the parturition,  and then the conduct to be folloAved is clearly evident.
   Certain tumors are also sometimes present  in the great cavities, especially
 that of the abdomen, Avhich may render spontaneous delivery difficult, and
 occasionally  even  impossible.  A very curious case is mentioned by MM.
 Guilleton and  Oilier, in Avhich the obstacle  to delivery  Avas occasioned by
 an abnormal  enlargement of both  kidneys, due  to an  hydatiform hyper-
 trophy of the glandular element of the Malpighian bodies.  Tractions so
 strong as to tear aAvay  the loAver extremities  of the child failed  to deliver
 it; but fortunately  the pains  returned, and  the labor terminated sponta-
 neously in a feAV hours.
   In another case, quoted by Siebold, the child had presented by the pelvis,
 though the head Avas the first to appear, and was expelled Avithout  much
trouble.   The delivery of the body, however, required strong and long-con-
tinued tractions.  The  size of  the  abdomen Avas  enormous;  it,measured
seventeen inches in circumference, and eight inches from the xyphoid  car-
 tilage to the  pubis.  At  the  autopsy, the kidneys appeared as tAvo  large
tumors, weighing two  pounds; each one Avas six inches long, four inches
Avide, and three inches thick.   (See, in  the  Journal Hebdomadaire, 1855,
the bibliographical  reference to several similar  cases;  see also Tarnier,
 These de  Concours.)
   Still another case of dystocia, due to the enormous  bulk of a  cancerous 
DYSTOCIA  DUE  TO  THE  FCETUS.
861
liver, is reported by M. Noeggeralt.  Though the forceps wt te applied, the
extraction  of the head required  the entire strength of the operator; and
even then the pains, though very poAverful, failed to deliver the shoulders;
so that, having  dragged fruitlessly upon the head, it Avas necessary to hook
the fingers in the axillae, and draAV upon them forcibly.
   The principal bulk of the foetus Avas due to the abdomen, which had four
times its normal size.   An immense tumor, the  liver, filled  its  cavity;  it
weighed tA\o and  a  quarter pounds,  measured  eight and three-quarter
inches in width, six  inches from below upAvard, and three inches in  thick-
ness.   The tissue proper of the liver was  met Avith  here and  there, but the
greater part of  it Avas  replaced by a heteromorphous  mass resembling the
gray substance  of the  brain.

   [Various other tumors have been met with on the  head, neck, and  lumbar and
sacral regions.
   Tumors of  variable size are sometimes developed upon the head, the most com-
mon being encephaloceles and meningoceles.   The latter variety occur more fre-
quently than  the former, and sometimes acquire a volume equal to or greater
than that of the  head itself.   In a case of the kind which I saw at the hospital of
the Clinique, the child presented by the shoulder.   Whilst turning, I  felt a round
and resisting tumor  by  the  side of the head which I took for the head of another
child.  The operation was  continued and  the feet brought  down.  At first, the
extraction was easy,  but when  the  body had  been  delivered I encountered an
unusual difficulty in the  extraction of the head.  It came doAvn, hoAvever, suddenly,
whilst  drawing upon it,  and with it a large tumor attached to the occipital region.
A plaster cast which I had made of it is now deposited in M. Depaul's anatomical
collection in  the hospital of the Clinique.  Dissection  proved the tumor to be a
meningocele.
   Large tumors  may also be attached to                 Fl<}-115
the neck, as  in  a case of dystocia pub-
lished  in the Archives   by  31. Monod
where  the  tumor, as large as the head
of a child at  term, was  attached to the
neck by  a  pedicle which allowed it to
turn to either side.  The vertex presented,
and after twenty-four hours of labor it
became necessary to apply the forceps.
The child,  though born  alive, lived  but
five hours.   In this case, the tumor ap-
peared to be cancerous.   At  other times,
the neck is affected with a tumor formed
by an hypertrophied  thyroid gland.   In
n case of the  kind which I saw quite re-
cently, the tumor avus of the size of  the
fist.
   The  scrotal, sacral, and  lumbar re-
gions are quite frequently occupied by
large tumors, such as hydroceles, spina
bifida  with  hydrorachis,  cancer  and
foetal inclusion,  all  Avhich  may  cause
irii'atci- or less difficulty in the extraction
of the child.   31. Depaul relates, in a
Dote, that he  saw two children at the  Clinique in whose  birth there had been soma
 
862
DYSTOCIA.
difficulty, and which had between the thighs an oval-shaped tumor  almost ad large
as their respective heads.   It was entirely distinct from the genital parts, arising
from and seeming to lose itself in the deep-seated cellular tissue of the perineum.
Careful dissection proved it to be composed of encephaloid matter.
  Spina bifida with hydrorachis may affect the entire length of  the spinal column,
though it is only when it affects the lumbar region that it is liable to form a tumor
large enough to interfere with  delivery.  I reported two cases in my thesis for the
Concours, one of which was furnished me by M. Guibout.  For a drawing of it, see
Fig. 115.
  A tumor in the scrotal or sacral region, large enough to require active interven-
tion, may be due to foetal inclusion.   Several cases of  the kind may be found in a
paper published by Dr. Constantine Paul;  and my colleague 31. Joulin also devoted
a long chapter to it in his thesis for the Concours,  (Paris, 1863).]

   In  cases like these, the difficulty cannot be foreseen, nor even suspected,
until  it  begins to exert  its  influence  upon the labor.   Tractions upon the
head, arms, or axillae, when the head presents, and upon the lower extremi-
ties under other  circumstances, should  be made at first moderately, and
aftenvards strongly; but, should  they fail and the child be  dead, it were
better to perform embryotomy than to  continue them  so long as to risk
laceration of the maternal organs.  Evidently, if the tumor contain a fluid,
the first thing to  be done Avould be to evacuate it by one or more punctures.

   § 5. Anchylosis of the Fcetal Articulations.  Gibbosity.
   Dr. Busch  has recently had  an opportunity of  observing a very singular
case of  dystocia, dependent on  anchylosis  of  the articulations  of  the
child's limbs, in Avhich the forceps Avere applied, but after the extraction of
the head, the trunk could not be delivered.   Being  unable to discover the
cause of the difficulty, repeated tractions were  made, at first moderate, but
aftenvards more  poAverful, when a cracking noise  Avas heard, and the upper
part of the trunk cleared the  external orifice; but  the loAver portion of it
likeAvise became  arrested, and, as the child was  dead, it was dragged out
Avithout hesitation, and the same  cracking  sound Avas again heard.   At the
autopsical examination, it appeared that the articulations of the limbs had
been  anchylosed  in the  ordinary^ flexed position exhibited by the foetus in
the Avomb,  and  that the bones  of  the  arms and thighs Avere fractured.
(British and Foreign Med. Review, p. 579, April, 1838.)
   Our  colleague Dr. Joulin mentions  several other similar cases.  Still
more  rarely is  delivery made difficult by  deformity (gibbosity)  of the
vertebral column.
                           ARTICLE  IV.
                          FCETAL MONSTROSITIES.
   As the cyclops, the anopses, the acephalous and anencephalous foetuses are
delivered  as easily as those having a  normal conformation, we  have  no
occasion to treat of them here.

   [We would merely remark that in these cases,  the diagnosis of the  presentation
is rendered difficult by the  deformity of the parts with Avhich the finger  endeavors
to come in contact.  Anencephalous cases, however, afford certain  peculiar indica-
tions which it is of interest to know.  Whenever the finger touches the presenting 
DYSTOCIA  DUE  TO  THE  FCETUS.
863
part, the  foetus is affected with convulsive and irregular movements which soon
attract attention; the motions being probably due to direct irritation of the stump
which is  generally surmounted  by the hairy scalp in cases of this kind.  By this
Bign I was enabted to diagnose an anencephalous foetus before the membranes were
ruptured, to the great  astonishment of the students at the  hospital of the clinic
where the labor occurred.]

                           ARTICLE  V.  .
             dystocia occasioned by multiple fcetuses.
  § 1. Of Multiple and Independent Foetuses.
  We pointed  out the signs, in the article on gestation (see page 270)  by
Avhich the presence of tAvo or more children in the uterine cavity  might  be
recognized during pregnancy, and  described  normal twin labor in another
chapter (see page 375).  It is now our  duty to indicate  the difficulties pecu-
liar to this form of labor.
  Usually, as Avas stated, the birth of  the second  soon folloAvs that of the
first, but if delayed, friction over the body and upon the neck of the womb
are sufficient to stimulate contractions which soon complete the delivery.
Generally, therefore,  the action of  the  womb must be Avaited for patiently.
(See  page 377.)  But is  the  labor to be abandoned wholly to  nature, or
should Ave attempt to deliver at once?   In some instances, there can be  no
hesitation as to the  proper course;  thus, when the birth of the first child
has been tedious and difficult, and  has  required the intervention of art, and
the forces of the patient seem to be exhausted  by the  former effort; when
any accident Avhatever that threatens the life of the mother or of the second
twin, has occurred during or after the delivery  of the first; and Avhenever
the second one presents in such an unfavorable position1  at  the superior
strait as  to demand  the pelvic version, this ought  to be performed imme-
diately.  But in all  these cases the expulsion should by no means be rapid,
and the accoucheur will draAwery slowly on the pelvic  extremity, so as not
to empty the uterus  too  soon, and thus avoid  the inertia  and attendant
hemorrhage which might  result in consequence of a  rapid depletion.  It
would even be prudent, Avhen  the defective position shall have been con-
verted, by the  evolution, into a  presentation of  the pelvis, to trust the rest
of the delivery to the expulsory efforts of the womb.   The  application  of
the forceps AviU  rarely be necessary, because, if  the head is  so far engaged
as to  render  pelvic version impossible, the labor will  probably terminate
without  assistance.  Nevertheless,  should the incapacity of the uterus  be
complicated with any accident serious enough to compromise the life of the
mother or child, it would  be proper to  have recourse to this instrument if
the  head had arrived at the inferior strait; but in all other cases the pelvic
Aversion ought to be preferred,  because the  introduction of the hand and the
evolution of the foetus will not fail, by  the irritation they produce, to deter-
mine the retraction of the uterine walls, and thus prevent subsequent inertia.
  AVhen one of the twins, though dead, has remained in the uterus for sev-

  1 It is not very unusual to find the second  child presenting by the  shoulder; which
ts probably owing to the vacuum in the womb after the expulsion of the first one, a
roid that singularly facilitates the displacement of the second. 
864
DYSTOCIA.
 eral months, whilst the development of the other was constantly progress-
 ing, the little abortion is ordinarily expelled simultaneously with, or shortly
 after, the first child ; but unless the accoucheur is very careful, and the size
 of the womb after the delivery should  not excite his attention, its sojourn
 there may be considerably prolonged.  No doubt, in these cases, the hand
 ought to be carried up into the Avomb, for the  purpose of delivering the
 aborted foetus, but this  Avill not always  prove an easy matter.   In a case of
 the kind, communicated to me by Dr. Casaubon, the internal uterine orifice
 became strongly contracted immediately after the extraction of the placenta,
 and it was not without great difficulty that he eventually succeeded in over-
 coming its resistance, and reaching the uterine cavity.   The little product
 was  then removed, and proved to.be an abortion of four months.  The other
 infant had arrived at the end of the eighth month.
  In certain cases, the  presence of tAvo children may render the delivery
 difficult, and require some special precautions; thus, it may happen : 1. That ■
 both present simultaneously at the strait, and retard  each other's expulsion ;
 here the most movable head  should be  carefully pushed up, so  as to permit
 the other to engage first.   The difficulty will be greatly enhanced if the tvA'o
 heads be engaged  in the excavation at  the  same time, and  neither of them
 can be pressed back; under such circumstances, the  application of the for-
 ceps upon the one that  appears the most engaged, and, if this does not suc-
 ceed, the perforation of one of them, seem to me the only practicable opera-
 tions.  HoAvever, even here, very prompt action is unnecessary, for it might
 happen, if both heads were small, that a natural expulsion could be effected;
 an example of Avhich is reported by Allen, in vol. xii. of the Medico-Chirur-
 gical Transactions.  The same plan  is to be pursued Avhen, instead of the
 heads, the breech  or the feet of the two  infants present together.
  2. The first child may present by the shoulder; here,  the pelvic version
 is evidently indicated, but  in  performing it the  operator must be very care-
 ful to seize the feet of the  right child before commencing the evolution, for
 if both the bags of waters were ruptured, nothing Avould  be more easy than
 to get hold of two  feet belonging to different children.  ItAA'ere much better
 to turn by draAving on one  foot only.  (See Version.)
  3. Where  the first presents by the feet, Avhether  spontaneously or as a
 consequence  of the pelvic version, the greater part of the trunk is extracted
 without difficulty,  but the head may be arrested in the excavation or above
 the superior strait.  Thus, in the twentieth observation of the fourth Memoir
 of Madame Lachapelle, the  head of  the first-born had draAvn under it  that
 of its brother, Avhich had  a  tendency to present by the vertex, so that the
 latter one blocked up the passage of  the former, AAdiile the first prevented
 the second from  getting above the superior strait; but, fortunately, the chil-
 dren Avere small, and the head of the second twin escaped  spontaneously,
alongside of the  neck of the first, and then the head of the first followed the
neck of the second.  A very similar case, given  by Dr. Envin, is related by
Dr. Dewees.  (Just such a  case is represented in Fig. 116.)   Had these two
foetuses been  of the ordinary  size, it is clearly evident that  their expulsion
could not have been effected  until  one or possibly both heads had been re-
duced by craniotomy.   The mutilation  of one child seems  to me the only 
DYSTOCIA  DUE TO  THE  FCETUS.
865
 recourse Ave have in these difficult cases; thus, it has properly been recom-
 mended to amputate the neck of the  first twin, which  would render  the
 spontaneous expulsion of the second
 one possible, or at least Avould per-                  FlG- H6.
 mit its extraction  by the forceps;
 after Avhich, the head of the muti-
 lated infant should be sought after
 and brought down.  HoAvever, be-
 fore resorting to this cruel operation,
 an application  of the forceps ought
 to be attempted on the head that
 descended  first, as  appears to have
 been done successfully by a surgeon
 of Dijon.  In fact, from the small-
 ness of  the children, it  is possible
 that, in many cases,  the  second
 head Avill  afford but a feeble  ob-
 stacle to the passage of the trunk
 of the child Ave are endeavoring to
 extract by the  instrument.
   4. M. Jacquemier relates  a curi-
 ous  case Avitnessed by him  at  the
 Maternity Hospital. A Avoman, Avho
 had been in her labor  nine days,
 was brought to the hospital in a dying condition; the waters were discharged
 three days before, and the forceps had been  applied Avithout success.   At
 the  autopsy, two children Avere found  in  the Avomb.  One head  had  de-
 scended into the excavation in the left occipito-cotyloid position, and had
 passed  the uterine orifice.  The other child was in the second position  of"
 the left shoulder; its  head rested in the right iliac  fossa, and the front of its
 neck, which Avas  situated beloAV the anterior shoulder of the first foetus, em-
 braced the neck of the latter, in a semicircle,  so as to prevent a further  de-
 scent of the trunk; thus explaining the fruitlessness of the tractions made
 by the forceps.   Both children Avere large.
   f). Again, tAvo feet  occasionally  present at the orifice; Avhen, if the accou-
 cheur deem it  advisable to aid the expulsory  efforts of the womb  by trac-
 tions, he might, by supposing they belonged to one child, draw on both, and
 thus engage parts of both tAvins at the same time, Avhich could not  pass out
 together;  therefore, if there  is the least  doubt  of the character of the preg-
 nancy,   he  should ascertain,  before making any  tractive  efforts Avhatever,
 that the two limlis really belong to the  same individual, which is done  by
 passing  the hand up into the Avomb as far as the  hips;  though it must  be
 confessed that  this diagnosis is frequently attewded AA'ith great  difficulty-
 Here, again, it  is better to draAV upon  one foot only.
  Pleissinan states that, on one occasion, he found the orifice plugged up  by
 the parts  tlmt  had become engaged, and which at first  sight appeared to
him to be a quantity of hands and feet. A more careful examination enabled
him to distinguish four inferior extremities, Avhich were delivered as far  as
      55
 
866                           DYSTOCIA.
the ham, and one  arm.  "At first," he  says, " I was in great perplexity,
because I could find no Avay of introducing my hand into the womb, for the
purpose of distinguishing and  seizing the tAvo feet belonging to each child,
and because  all my efforts to make even  one  of these extremities go back
again  proved abortive; besides Avhich, in drawing on any two of them, I
might  confound and bring doAvn the feet of two different foetuses at  the
same time; and, lastly, even if I succeeded in seizing the tAvo feet belonging
to the same child, I might, by draAving on them, engage the other parts, and
thus augment the difficulties.  Being greatly embarrassed  as to the proper
course, and yet obliged to act, the employment of  a measure recommended
by Hippocrates, under different circumstances, happily suggested itself; it
Avas, to  suspend the patient  by her feet, hoping  that the heads and  the
bodies  of  the children would, by their Aveight, draw one or more of the  ex-
tremities towards the fundus of the Avomb, winch Avas  still distended by  the
waters.  The  husband and brother-in-law of the woman passed their arms
under  her hams, and thus held her suspended, so that only the head and
shoulders  rested on the bolster.  I intended, as soon  as I mounted pn  the
bed, to press back one or more of the  free extremities into the womb, but
two had already returned from the mere  position of the  mother, and  the
other three soon followed by the aid of my fingers.  Immediately aftenvards,
I Avas enabled to introduce my hand into  the  uterus, and  to withdraw suc-
cessively therefrom three children by the feet."
   In bringing fonvard this  case, I  only desire to  illustrate what has been
said concerning  the  difficulty of diagnosis.  I ought  also to call attention
to the impossibility of the reduction, and the singular procedure resorted to
with a  success that seems to Avarrant its employment  again under similar
circumstances.

   § 2.  Of Multiple and Adherent Fcetuses.
   The signs  by which we are able  to  detect  the  presence of twins can in
no wise aid in ascertaining the adherence, or the more or less intimate fusion,
of tAvo living  beings into each other.  The diagnosis is likeAvise very difficult
at the period  of labor; for, even after  the twin pregnancy has been recog-
nized, it is only by negative evidence that we  can  suspect  the  adhesion of
the tAvo children.
   If two bags of waters are detected by the finger,  if it is necessary to rup-
ture the membranes twice, if  the Avaters are discharged at  tAvo separate and
distinct periods, the  presence of independent  tAvins in the  Avomb may  be
regarded as certain ;  for there are never two envelopes  for a double monster,
and tAvo perfect twins are very seldom inclosed in the same amniotic pouch.
Again, if two feet or even a single one descend Avith the head, more particu-
larly if the feet yield to the tractions made on them, and appear at the vulva
without the head  having a tendency to reascend,  Ave  may affirm there  are     j
two infants;  because a monster is never composed of two individuals so
united  that the head of the one is alongside of  the  feet of the other; but if
several  limbs present  simultaneously, Ave can only ascertain  Avhether  the
children to Avhich they respectively  belong are joined  together or are inde-
pendent, by carrying the hand  up into the womb.   (Duges, Mem. de VA ca-
demie.) 
DYSTOCIA  DUE  TO  THE FCETUS.
867
  Is it proper to interfere in all cases, Avhether the monstrosity be recognized
jr not, or should the delivery be abandoned to nature for a certain length
of time?  The recorded instances, Avhich prove that a spontaneous delivery
may take place, are too numerous at the present day to Avarrant an active
intervention until after a sufficient length of time has been accorded to the
uterine contractions to effect the expulsion.   The mechanism by Avhich the
delivery is finally accomplished will also vary according  to the particular
kind of monstrosity.
   When the tAvo foetuses are united by the breech or head, their expulsion
takes place without any marked difficulty, and they generally escape one
after  the  other, more  particularly Avhen they happen  to  be joined at the
breech.   But if connected at the occiput, the point of union is seldom flexible
enough to permit the two heads to descend simultaneously; and if the patient
is at her full term, the intervention of art will become necessary.
   Where  there are two heads for a  single trunk, the mechanism varies ac-
cording to Avhether the monstrosity presents by the vertex or by the breech;
but the delivery is still possible, if the tAvins are slightly adherent  and so
movable as not to be invariably parallel, for then the two heads may engage
successively and not simultaneously.  In the vertex presentations, the ante-
rior head, Avhich is the most inferior on account of the obliquity of the body
of the child situated  in the line of the  axis of the superior strait,  engages
first;  and then the other, Avhich had been primitively arrested by the sacro- •
vertebral  angle, follows it.   On the contrary, Avhere the infant  is delivered
by the breech, the  posterior head Avill engage  the first, in consequence of
the inclination impressed on the trunk by the axis of the pelvic canal; and
the anterior one, Avhich Avas hitherto delayed by the symphysis pubis, will
engage immediately afterAvard.
   When each head has its  OAvn body, but the two trunks are united by their
lateral, anterior, or posterior faces, whether throughout  their Avhole extent,
or only in a partial degree, a spontaneous delivery is more difficult than in
the former cases;  but when it does occur, it takes place just in the same way.
If there is only one head for tAvo  bodies, the latter are expelled simultane-
ously, and the only difficulties Avhich can then present, depend on the unusual
size of the head, Avhich is sometimes very large.
  The process does not always advance as favorably as Ave have just stated,
since it is  not at all unusual for one of the heads (where the double condition
involves the whole body, or is  limited to the head) to be  arrested above
either the sacro-vertebral angle or the symphysis pubis, and thus delay the
subsequent descent of the one that is already engaged, or on the  point of
engaging.
  What has just  been stated  concerning the  mechanism  by Avhich the ex-
pulsion of the bicephalous foetuses is effected, Avould naturally lead us to
suppose, that, Avhenever one of the heads shall have been arrested above the
superior strait, the  pelvic version  should be resorted to, if the  monstrosity
presents by  its cephalic extremity  or  trunk; and if the breech descends
first, to draw on the loAver extremities.  But, in either case, when the greater
portion of the body is delivered, it would be necessary to carry it up  in front
of the symphysis pubis, so as to favor the engagement of the posterior head, 
868
DYSTOCIA.
prior to the anterior one.   Again, if the head that presents first shall havt
been engaged too long in  the pelvic excavation to  admit of being pressed
back, and of the feet being brought down, it Avould  be proper to make an
application of the forceps, if the  foetus were  still living; but, under such
circumstances, this latter measure will often prove ineffectual, for the trac-
tions made by the instrument Avill not overcome the resistance offered by
the second head.  We  have, therefore, in this  case only to choose betAveen
a bloody operation on the mother, and a division of the child's neck, which
would permit the head that offered first to be removed, and thus render the
pelvic version practicable.   And here, notAvithstanding the high authorities
to the contrary, I do not hesitate  to advocate the mutilation of the  foetus;
for, in cases of this nature, I would have no scruple in sacrificing the infant's
life to the safety of the mother.
                        CHAPTER  XYI.

             ARTIFICIAL DELIVERY OF  THE PLACENTA.
  Natural delivery of the placenta Avas described on page 381.  We have
now to study the difficulties and accidents Avhich may attend the process, and
for  this purpose shall devote to them two different articles.

                           ARTICLE  I.
                DIFFICULT  DELIVERY OF  THE PLACENTA.
  The difficulties that may require an artificial delivery of the after-birth are
caused either  by inertia of the Avomb,  excessive volume of the placenta,
weakness of the umbilical cord, irregular  contraction of the uterus, or by
intimate adhesions of the placenta itself.
  AATienever repeated attempts to  effect its delivery, made according to the
rules stated (p. 381), prove ineffectual, the attendant ought to search for the
cause of the delay, both  by abdominal palpations and by a vaginal explo-
ration.  One of two things will then occur: either the placenta will be found
lying over the internal orifice, or it will be so high up that the finger cannot
reach it.  Supposing the previous tractions had been made in the proper
direction, an obstacle to the delivery in the former case could only depend
on the unusual size of the after-birth, on the fragility of the umbilical cord,
or on a contraction  of the uterine orifice; in the latter, the placenta must
evidently be retained at the fundus, either by abnormal adhesions, or by the
irregular contraction of some part of the uterine Avails.  This first diagnosis
being once established, the operator only has to decide upon Avhich of those
circumstances the delay is dependent.

  § 1. Inertia  of  the AVomb.
  We have hitherto stated that the contracted uterus forms a  large,  hard,
and resistant  tumor  in  the sub-umbilical  region after the child is  born.
Now, it may happen, either from the general debility of the patient, or frnni 
            ARTIFICIAL  DELIVERY  OF  THE  PLACENTA.        869

 the feebleness or atony of the Avomb itself, that its organic contractility is
 not aroused  and the organ still remains after the birth of the child in a
 state of partial or complete inertia.
   Th!? inertia of the Avomb (which will  claim our special  attention Avhen
 treating of the hemorrhage that so frequently accompanies  it after  the de-
' livery) may  be simple or  complicated Avith flooding;  but Ave have  only to
 speak of the first variety at the present time.
   This condition is indicated by the large, soft, and insensible tumor, Avhich
 is detected by applying the hand upon the abdomen.
   If the inertia  of the Avomb  is not attended with flooding, it is probable
 that  the placenta  still remains undetached;  and therefore no imprudent
 tractions should  be made on  the cord, lest a separation  occur before the
 inertia is remedied.   This Avould inevitably produce a frightful hemorrhage,
 which might cost the patient  her life in a feAV minutes; or, should the pla-
 cental adhesions  resist the tractive efforts, the womb Avould be drawn doAvn
 along with the after-birth, thus producing a partial or complete inversion
 of the organ.  It  is, therefore, a  truly fortunate circumstance Avhen the
 inertia is manifested before the separation of  the after-birth is commenced.
 A further source of hemorrhage is  found in the umbilical vessels; but this
 accident is exceedingly rare, and besides it can easily be remedied by apply-
 ing a ligature on the cord.
   The best course to be  pursued in cases of simple inertia, is to Avail until
 the uterus regains its poAvers; the  return of the contractions might  be ac-
 celerated, hoAvever, by moderate frictions over the lower part of the belly,
 or by  titillating the os uteri Avith one or  tAvo fingers in the vagina, and by
 the application of cold compresses over the  hypogastric region, and  on the
 upper part of the thighs.   In cases of partial  inertia, some  English prac-
 titioners, Dr. Murphy in particular (London Med. Gaz.), have recommended
 a tight bandage around the abdomen; or, preferably, a resort to immediate
 pressure over the uterus, by applying both hands on the sides of the organ.
 M. Guillemot asserts that he has often succeeded in arousing and keeping
 up the contractions by plunging the end of the cord in a glass of cold Avater;
 but we can scarcely comprehend hoAv this singular result can occur.  The
 patient's strength is to be kept up at the same  time by some broth, or, pos-
 sibly, by a little good Avine, or brandy and water.

   § 2. Excessive Volume of the Placenta.
   This may be either real, or due to the  collection of large  coagula  in the
 pouch of the membranes,  created by the inversion of the placenta in  falling
 upon the os  uteri, after  its detachment.  This source of difficulty is easily
 recognized  by observing the unusual volume of the uterus above  the pubis,
 and by detecting  the detached  mass at the os uteri  by the finger.
   In  most  instances, the natural contractions of the  womb, assisted  by a
 moderate traction upon  the cord, are all-sufficient for  the  delivery of the
 after-birth ;  though  it is  occasionally necessary to pass the  hand into the
 vagina and  to carry one  or tAvo fingers  up into the uterine cavity for the
 purpose of hooking it doAvn.   AAThen the increased size is owing to the accu-
mulation of coagula  in the pouch, the membranes, if  within reach of the 
370
DYSTOCIA.
finger, or the placenta itself, should be perforated so as to afford an outlet
to the fluid part of the blood, Avhereby the total mass is diminished,  and its
subsequent expulsion or extraction facilitated.
   The simplest method is, to seize  the placenta Avith the entire hand, and,
after squeezing it, in order to expel the clots, AvithdraAV it at once.

   § 3. AVeakness  of the Cord.
   This Aveakness, Avhether OAving to deficient development of the cord itself,
as happens in cases of premature labor, or to the particular mode of distri-
bution of the umbilical vessels, so Avell described by Benckiser  in his inau-
gural thesis (see Umbilical Cord), may facilitate its rupture;  and hence the
operator ought to be very careful in pulling on this part.   Again, a rupture
of the cord during the delivery may be dependent on its oblique attachment
to the placenta.  Therefore, as a general rule, Avhenever the hand  feels it
giving way during  the traction (for it produces a  peculiar  yielding sensa-
tion), the attempt should be discontinued ;  and, unless there are some  special
reasons to the contrary, the further delivery must  be left to the powers of
nature, or else the placenta  itself should be laid hold of, if it be deemed
proper to extract it immediately.
   In  conclusion, if, notAvithstanding all proper precautions, the cord  does
become ruptured, the accoucheur has  only to introduce the hand into the
vagina, and pass up  two  or three  fingers into the uterine cavity, so as to
seize and extract the placenta.
   It is then sometimes difficult to distinguish the placenta  from the wall of
the uterus  itself, thus exposing the operator to make  dangerous tractions
upon  the latter.  The following signs may enable us to avoid committing
an error  of this kind:  1. The  fingers applied to  the  foetal surface of the
placenta  can distinguish  the projections formed  by the vessels Avhich  are
distributed upon it.  2.  Pressure  upon the  placenta would hardly be per-
ceived by the patient, whilst it Avould be painful if applied to the wall of the
uterus.   3. Lastly, the other hand  applied upon the hypogastric region, is
sensible of a greater thickness of parts intervening betAveen it and the hand
Avithin the organ than could be due simply to the united  thickness of the
walls  of  the abdomen and of the uterus.

   § 4. Irregular  or Spasmodic Contraction of the  Uterus.
   The causes of uterine spasm are very obscure ; though, according to Stoltz,
the predisposition exists in the organ itself.   If any exterior causes can  con-
tribute to its production, they certainly must be those which have a  special
action on the Avomb: such as, improper frictions or manipulations, pulling
on the cord, and the  abuse of stimulating remedies, the ergot particularly.
Again, the irregular contractions of the uterus are more frequently remarked
after a twin labor than others.   The modern authors, Avho  have made this
a subject of special study, do not fully agree Avith  each other, in  regard to
the sequelae of  these irregular contractions.  The  different  forms exhibited
by the uterus in such cases have been reduced, by M. Guillemot,  to  tAVC
principal varieties: the  one depending  on the conformation of the  womb,
and the  other developed as a consequence of the presence of some foreign 
           ARTIFICIAL DELIVERY  OF  THE  PLACENTA.        871

body in the viscus.   The former  is designated by him  as the hour-glass, or
spasmodic contraction of the neck at its internal orifice;  the latter by the
term encystment, or the irregular  contraction of the body of the Avomb.
  Wc  shall folloAv the  example of M. Stoltz, by admitting four  distinct
varieties of uterine spasm, namely: 1st,  a spasmodic contraction of the
external orifice of the neck ;  2d,  that of its internal orifice;  3d, that of one
or more portions of the body of the uterus; and, 4th, a spasmodic  contrac-
tion of the Avhole Avornb.
  1. Spasmodic  Contraction of the External Orifice. — A person avIio has had
many opportunities of observing the softness  and flaccidity of the cervix
uteri at its  lower part after the child is- born, can scarcely comprehend the
possibility of spasm at its outer orifice; and hence many authors have alto-
gether denied its existence.  Besides, it must be evident that,  even if such a
condition were to occur, it Avould  constitute but a momentary obstacle to the
delivery of the after-birth; and therefore Ave Avould only have to Avait until
the spasm of the orifice  had  yielded to the force of the contractions.   Or,
if any accident should occur requiring prompt delivery, the resistance might
be surmounted  Avithout difficulty.
  2. Spasmodic Contraction of the Internal Orifice. — This is what M. Guille-
mot understands by the term hour-glass  contraction of the wouib; and Ave
quote a considerable part of his excellent description of it.  AVhen the hand
is introduced, the cervix is found projecting  into the vagina, and so  dis-
figured that it resembles a section of the large intestines;  but about five or
six inches above this, the finger is arrested by a kind  of stricture, Avhich is
the wrinkled and contracted internal orifice.  According to Madame Boivin,
the uterine neck sometimes measures five or six inches in length and four to
five in diameter, in  this state of flaccidity; the cavity of the Avomb  contain-
ing the placenta is found above the retracted part.  In some instances the
uterine walls are firmly contracted around this mass, Avhilst  at others  they
are in a state of partial or complete inertia.  The cavity of the Avomb is
thus divided into tAvo portions.   AVhen the upper one is contracted on  the
placenta, as most generally happens, its volume does not exceed the moiety
of the Avhole organ ; and hence the retraction, although seated at the  internal
orifice, seems to exist very near  the middle of the uterus;  which  circum-
stance has induced many practitioners to suppose that they had encountered
an irregular contraction of the body of the womb.
  In most cases  the after-birth is retained entirely within the superior cavity;
but this is not ahvays the case, for, in some instances, the vascular mass has
been found strangulated, to a certain extent,  by the stricture of the neck,
one part being retained  in the upper portion  and one in the lower.  AVhence
it may happen :  1st, that a very small portion of the placenta projects into
the vagina ; or, 2d, that it is strangulated near its central part;  or,  3d, that
more than one-half of the placenta hangs doAvn below the strictured orifice;
Avhich different  circumstances, as  Ave  shall have occasion to sIioav, modify the
treatment.
  The hour-glass contraction  is recognizable  by the shape of the uterus, and
bv the resistance presented at the internal orifice, both  to  the placenta and
L.o the accoucheur's  finger.  The organ is found hard and contracted, AYhen 
872
DYSTOCIA.
 felt through the abdominal Avails, and all tractions on the cord prove  inef-
 fectual;  besides, the operator, by resorting to the touch, will find the placenta
 above the internal orifice, which is contracted, whilst the walls of the neck
 beloAV are  soft, flabby, and  pendent in the vagina; and, Jastly, there is no
 discharge  of coagula, and sometimes even no  blood of any consequent
 escapes.
   When the stricture is not accompanied by any pressing symptoms, Ave
 should wait, for the spasm generally gives way in the course of a feAV hours;
 the uterus then regains its  normal form, and the after-birth is  expelled.
 Should it  persist longer than four or five hours, the  opiate  preparations
 might first be resorted to, folloAved by venesection, if indicated by the gen-
 eral  phenomena of plethora; bathing might, likewise,  prove very  useful.
 But the difficulty of watching the state of the uterus during its administra-
 tion must restrict its use greatly.   But if, notwithstanding the employment
 of all these measures, the spasm does not yield, or if it is complicated by an
 alarming hemorrhage, Ave must forthwith attempt  the dilatation of the
 strictured part.  This is effected  by first introducing one finger, then tAvo,
 and then three, with a vieAv of enlarging the orifice by degrees until it will
 admit the whole hand.  The advice of M. Stoltz, to smear the fingers with
 belladonna ointment, might prove  serviceable.   Should a portion of the
 placenta be engaged in the retracted part, our  course would evidently vary
 under the different circumstances alluded to above.  For instance, if a very
 small portion only of the after-birth is engaged, the operator ought to push
 it up, and then penetrate into the uterine cavity, in the way just described;
 but if strangulated near its central part, the fingers are to be slipped up be-
 tween it and the neck, and then the part  that  is  still above the stricture is
 to be gradually drawn  down.   Again,  if  most  of the  placental mass is
 already clear, we must get hold of  this free portion, and  by compressing it
forcibly in the hand, endeavor to reduce the size of the  strangulated part,
and thereby effect the delivery of the Avhole.
  3.  Irregular  Contractions of the Body  of  the Womb.— The Avomb  in con-
 tracting becomes accurately applied on the body contained within its  cavity;
 and, of course,  where the placenta still remains undelivered, the Avomb re-
tracts upon it.  As  the  contractions operate at all parts, the Avails of this
organ, being opposed to the circumference of the placenta, and, consequently,
meeting with little or no resistance, gradually approach each other, and shut
it up within their cavity; this constitutes the inclusion of the placenta; and
it may assume tAvo very distinct forms, to Avhich different names have been
 applied, i. e., the encystment  and  the encasement.
  Encystment is that variety in which the placenta is so surrounded on all
sides, excepting at the opening of the cell for the entrance of the umbilical
 cord,  that  it is absolutely imprisoned.  Encasement is  that in Avhich the
 uterine walls in contracting upon the circumference of the placenta, consti-
 tute around its  margin a kind of collar, or  frame,  Avhich encases it, just as
 the turgid  conjunctiva surrounds the cornea in chemosis.
  These two species  may either  be partial or complete:  the encystment is
 said to be complete, when the placenta is altogether shut up in the cell or
 cyst  formed by the  retracted uterine Avails; and incomplete, where tome 
ARTIFICIAL  DELIVERY  OF  THE PLACENTA.        873
Fig. 117.
portion of it breaks out of the door of the cell.  In the latter case, the cell
is perfect, being lined throughout by the centre of the placenta, whilst the
other parts of the latter, that have escaped from the cyst, are attached to
the neighboring portions of the uterine Avails.
  The encasement is complete,  Avhen the  collar formed by the retracted
uterine fibres surrounds or encases the Avhole circumference of the placenta;
and incomplete, yvhere it only exists on a part of the periphery of this vas-
cular mass.
  In some instances, the womb is not moulded on  the circumference  alone
of the placenta.  " For if," says M. Velpeau, " the after-birth were solid
and even, like the head, the womb in contracting Avould
necessarily retain  the  form  of a pouch; but  the coty-
ledons, in the  process of the detachment, may separate
from each other, and the placenta Avould  then offer more
resistance in some parts than  in  others;  so that the
uterus soon  divides into several  compartments, or  divi-
sions, more or less distinct from each other, and each of
Avhich embraces some portion of the after-birth."   In
these cases,  the hand, in effecting the artificial delivery,
Avould necessarily have to penetrate through four, five,
or occasionally even six circular strictures, after  having
dilated them.
  The encystment may be complicated by  a retraction
of the internal orifice (see Fig. 117); but, in most of the
recorded cases of this  kind, the resistance has easily
been surmounted.
  It may take  place at any portion of the  Avomb Avhat-
ever, though more rarely at the fundus than elseAvhere;
Avhich is probably owing to the circumstance of the  fibres  in  this region
being more active, so that the detachment of the placenta, when it is inserted
at the fundus, is accomplished much sooner.
  The encystment may be recognized Avithout  much  difficulty; for, by pal-
pating the loAver part of the belly, tAvo tumors are  detected just above the
pubis, formed by the body of the uterus ;  the
larger of which contains the after-birth, and             FlG-118-
the  other, placed beloAV or towards one side,
and joined  to the first by a kind of neck,
constitutes the remainder of the uterine globe.
And, by following the cord Avith the index
finger up into the  cavity,  Ave find its  loAver
portion but little retracted ; though further
up the ringer detects a small rounded  open-
ing, the orifice  of the  cell  through Avhich
the  cord passes ; and beyond it are the irre-
gular Avails of the cyst, inclosing the placenta.
  Here, also, the accoucheur ought to Avait,
if the encystment  is not complicated by any
accident; endeavoring, hoAvever, in the mean-
while, to favor the return of the Avomb to its
The  hour-glass contrac
  tion of the womb.
 Mode of dilating the strictured part.
normal form, by a resort to 
374
DYSTOCIA.
the measures  before  advised.  AVhen any danger  threatens the n.other's
life, he ought  to  dilate the orifice of the cyst Avith the ends of the  fingers,
and thus penetrate carefully into its cavity.  (See Fig. 118.)
  AVhile these attempts are being made  internally, the other hand, placed
on the hypogastrium, must grasp  the  fundus,  and  keep  it  in position.
Douglass, who devoted particular attention  to this subject, avers that the
placenta  is generally still adherent; but Ramsbotham, Dewees, and several
others assert, on the contrary, that  it is  usually detached.  In the former
case, the  operator Avould  have to attempt  its separation; always taking the
precautions mentioned below.  It is to be delivered by taking hold of one
border, Avith a vieAV of making it clear the mouth of the cyst more readily;
and if it is but partially  encysted, the index finger is entered  and passed
around that portion of the placenta held by the periphery of the opening;
in this way both relieving the stricture and disengaging the encysted part.
  Instead of attempting to dilate the mouth of the cell, Avhich  is often very
difficult,  M. Dubroca, of Bordeaux, has  suggested a new plan, Avhich  is
styled by him the method of erosion; it consists of the introduction of a finger
into the opening of the cell, and then, with it, tearing  up and reducing the
placenta  to fragments, Avhich are afterwards expelled.  He  says this mode
proved successful in  some instances in Avhich he could not succeed  in pass-
ing two or three fingers into the cyst in the usual Avay.
  4. Spasmodic Contraction of the whole  Organ.—M. Stoltz relates an  in-
stance in Avhich he was called to a Avoman Avho had been delivered an  hour
previously^ by a midwife, after the administration of tAvo scruples of ergot;
the midwife, being unable to extract the after-birth, thought proper, before
sending for him, to exhibit a sixth dose of eight grains.   On his arrh'al, he
found the Avoman's general condition favorable;  the  fundus of the uterus
extended nearly up to the umbilicus, and the entire organ Avas  developed as
much as  at the fifth  month; but its Avails were contracted to such a degree
that it was quite firm and  hard.   FolloAving up the cord, the index finger
reached the external orifice, Avhich was greatly retracted, and scarcely per-
mitted the introduction of the first phalanx ; every part of the Avomb Avithin
reach Avas firm and  contracted, just like  the fundus and body.  Of course,
the delivery of the after-birth Avas out of the question ; besides, no complica-
tion indicated  its necessity.  It Avas then about half-past tAvo o'clock in the
morning; a draught, consisting of half a drachm of  Hoffmann's anodyne
liquor, and tAventy minims of the common tincture of opium, was adminis-
tered.  The fundus of the womb did not seem to be any less contracted at
nine o'clock in the morning; but, by operating Avith care, M. Stoltz succeeded
in dilating the orifice, and in passing three fingers up to the root of the cord ;
but being  unable to get any further, he withdreAv his  hand, and directed
injections of a  decoction  of belladonna  and  hyoscyamus.   These Avere re-
peated every half hour, and at the fifth  injection  the  midAvife found a por-
tion of the placenta engaged in the vagina; she forth Avith dreAv upon it, and
succeeded  in extracting  it, twelve hours after the child's birth.  Should a
similar case again occur, the prudent course of the  Strasbourg professor
ought certainly to be folloAved.   In addition to Avhich, venesection, tepid
bathing,  &c, might be resorted  to, if  indicated by a plethoric  condition of
the patient. 
            ARTIFICIAL  DELIVERY  OF THE  PLACENTA.        875

   [Although  spasmodic  contraction  of the entire uterus,  the  external orifice in
 jluded, is rare, tetanic spasm of the internal orifice and of the body, the external
 orifice remaining very dilatable, is not an uncommon event.  Whatever hinders
 the expulsion of the placenta, all obstructions causing it to be retained too long in
 the uterus, predispose to spasmodic contraction of the organ.   What, however, oc-
 casions it oftener than anything else is the untimely administration of ergot.  In
 all cases of the kind which I have witnessed, it appeared to me that the fundus of
 the womb Avas very high up, as though the body of the organ had become elongated
 by a  moulding process upon the strongly compressed placenta within it.  There-
 fni-c, Avhen one is  so fortunate as to succeed in dilating the internal orifice with one
 or tAvo fingers, it is necessary  to pass them  very  far up in  order to reach the
 highe-tt part of the placenta, which they are then to be hooked around  in order to
 its withdrawal.  Such is the process  to which Ave give the preference.]
   On the Avhole, then,  it would appear that the  irregular contraction is gen-
 erally partial, though  it  may be  seated at any or every part  of the organ;
 and  further, that  all these cases are to be treated in the same Avay.   That
 is: 1st, to Avait  patiently; 2d, in the course of a feAV hours to  resort to fric-
 tions over the fundus,  to titillations of the os uteri, and opiate preparations
 by inunctions or injections, belladonna to the cervix, either in the form of
 extract or decoction, venesection, and general or local bathing.  Burns re-
 commends the sudden  application of cold compresses.  In  most  instances,
 the administration  of antispasmodics by the mouth, such as sulphuric ether,
 hyoscyamus, belladonna, or  opium, is of unquestionable service; and  3d,
 when there is any complication that endangers the patient,  the forced, though
 sIoav, gradual, and  careful introduction of the hand, and extraction of  the
 placenta.

   § o.  Abnormal Adhesions.
   In the present state  of our science, it is very  difficult to point out a satis-
 factory cause for these abnormal  adhesions of the  placenta.   According to
 most authors, they  are owing to a fibrous  transformation of the cellular fila-
 ments Avhich hold  the placenta and uterus together,  Avhereby they acquire
 a degree  of solidity sufficient to withstand the uterine forces.   These adhe-
 sions ' have  also been  referred to the degenerations of the placental tissue
 itself, as Avell as  to  various osseous  and calcareous concretions.  In a  case
 detailed by M. Stoltz, the bond of union Avas evidently formed by a  layer
 of coagulated blood, which had served to  arrest a hemorrhage at the fourth
 month of gestation.  M. Dubois appears to accept this vieAV  (Oral Lessons),
 and attributes these adhesions to patches of a Avhitish matter of a greater or
 less degree of hardness, evidently of a fibrinous nature,  and  increasing in
 density with the age of the sanguineous  effusion of Avhich  they are the only
 remains.   According to M. Gendrin, the adhesion is made  by the circle
 which the reflected decidua forms  around  the  placenta.  Sometimes it is
  1 Dr. Dubois furnishes an instance of an abnormal adhesion of the placenta, in which
the latter was covered by an osseous or cretaceous substance; but Gooch, who reports
the case, further remarks, that he found the placenta partly ossified three times in the
same woman, and that he never had any difficulty in delivering the after-birth.
  Monro and Merriman also mention several cases where they noticed patches of ossi-
fication on  the  uterine surface of the placenta;  in which the latter, they go on to say,
adhered, perhaps, a little more than usual. 
876
DYSTOCIA.
 only produced at a few points of the uterine surface of the placenta, by the
 conversion  of some  part of the organ into a non-vascular, cellulo-fibrous
 tissue, by the accidental atrophy of one or more of the placental cotyledons;
 which atrophy not unfrequently occurs.   The generally received opinion is,
 that these abnormal  adhesions result in consequence  of an inflammation of
 the  placenta, or of the uterine Avail during gestation,  which is terminated
 by the exudation of  plastic and coagulable lymph  between the contiguous
 surfaces.  Our own  belief is,  that these adhesions are caused  by the fibro-
 fatty degeneration and atroplw of the villi of the chorion and of the cotyle-
 dons Avhich they form.   (See Fibrous Lesions of the Placenta.—Diseases of
 the Placenta.)   But Avhatever  may be the cause  that produces such adhe-
 sions, there are certain persons Avho  appear to  have an unfortunate predis-
 position to them, since  they suffer  from this accident at every confinement.
   The adhesion may be more or less extensive ; sometimes existing over the
 whole placental surface, but at others restricted to certain parts; for instance,
 it may exist at  the margin or circumference of the after-birth, the centre
 being detached ; * or it  may be restricted to one or more points of its surface.
 It likeAvise  offers various  degrees  of resistance;  occasionally  being feeble
 enough to yield readily, even to moderate tractions;  though it is sometimes
 so strong that either the placental or the uterine tissue yields  rather  than
 the bond  of  union.   In some  instances, the adhesions are so firm that they
 cannot be broken up without the greatest difficulty,  even after  death.  For
 example,  Morgagni found  a portion of the detached placenta  hanging in
 the uterine orifice of a woman, yvho  died thirteen days after  her  confine-
 ment ; but the other part of it Avas so adherent that he  could scarcely sepa-
 rate  it Avith  a scalpel.  The adherent portion Avas indurated, and some traces
 of inflammation were found on the corresponding part  of the womb.
   AVhenever a considerable period of time has elapsed  after the labor, with
 out the delivery of the after-birth  being effected, and yet the globular form
 of the uterus,2 its hardness and manifest  contraction, clearly shoAV that it is
 striving to detach and to expel the secundines, and where the finger, passed
 through the  cervix uteri, does not detect  the placenta, we have  every reason
 to suppose that there is an unnatural adhesion of this mass.  The following
 signs will  then confirm our suspicions: after drawing  on  the placenta by
 means of  the cord, the latter  will be found to  mount up  as  soon as it is
 relaxed;  during  the contraction,  the uterine  globe becomes  harder and
 diminishes in volume,  but  after the pain is over, it returns to its former
 condition  much sooner  and more perfectly than in other cases;  and, lastly,

  1 It frequently happens,  says Leroux  (Traite  des Pertes de Sang, page 306), that the
placenta is  thus detached at the middle, but remains adherent by its margins.  The
same  thing was observed  by  Albinus,  in a woman whose  womb  he  has sketched.
 "The female," he says, "whose uterus is represented in several of the plates, had a
detached placenta, and there was a considerable quantity of clotted  blood between  it
and the organ; it was adherent, however, around the whole border, Whereby flooding
 was prevented."  (Louis1  Translation of Van Swieten, t.  vii. p. 145, and Heister, t. ii
chap. civ. p. 459.)
  'l I  think, says John Ramsbotham, that I have  observed  a slight alteration in the
shape of the uterus.  It presents a less regularly spherical form, and its fundus also
exhibits a certain  degree of conicity.  (Obs. on Midwifery.) 
           ARTIFICIAL  DELIVERY  OF THE  PLACENTA.        877

the existence of this complication is rendered unequivocal  by carrying the
hand up into the uterus.
  The abnormal  adhesions of the placenta may exist alone, or they may be
complicated Avith some  accident;  its partial  adherence is nearly ahvays
accompanied by a more or less  profuse  hemorrhage.   In  cases of simple
adhesion, the accoucheur should ahvays  Avait, for a delay of a feAV hours is
often sufficient to effect  the separation ; then, after Avaiting for a couple of
hours, the  uterus is  stimulated  to  contraction  by the  various means
before indicated;  but  if these prove  insufficient, an injection  of  cold
Avater is to be throAvn into the umbilical vein.  After having cut the end of
the cord, and squeezed the vein so as to free it entirely of any  blood it  may
contain, the cold liquid is injected into this vessel with a sufficient degree of
force to diffuse it throughout the placental mass. This ought to be repeated,
taking care to  retain  the  fluid in the after-birth for  several minutes by
securing the cord.  This injection evidently has a twofold operation, affect-
ing both the placenta  and the Avomb; that is, it distends the former by the
introduction of a new liquid  into its vessels,  thereby augmenting its size
and Aveight; and the impression of cold on the internal surface of the latter
brings on its contraction.   This measure, therefore, ought  not to  be  over-
looked.
  AArhere it fails, tractions on the umbilical  cord are to  be resorted to;
though ahvays, as advised by Levret, perpendicularly to the surface of the
placenta.   If tAvo sheets of moistened paper are  stuck  together, continues
this author, for the purpose of illustrating the importance of his  precept,
and you endeavor to separate them by sliding one over the other, that  is to
say, by drawing them parallel  to their planes, you tear  rather than detach
them ; whilst, by pulling perpendicularly to those planes, you  will separate
them Avithout  the least  effort, as also Avithout  any laceration.  In order to
obtain a similar result in practice, the umbilical cord is carried toAvards the
side not occupied by the placenta, by the intervention of tAvo fingers passed
into the vagina beyond the uterine orifice.   But it is impossible to carry out
this rule, as Velpeau and Guillemot justly remark, because both the fcetal and
the uterine surfaces of the after-birth are in  contact with the Avails of the
organ; besides, the fingers can only sustain the cord beloAV the cervix, and
hence, as a natural consequence, the cord  Avill  ahvays be parallel Avith, not
perpendicular to, the long axis of the womb, in Avhatever manner it be held.
The same effect is produced equally well, in their opinion, by draAving on it
without this artificial  pulley.  Though Avhichever  plan  be resorted to, the
operator  must never  exert force enough in making the tractive efforts to
rupture the cord, and he should desist as soon as he  finds it yielding.
  But, supposing all the local and  general  irritants, the  injections into the
umbilical vein,  and the tractions upon  the cord just recommended, have
proved ineffectual, Avhat is to be done ?  AVhen the adhesions are complicated
by any hemorrhagic or convulsive affection, all accoucheurs are harmonious
on one point, namely, to persist in the attempts to effect the extraction.   But
the  same unanimity does not exist with regard to cases of simple adhesion;
for some, dreading the  disastrous  phenomena that may result from the reten-
tion  and subsequent putrefaction of the placenta,  and the absorption of 
878
DYSTOCIA.
putrid matters, are in favor of terminating the delivery at every hazard;
while others, on the  contrary, fearing  still  more the  consequences of  the
manipulations Avhich are  necessary  for  effecting the detachment of  the
placenta,  advise us to  abandon the  Avhole  to  nature; at the same time
recommending the ulterior symptoms to be met  and  combated as they arise
by the appropriate  measures.
  Our own opinion is, that the course of Levret, of Baudelocque, of Desor-
meaux, and M. P.  Dubois, is the best adapted to cases of this kind ; that is,
after  having employed the various means Ave have spoken of,-to introduce
the hand  into the uterine cavity, following  the  cord, Avhich is then the best
guide up to the placenta.  Should this have been torn aAvay, the latter could
be recognized by the vascular ramifications which characterize its fcetal sur-
face, by its elevation  above the inner face of the uterus, by its consistence,
and by the dull sensation felt by the  patient yvhen the  fingers bear upon it.
The point of attachment  being discovered, the next  step  is to  ascertain
whether the adhesion is complete or partial; in the latter case, it is recom-
mended to insinuate the open  hand  betAveen the external  surface of  the
placenta and the uterine wall, and then slit up the adhesion with the finger,
                               just  as you would cut  the leaves of a book
                               with  a  paper-knife; (Fig. 119.)  It is cer-
                               tain,  hoAvever, that  it  is a piece of advice
                               Avhich  it will be found  impossible to follow.
                               M. P. Dubois thinks it is better to seize the
                               detached part  Avith the Avhole hand,  and
                               pull upon it, Avith a view of completing the
                               separation of the rest; but if this proves
                               unsuccessful, he next tears and brings aAvay
                               all the  lose portion.  These abnormal adhe-
                               sions are most readily  overcome by a short
                               scratching  motion  Avith the  ends of  the
                               fingers.  All attempts of this kind ought,
    Mode of breaking up the adhesions of   however, to be made  Avith  great caution:
           the placenta.            .        .   .
                               leaving the ulterior expulsion of those parts
that still  remain   adherent, to nature, Avithout  resorting to any  further
attempts.   We could bring fonvard  numerous  cases in proof of the sound-
ness of this precept.  For  example, Ave  have knoAvn a rash operator to per-
forate the uterus completely Avhilst striving to separate an adherent placenta;
and Leroux, of Dijon, notAvithstanding all his dexterity, had the misfortune
to detach  quite a considerable part  of the internal muscular plane, in a case
of partial adhesion, by pulling too strongly on  the  detached upper portion
of the after-birth, in order to separate its  still adherent loAver part.  Death
soon followed in the case Ave allude to;  and the  surgeon of Dijon had a pro-
fuse hemorrhage to encounter in his, but he fortunately succeeded in arrest-
ing it by the application of the tampon.
  AVI; en the placenta becomes separated at its central part, the  margins
being still adherent, a cavity is usually  created  at that point, in Avhich  the
blood accumulates.   Under such circumstances, the  centre of the mass may
be perforated, and the fingers be passed  up through the opening, to complete
 
           ARTIFICIAL  DELIVERY  OF  THE  PLACENTA.       879

the detachment; at least, such was the course adopted by Heister and Leroux.
Furthermore, where the placenta is adherent throughout, the  accoucheur
operates on its external face, by slipping up the hand behind the membranes;
and Avhen it reaches the circumference of the after-birth, he first endeavors
to detach one part, and, where successful, he pursues  the same course as if
it had originally been a case of  partial adherence.
   Finally, let us add, that it is not proper to  persist too long, Avhen a part,
or even the whole, of the placenta holds out against the properly conducted
manipulations just advised;  for its  expulsion  Avill  probably  take place
sooner or later, either all at once, or in fragments.
   [The membranes, as well as the placenta, sometimes become abnormally adherent
at some points of their surface, and the  difficulty thus  occasioned  may be recog
nized in the following manner.   At first,  all the phenomena of the delivery of the
placenta take place as usual, and the  detached placenta is forced down  upon the
internal orifice or into the upper part of the vagina; but from thence it is with
difficulty brought to the vulva.   It is found to resist the tractive effort, to be held
back, as it were ; and if a finger be passed behind the symphysis pubis, the mem-
branes are found to be in a state of tension.  Any sudden application of force would
inevitably extract the placenta, but at the same time would leave a portion of the
membranes in the cavity of the uterus.  In order to avoid  so unfortunate a result,
it is important to temporize, to  draw very gently but continuously upon the  mem-
branes, and also rotate the placenta so as to twist them and  give them greater poAver
of resistance.  Finally, if necessary, the  hand may be passed into the vagina, and
by following up the membranes the point  of adherence may be reached and detach-
ment accomplished.  Although retention of a shred  of membrane is a less serious
occurrence than retention of a cotyledon of the placenta, it may, nevertheless, give
rise to secondary hemorrhage.  (See Secondary Hemorrhage.)]

   § 6. Of  Partial and  Complete  Retention of the Placenta.
   By conforming to the rules just mentioned, Ave shall rarely fail  in extract-
ing the placenta completely; but we have seen  that there are nevertheless
some cases in Avhich a larger or  smaller  portion of the after-birth is  neces-
sarily left behind, and its expulsion confided to the resources of the economy.
Whether this abandonment be obligatory, or the result of ill-directed trac-
tions on the cord, or of improper attempts to effect  the separation of the
adherent placenta, it may lead to various  consequences, some  of Avhich are
very serious.   It is, therefore, very important to  determine the fact, Avhich
may almost always be done by a careful examination  of the placenta.  The
only difficulty Avhich could arise, Avould be occasioned by its separation into
fragments in consequence of  its  very close adhesion.
   a. Hemorrhage is almost ahvays the immediate consequence of the reten-
tion of any considerable part of the placenta, and its -amount is generally
proportionate to the size of the abandoned portion.  Sometimes, hoAvever, no
flooding occurs ; either because the uterus contracted properly after the sepa-
ration of the placenta, or because the fragments left behind remain  attached
to the walls of the organ.  In the former case, the contraction of the womb
diminishes the discharge after the lapse of some  hours; and during the feAV
succeeding days, excepting the violent  colicky pains occasioned by the efforts
of the uterus to expel the foreign body, the patient suffers little more than
the discomforts attendant upon  a moderate hemorrhage. 
880                           DYSTOCIA.

  It is not long, hoAvever, before these frequent after-pains seem to give rise
to an unusual tenderness  of  the  uterine tumor; and, finally, even  slight
pressure becomes painful.  The lochia, which hitherto were composed entirely
of blood, present a different character.  They are mixed Avith  a very fetid,
sanious fluid, and become very irritating to the  genital parts.  If the tem-
perature  should chance  to  be high, and  especially if the most scrupulous
regard is  not paid to cleanliness, they diffuse such a disgusting odor as to
render the chamber untenable ; and, as  M. Jacquemier observes, the assist-
ants are liable to suffer severely from it.
  This change in the lochia is due to the putrefaction of some portions of
the placenta.  As parts of the adherent mass become gradually detached,
they fall into the cavity of the uterus, where  they are liable to remain for
some time.  The contact of air which readily  reaches the uterus soon gives
rise  to putrefaction, and the  decomposed fragments  communicate to  the
lochia the odor Avhich characterizes them.
  B. Putrid  Absorption  of  the Placenta.— These  local  phenomena rarely
appear Avithout being accompanied by  a sensible  alteration of the general
health of  the patient.   After a longer or shorter time, a violent chill comes
on, attended Avith extreme restlessness and anxiety, the pulse becomes rapid,
and  the skin  dry and burning; the  face is alternately pale and  flushed,
though mostly pale; the respiration is  anxious  and frequent;  the  tongue,
Avhich is ahvays dry, is  sometimes white and sometimes red; the patient
complains of pain  in  the head, attended  occasionally Avith throbbing, and
soon delirium, at first intermittent and finally constant, is added to the other
symptoms.  The latter become more and more serious ; the abdomen is  dis-
tended and very tender;  inclinations  to vomit, sometimes even  profuse
vomiting,  and, occasionally, frequent and involuntary  alvine discharges,
shoAV that the alimentary canal shares  in the general affection.  Finally,
the pulse  becomes more and more rapid,  thread-like, and undulating;  the
debility and restlessness are extreme, there is  no cessation of delirium, and
death closes this terrible scene five, ten,  or fifteen days after the invasion of
the first symptoms.
  Peritonitis, Avhich is in some  cases indicated by the tenderness and  dis-
tention of the abdomen, does not ahvays occur, and death may result simply
from the species of poisoning occasioned by the absorption of the putrefied
fragments of the placenta.   The symptoms presented by the patient are then
simply those of the fevers commonly called adynamic and ataxic.
  The result  is not  necessarily fatal,  and especially Avhen the disease is
uncomplicated Avith peritonitis, the patient may  escape from the danger
which threatened her.
  After a certain length of time, the retained portion of the placenta may
become suddenly detached,  and be expelled bodily; upon Avhich, the grave
symptoms to which its decomposition  had  given rise, cease almost imme-
diately.
  Sometimes, and under the use of frequent injections, the discharge seems
to lose  its  fetidity and irritating qualities,  and becomes more decidedly
purulent.   Some detached portions of the placenta are found diffused in it,
and parts are also brought aAvay by every injection; rather  larger portions 
            ART.FICIAL  DELIVERY OF  THE  PLACENTA.        881

 occasionally present  at  the cervix and may be extracted with  the finger.
 Whilst the Avomb is thus ridding itself of the putrid  matter which it con-
 tains, the general symptoms improve, or,  at least, are not aggravated.  The
 economy seems  to resist the  deleterious  influence to which it is subjected.
 The patient may remain in this condition for several Aveeks Avith an almost
 constant febrile movement, accompanied  noAV and then with exacerbations
 preceded  by slight chilliness, and moderate disorder of the digestive appa-
 ratus, until, finally, Avhen  the remainder of the  placenta is expelled,  the
 fever ceases,  the strength returns, and the patient is restored to health.
   These serious accidents, which are ahvays to be feared Avhen a consider-
 able portion  of the placenta is  retained Avithin the Avomb, do not, hoAvever,
 always  result from this retention.  It may remain  there for a long time
 after the delivery Avithout seriously  affecting the woman's health, and be
 disposed of in tAvo different but equally strange ways.  I allude to the late
 expulsion and absorption of the placenta.
   c. Late Expulsion of the Placenta.—The retention of a portion of the pla-
 centa is almost always attended by a profuse hemorrhage.  This, however,
 does not invariably occur when the entire after-birth remains in the cavity
 of the uterus, Avhich rarely happens except after abortions.  If, in short, the
 adhesions are noAvhere destroyed, and the utero-placental vessels  are unrup-
 tured,  the reason of the  absence  of hemorrhage, and often even of  the
 lochial  discharge observed under these circumstances, is evident.  The flood-
 ing then comes on only Avhen  the uterus at last contracts  in order to expel
 the foreign body.
   This  expulsion  may  be  accomplished at  once,  and  the  completely
 separated placenta be discharged whole.  The hemorrhage, Avhich  had lasted
 four, five, or even ten days, being the time  sometimes necessary for its separa-
 tion, ceases  immediately after, as by  enchantment.  This  hemorrhage is
 ahvays far less profuse Avhen the detachment of the placenta takes place at
 a remote period from the expulsion of the child.  The constant contraction
 of the uterus, which tends  unceasingly to  resume the dimensions  of the un-
 impregnated  condition, necessarily lessens the calibre  of the vessels and
 alnrost  obliterates them, so that their rupture at that time is an affair of
 little moment.  On examining the placenta, it is found to have  undergone
 no alteration, it  exhales no  unpleasant  odor, and although it  may  have
 remained several days, Aveeks, or even months, in the cavity of  the uterus
 after the expulsion of the child, it is as fresh as though the latter Avere just
 born.   Its vitality had been preserved  by the integrity of its vascular con-
 nections, and its prolonged  retention been  thus rendered innoxious.
  I have just had occasion to notice a case of the kind, afforded by a young
 Avoman three months and a half gone, who miscarried tAventy-four days ago.
 The placenta had  remained since then Avithin the cavity of the uterus, and
 a profuse hemorrhage having occurred  in consequence of its detachment, I
 was obliged to extract it artificially.   It Avas already engaged in the cervix,
 and its  AvithdraAval presented  no serious  difficulty; the extreme Aveakness
 of the  patient  forbade temporizing.   It   had no appearance  of decom-
position.
      56 
882
DYSTOCIA.
   [I met with two similar cases in women who were delivered at term.  A portion of
 the placenta having been left in the womb, both of them were taken with severe
 hemorrhage; one on the ninth  and the other on the seventeenth  day.   In both
 cases, I found  the os uteri partially open, enabling me  to extract a cotyledon of
 the placenta which presented not the slightest evidence of putrefaction.]

   Unfortunately, the slowness Avith which the detachment of  the placenta
 sometimes takes place, may so prolong the discharge as to  give  rise to tin-
 other accident.   AMien, in fact, a cotyledon  is thus  separated, it  no longer
 shares  in  the circulation  of  the adhering parts, and  remains  suspended
 Avithin  the cavity of the womb.  After a time, it becomes detached from the
 rest of  the  placenta,  and if its size or the contraction of the  orifice prevents;
 its being discharged immediately, it decomposes, and may give rise to some
 of the  accidents already mentioned.   Generally, however, its expulsion is
 not long deferred, or  else the practitioner deems it proper to extract  it; still,
 it is  impossible to avoid the hemorrhages, the repetition of which on the
 occasion of each partial  separation at last weaken the patient greatly, and
 may even endanger her existence.
   D.  The complete absorption of the placenta is. so extraordinary a phenom-
 enon, that  the  first observations published were  received very doubtfully.
 Nothing short of the great authority of such names as that of Naegele, together
 with  the  strict  detail Avith Avhich the cases  are  related, were required to
 obtain for them a place in  obstetric science.  Yet it is so easy to be deceived
 in such cases, that even after the observations of Naegele, Salomon, and
 Velpeau, doubts will occasionally suggest themselves.  Is it  not possible,
 indeed, that, notAvithstanding the strictest  surveillance, the placenta might
 have been  expelled  unconsciously ?   Is it not  possible that the  species of
 sanious detritus, to Avhich its decomposition gives rise, may have  formed a
 part of the  putrescent lochia discharged in such cases ?   Finally, may it not
 have been that its prolonged retention and late expulsion were regarded as
 instances of absorption ?  In fact, that after a woman had thus retained her
 placenta for several months without  her health having suffered materially,
 it may have become detached without a great deal of hemorrhage,  and small
 and shrivelled  as  it was, have been  discharged during strainings  at stool
 without the patient herself being aware of it.
   Most of the published  cases are, doubtless, liable  to one  or the other of
 these explanations; yet it must be confessed  that there are others, in Avhich
 there Avould seem to be no doubt that the placenta had really been  absorbed.
 After all, analogous  phenomena  are not Avanting.  In  extra-uterine preg-
 nancies, has not the foetus often been found reduced to its  bony portions, in
 consequence of the absorption of the other fluid or solid parts ?  Has not the
 same thing  been known to  take place Avithin the uterus when a dead  foetus
 had  been retained for a long time?   The absorption  of a placenta is cer-
 tainly not more wonderful, especially in  cases of abortion, Avhen the pla-
 centas are  small and imperfectly formed,  as  in most of the instances men-
 tioned.   The  possibility of the occurrence  cannot, therefore, as yet.be abso-
lutely denied, though it should be received Avith a certain degree of reserve.
   Indications.—AVe have dwelt sufficiently upon the proper means  of pre-
 venting the entire or pari;al retention of the placenta, and have but a Avord 
           ARTIFICIAL DELIVERY  OF  THE  PLACEN: A.        883

to add respecting the prudence which should govern all attempts at extrac-
tion.  Although the dangerous accidents to which the woman is exposed,
require that we  should attempt all that is humanly possible, in order to
effect its extraction, it should be remembered that too long-continued efforts,
Avhether to introduce the hand through a contracted orifice, or to rupture the
too  strong adhesions, are liable to  produce equally serious consequences; in
fact, that post-puerperal inflammations and even ruptures  of the uterus have
frequently resulted from these forcible  detachments; and,  finally, that a
placenta retained wholly or in  part within the uterus, may not be expelled
until after the lapse of several months, or may  be  absorbed  Avithout sen-
sibly affecting the health of the mother.  Although these latter occurrences
are rare, they are yet sufficient to  justify, and even  require  the relinquish-
ment of all violent and dangerous efforts.   It Avere impossible to  furnish
here an absolute rule of action, and it must be left to the intelligence and
prudence of the practitioner, to determine, hoAv far he shall proceed in such
cases.
  The  indications to be  fulfilled,  when a portion of the  placenta has been
left behind,  either voluntarily, or  through aAvkAvardness,  vary  according to
the period at which our services are demanded.
  A'ery often a quite profuse hemorrhage is  the first accident to appear, and
efforts  should be made  to  restrain it  by  means of cold applications to
the hypogastrium, groins, and thighs, by frictions upon the body and neck
of the  uterus, and, Avith the object of obtaining a more thorough contrac-
tion of the organ, ergot should be administered.   These measures will very
rarely be found insufficient, provided the uterus is properly contracted; but
should the accident be complicated by inertia, the measures to be indicated-
hereafter should be resorted to.
  Care  should be taken as regards relieving the violent after-pains Avhich
torment the  patient, by the use of opiates, since  the contractions of Avhich
they are the result, tend to separate and expel the adherent mass.
  The  ulterior conduct of the practitioner must be governed by circum-
stances.  If the neck of the uterus appears  to  be  strongly contracted, if
the lochia are moderate in amount, and especially if their composition is
unaltered  and their color and smell unchanged, he should be satisfied with
watching  the patient  closely without  interfering with  the tendencies of
nature by an untimely intervention.
  As soon as the lochia become  sanious and fetid, he should resort to the
best means of averting their dangerous influence opon the economy.   Intra-
vaginal and  intra-uterine injections  practised frequently,  and continued
until the  returning  fluid is no longer imbued Avith  the  odor of decomposi-
tion, are very useful.   M. Ahillyamos recommends the use of large  quanti-
ties of  water ; he throAVS up an injection consisting of the Avarm infusion of
niarslimalluws, by means of a large syringe, every five minutes; he prefers
cold water, however, in cases of flooding.  This operation is effected by the
use of a long gum-elastic tube, one end of Avhich is fixed  in the  uterine
orifice, and the other extends beyond the vulva, or even the  foot of the bed,
so as to  obviate the necessity of uncovering her; the  returning fluid  is
collected in  a basin placed under the  patient.   I  think it would be more
mudent to make use of a double tube. 
884
DYSTOCIA.
  The patient  should also be examined frequently, in order to ascertain
whether  any portion of the placenta presents at the cervix,  and if so, it
should be extracted immediately, either Avith  the fingers,  Avith  Levret's
abortion  forceps, or Avith Prof. Pajot's curette.  The injections, indeed, are
not ahvays  sufficient,  being  incapable  of  bringing aAvay moderate-sized
fragments.
  Extreme fetidity of the lochia might possibly authorize the use of slightly
chlorinated injections.
  The patient  should  also have the advantage of the  best hygienic meas-
ures.   The chamber should be thoroughly ventilated and purified by every
appropriate means, and the linen changed as often  as_ possible.
  If, notAvithstanding these precautions, upon Avhich too much stress cannot
be laid,  symptoms of general infection should  appear, complicated with
peritonitis, purgatives, baths, calomel, and mercurial inunction, should  be
used at  the outset; but the first adynamic or ataxic phenomena must be
met Avith the tonic and stimulant treatment used in the latter stages of low
fevers.  Water containing  wine, preparations  of cinchona and  acetate  of
ammonia, may  all prove very useful.


                           ARTICLE  II.
OF  ACCIDENTS  THAT  MAY COMPLICATE  DELIVERY  OF  THE AFTER-BIRTH.
  The principal of these are hemorrhage,  inversion and rupture of the
womb, and convulsions.

  § 1. Hemorrhage.
  Of all the accidents that may precede, accompany, or follow the delivery
of the placenta, flooding  is certainly one of the most frequent,  and at the
same time, most terrible in its consequences.   It may occur conjointly Avith
either of the difficulties just described in the preceding article; and Avhen
this does take place, the indications then laid down ought to be  folloAved
up more  promptly. But, in addition to  those circumstances, hemorrhage
may likewise take place after the child is born; and this claims our special
attention, since it  is nearly ahvays  accompanied by complete  or partial
inertia of the womb.  AVe have therefore to examine successively the causes,
symptoms, diagnosis,  prognosis,  and treatment of this  inertia,  considered
with particular reference to the accident in  question.   AVe shall thus com-
plete  the history  of puerperal hemorrhage, which was hitherto only de-
scribed in part; namely, during the first six  months, in  the article on Abor-
tion;  and during the last three months, as also pending the labor proper, in
that on Accidental Dystocia.
  A.  Causes.—After  the delivery of the child, and even during  the pro-
gress of  its expulsion, the uterine tissue becomes  gradually retracted by the
exercise  of its  contractility of tissue, whereby the cavity of the  organ  is
considerably diminished;  thus contracting  the vessels  that ramify  in the
substance of its walls  and reducing their calibre  in a greater or less degree,
thereby  interrupting  the  circulation, and of course preventing the utero- 
           ARTIFICIAL  DELIVERY OF  THE  PLACENTA.        885

placental vessels, which are torn by the detachment of the  placenta, from
becoming the source of a profuse hemorrhage.  Noav, under certain circum-
stances, this contractility of tissue  is very  feeble, and  in others it is alto-
gether Avanting; in the former case  the inertia of the Avomb is partial, in
the latter  it is  complete; again, it may be total or partial,  according as it
affects the whole or a part of the uterine Avails.  All which various  degrees
of the affection  may be developed under the influence of the same causes.
  The causes of hemorrhage from  inertia are either predisposing or deter-
mining ; under  the former head, av liters have enumerated:  1st, a plethoric
and sanguine habit, a precocious and usually copious  menstruation;  more
particularly when  venesection has not  been  resorted to in anticipation,
during the latter months of pregnancy;  2d, a lymphatic temperament; for
those women avIio have a soft and lax fibre, or possess but little muscular
poAver, and Avho  are nervous and irritable, are more liable  than others  to
this  affection; 3d, the occurrence of profuse flooding  after  former labors.
We might  bring fonvard numerous cases, all tending to prove the unfavor-
able  influence of previous floodings; and, therefore, from the mere fact of
their occurrence at one or more antecedent  labors, the  accoucheur ought to
take suitable measures to prevent their reappearance.
  Under the head of the so-called determining causes, we may classify: 1st,
the  exhaustion  incident  to a protracted and  painful labor;  or, in  other
Avords, all the obstacles that may oppose the natural delivery of the foetus;
2d, a very  short labor, and its rapid termination from the stupor of the
walls, caused by the rude and hasty  depletion of the  organ; hence a very
large pelvis, a laceration of the cervix, and a want of resistance at the peri-
neum, all Avhich facilitate the rapid expulsion of the child, may, from that
fact alone,  become sources of inertia ; 3d, an excessive distention of the Avomb,
whether dependent on a dropsy of the amnios or a twin  pregnancy, may
paralyze, as it Avere, the contractility of the uterine tissue; 4th, according to
Madame Lachapelle, Ave must further add a dragging of the uterus, in con-
sequence of an  adhesion  contracted  Avith the omentum during gestation;
Avhereby the perfect retraction of the organ after labor is impeded.
   There can be no doubt that the various circumstances just  alluded to may
of themselves give rise to inertia; but, as a general rule, their influence will
be of short duration and easily set aside, if it is not favored by the existence
of some predisposing cause.   It is to  the latter, especially, as M. Guillemot
observes, that Ave must refer the chief part in the production  of those hemor-
rhages that occur after the child is born.  In fact, Avhere they exist conjointly
in the same woman, there is  every reason to fear the occurrence  of that
accident; whilst, if absent, the supposed determining causes usually have
but little or no effect.
  The influence of those  causes is  ordinarily manifested in the course of a
few minutes after the child is  bora; though sometimes  the inertia is second-
ary, as it Avere, not coming on  for several hours, or even not until several
days afterAvards.  The Avomb  having  contracted properly immediately after
the delivery of  the  child or after-birth, then becomes relaxed by  degrees,
and  ultimately gives  rise to a  frightful hemorrhage.
  B.  Symptoms.— Where the uterus contracts properly as soon as the labor 
686
DYSTOCIA.
is over, a hard, globular, rounded tumor is found in the hypogastric region,
occupying nearly all  the space between  the umbilicus and pubis.   This
tumor is the  seat of intermittent pains of variable intensity, and is ahvays
harder while they last.   An absence of these characters indicates inertia of
the organ; that is, by palpating the  loAver  part  of  the abdomen, Ave find
nothing but  softness  and  flaccidity  throughout;  for the abdominal and
uterine walls are so easily depressed, that they can be pushed back against
the posterior  ventral parietes; and, indeed, Avhere the inertia is complete, it
is even impossible to make out Avhich are the uterine and Avhich the abdom-
inal Avails.   Again, by  carrying the  hand up  into  the  Avomb, it  readily
passes through the relaxed cervix, and finds the uterine parietes everyAvhere
flabby and wrinkled like a bit of old rag.  Should the inertia be partial,
the uterine structures seem to  be thicker, and to have a more marked con-
sistence; but they are still readily distended, and are far from offering their
characteristic resistance.
  This condition  may exist without hemorrhage, if the placental adhesion
still remains  intact at  every part  of its  uterine  surface; but whenever a
separation has occurred,  flooding is  clearly inevitable.   Of course, the latter
Avill be the more copious as the detachment is nearly or Avholly completed
at the time the inertia is manifested.
  The signs by which the existence of hemorrhage is recognized  are easily
made out; but the discharge  is sometimes so sudden  and profuse, that, it is
not  detected until  the Avoman's life is already seriously endangered.  The
patient generally complains of a feeling of weight about the stomach ; and,
soon after, pallor of the face, dimness of vision, smallness of the pulse, weak-
ness, syncope, and all the most alarming general  symptoms  are manifested.
To these are  added  some phenomena peculiar to the uterine discharge; such
aa, pains in the loins, a  spasmodic  chill,  and a  dragging sensation at  the
epigastrium,  sometimes resembling that caused by hunger; and, in the latter
moments, there not unfrequently comes on a hysterical attack, or even some
convulsive movements.   As regards the local signs, they are variable ; and
hence, in this respect, the flooding  has been characterized as the external
and the internal.   AVhen it is external, the  blood, Avhich  inundates the  pa-
tient's bed, soaks  through  the mattress, and trickles down on the  floor,
cannot possibly permit any mistake as to the cause of the general phenomena
 just indicated.  But Avhen it  accumulates in the  uterine  cavity, the nature
of  the accident may escape  detection, or at least may only be recognized
when  it is too late to remedy  it.
   Every  circumstance whatever that constitutes  an  obstacle to  the ready
discharge of the blood through the uterine orifice, may give rise to an  in-
ternal hemorrhage; thus, a very considerable  obliquity  of the  womb, in
which the neck is carried high upwards and backAvards; occlusion of the os
uteri, by a part or the whole  of the placental mass, or by large coagula;  a
 badly applied tampon, or the closure of  the vulva by cloths ;  a  spasmodic
 contraction of the os uteri, (although, in  cases of inertia, this contraction is
 seldom considerable enough  of itself to  obliterate the outlet,) must neces-
 sarily favor  the formation of a clot that  might easily block up the already
 diminished cervix.   Let us add further, that the  elevated position in Avhich 
           ARTIFICIAL  DELIVERY  OF THE  PLACENTA.       887

 the pelvis is designedly placed for the purpose of arresting an ex ternal dis-
 charge, may prove a cause of internal hemorrhage.
   Whenever any obstacle  prevents the escape of the blood, the latter accu-
 mulates Avithin the uterine cavity, the Avails of which  readily  yield to dis-
 tention.   If the hand be then placed on  the belly, the womb Avill be found
 much enlarged, occasionally even attaining the height it  had during the
 latter months of gestation  ; the ball, formed by the retracted organ, is no
 longer felt at the usual place, its A'olume has increased, but its hardness has
 decreased; the finger in the vagina finds the uterine orifice, which is carried
 far backwards or is spasmodically retracted, obstructed by  the placenta, or
 by a clot;  and when passed  up  into  the Avomb, it detects there a large
 quantity of coagulated and fluid blood.   (C. Baudelocque.)
   c.  Diagnosis. — It  is scarcely possible  to mistake the nature of the acci-
 dent, Avhen  the  hemorrhage is external;  but this is far from being the case
 Avhen the  blood accumulates in the uterine cavity;  for, although  we have
 enumerated  the general debility,  syncope, &c, and the enlargement of the
 abdomen, as pathognomonic signs of flooding, yet these  circumstances may
 all be met with and still there may be no hemorrhage.
   The  increased size of the belly may be OAving to the fact that the intes-
 tines, after  having been so long  compressed by the developed organs, be-
 come expanded by the  gas they  contain; and  thus cause the abdominal
 walls, which are still soft and flabby, to SAvell up nearly to their previous
 size.  But any errors from this source will be corrected by the resonance of
 the abdomen on percussion, by the vaginal examination, and by palpating
 the uterine globe.
   " Sometimes," says  Madame  Lachapelle, " owing to the extensibility of
 the vagina, the Avomb is carried  up by  the distended bladder filled with
 urine, thereby singularly augmenting the  size of the belly.   In one instance
 that  came under  my notice, the pupils had become much  alarmed by this
 circumstance ; but I relieved their anxiety in a moment by the introduction
 of the catheter.  For the  prominence  of the  bladder, which is so  easily
 recognized by an  experienced  person, satisfied me at once as to the nature
 of the case;  and, besides, it Avas not accompanied by  any of the general
 symptoms of flooding."
  The accoucheur ought also to bear in mind that a syncope, occurring after
 childbirth, does not ahvays depend  on the loss of blood.   It is not unfre-
 quently obsenred shortly after very rapid  labors; for then the Avomb  being
 emptied at once, the compression to which the hypogastric vessels had been
 subjected  during the latter months of gestation is suddenly remoA^ed;  the
 circulation in them becomes free and unobstructed, and the rapid  determi-
 nation of the blood  from  the head and  upper extremities, towards  the
 vessels of the loAver parts, often gives rise  to fainting.  AA^hen it occurs, the
 horizontal position  and  the application  of a moderately draAvn  bandage
 around the belly, are  usually sufficient to  relieve the affection.
  An hysterical attack, coining on immediately after the labor, might be
mistaken for those  nervous phenomena that so often signalize the unfavor-
able termination of grave hemorrhage.
  But in all such cases, by resorting to the vaginal touch, and the palpation 
888
DYSTOCIA.
 of the hypogastric region, the accoucheur will clearly ascertain the retrac-
 tion of the organ; and, therefore, will not be likely to confound them with
 the symptoms dependent  on inertia of the womb.
   D.  Prognosis.—Flooding after labor is  an exceedingly dangerous acci
 dent; for a feAV minutes may decide the woman's fate.  Of course, the dis-
 charge Avill be the more profuse as the inertia is more complete and the
 separation of the placenta  more  advanced.   Other things being  equal, an
 internal hemorrhage is more dangerous, as a general rule, than  an external
 one:  simply because it is more apt to escape detection.
   Of the symptoms that are  common to both \-arieties of flooding, there
 are some which more  particularly indicate the imminency of the danger,
 and even a speedy death; such, for instance, as severe chills or convulsions,
 increasing  dyspnoea, prolonged syncope, sharp and  continued pains in the
 loins, together Avith vertigo and loss  of vision.
   " It should also  be  remarked that the  pupil is usually dilated,  that it is
 at times agitated by oscillatory movements, and that the dilatation is par-
 ticularly evident Avhen the syncope is most profound."  (Lachapelle.)
   e.  Treatment.—The treatment of uterine hemorrhage  from inertia is
 either preventive or curative.
   The preventive treatment  consists in breaking up the predispositions just
 alluded to, and in preventing the action of those causes which might deter-
 mine  inertia of  the womb  after labor.   In women of a full habit, Avhose
 menstrual  discharges have  usually been  copious, and in  Avhom  plethoric
 phenomena become manifested during pregnancy, it  Avould be proper to
 resort  to repeated  blood-lettings in  the course of the latter months;  and,
 even  during  the labor, if the fulness of the pulse, headache, and flushing
 of the face, seem  to require.  In those of a feeble and  delicate constitution,
 who have suffered from flooding in their former labors, measures calculated
 to arouse the contractility of the uterine tissue ought to be  employed in the
 latter stages  of parturition; that is, to  stimulate the  action of the uterus
 by external frictions and pressure, by the  application of  compresses soaked
 in some  cold fluid acidulated Avith vinegar, over the belly, and  more espe-
 cially, by the exhibition of fifteen to thirty  grains  of ergot, divided  into
 three  doses, about twenty minutes or half an hour before the child is born.
  Dr. Robert Lee (London Med.  Gaz., 1839, p. 713) recommends the fol-
 lowing course, namely: to rupture the membranes  at the commencement
 of the labor,  in those women whose previous history Avould cause us to fear
 a profuse hemorrhage after the delivery; without Avaiting for the dilatation
 of the os uteri, or  at  least  for the  development of strong pains; he then
 applies a bandage  around the abdomen, and  gradually tightens it as the
 labor advances.   The  subsequent  progress is abandoned to nature ; taking
 care to keep  the  apartment cool, and forbidding the employment of stimu-
 lants of any kind.  I have,  he says, several  times  adopted this plan Avith
success.
  There  are  still some other prophylactic  measures of great value, Avhen
there is reason to fear inertia of th* Avomb.   For instance, the best Avay of
 modifying the action of the determining causes, is to retard the termination
 of a rapid  labor  as much as possible, particularly in Avomen of a  lax fibre 
           ARTIFICIAL  DELIVERY  OF THE  PLACENTA.        889

and lymphatic temperament;  but, on  the other hand, to accelerate a long
and painful one by aiding the inefficient poAvers of nature before the patient
is wholly exhausted, and  before the  womb falls  into  a state of atony.
Doctor Clarke very properly advises the hand to be placed over the fundus
during the expulsion of the child, Avith a vieAV of affording it support, both
during and after  the  contraction.  Burns adds, that moderate pressure ou
the abdomen after the delivery of the placenta proves beneficial in keeping
up and stimulating the action of the organ.
  " But," says Madame Lachapelle, " if, notAvithstanding all your exertions,
and notAvithstanding the  most perfect rest, and the express charge to the
patient  not to bear doAvn, you find the accouchement progressing Avith a
fearful rapidity, you still have one resource left, that is, to leave the placenta
in the womb until fresh pains are excited.   For, in most instances, this body
is not entirely detached, and it resists the flooding so  long  as the stupor of
the Avoinb, caused by its too  sudden evacuation, persists.  In  the opposite
case, that is, Avhen the labor has been too long, the  placenta  is ordinarily
separated from the uterine wall, at least in a great measure; and  hence it
can no longer oppose the discharge of the blood.  From that time  its pres-
ence Avill only serve to keep up the feebleness of the  uterus, and by irritating
its Avails, exhaust  it Avithout any benefit;  you  should therefore proceed at
once to the delivery of the after-birth,  free the Avomb from  it entirely, and
take  advantage of the little energy remaining to  the latter to procure its
proper retraction."  (Pratique des Accouchements, t. ii.)
  The English  accoucheurs have taken advantage of the sympathy which
appears to exist betAveen the mammae  and the uterus, in order to overcome
the tendency of the womb to inertia in certain Avomen.   Belying  upon the
well-knoAvn fact that putting the child  to the breast often excites after-pains
within the feAV days immediately succeeding the delivery, they recommend
this to be done as soon as possible after the child  is born.  So great is their
confidence in this measure, that, according to Marshall Hall, no practitioner
Avould be justified in leaving a Avoman  Avho is  predisposed  to inertia of the
uterus, Avithout directing  a proceeding Avhich  is at once so simple, and so
sure to be effectual.  Besides the sympathetic excitement of the womb thus
produced, the suction Avould have the additional advantage of diverting the
blood from the uterus  by directing it toAvard the breasts.1
  I cannot too strongly insist upon the administration of from 15 to 30 grains
of ergot Avhenever there appears to  be  a tendency  to inertia after  delivery.
It is ahvays an  innocent remedy, and  one Avhich, I am sure, has prevented
many a flooding.
   Curative Treatment.—There is one special indication  presented after the
child is born,  namely,  that of arousing the uterine contractions, which alone
can put an end to the hemorrhage, as soon  as possible.   The means suggested

  1 Rigby advises, that whenever there is reason to fear hemorrhage from ii ertia after
delivery, the child be put to the breast  as  soon as the mother is changed and  put to
bed.  He assures us, that in several grave cases, in which  all other means had failed,
the uteri* contracted t-trongly and permanently as soon as the child had  seized  the
nipple.   In one case  only did the usual effect fail to take place, and this, Rigby thinks,
was due -o the fact of the child of another woman having been made use of. 
890
DYSTOCIA.
for this purpose are exceedingly various, but Ave shall endeavoi  to estimate
their respective values.
  Of all the various measures recommended for the flooding dependent upon
inertia of the Avomb, the easiest and most certain is a direct irritation made
simultaneously over the body, and on  the neck of this organ, by placing the
hand on the lower front part of the abdomen so as to rub, press, and squeeze
the uterine Avail, whilst  at  the  same  time two fingers are  passed into the
vagina to irritate and titillate the os uteri.  If these do not effect the object,
the Avhole hand is to be carried up into the cavity of the organ.
  Even supposing that the placenta has been expelled, the accumulation of
coagula in the cavity of the uterus prevents the retraction of its muscular
tissue, and the first thing to be done is to turn them out with  the hand, which
should be fearlessly introduced  into the  parts as often as may be required;
then irritate and  stimulate  its  internal  surface with the fingers, the other
hand keeping up  the frictions on the hypogastrium in the meanAvhile.  The
operator is sometimes obliged to compress and  knead the organ, as it Avere,
by bearing strongly on the abdominal surface, while the  hand in the cavity
serves  as a point  of support.
  This measure is preferable to all others, because it can always be resorted
to without alarming the patient, and is not likely to bring on an  inflamma-
tion of the organ, as is  the case with  most of the astringent and stimulant
articles advised by some Avriters.  The  injection of rectified alcohol, oil of
turpentine, spirit of vitriol, &c, into  the uterine cavity, recommended  by
Pasta to be used  in such cases as a caustic, ought to be banished  from prac-
tice.  Even the employment of strong vinegar requires the exercise of much
discretion.
  Should the irritation made by the  hands prove insufficient to arouse the
contractility  of the uterine tissue, we  must resort to  an application of cold,
which  acts both as a sedative to the circulatory system, and  as an astringent
on the muscular fibres.  Compresses dipped in iced water are to be applied
over the lower part of the abdomen, the genital organs, and the upper por-
tion of the thighs ; and a quantity of cold water might  be injected into the
vagina at the same time, taking care to pass  the extremity  of the canula
into the uterine cavity.  In a serious  case, the example of M. Evrat might
be advantageously folloAved; this gentleman carried a peeled lemon up into
the womb, and then expressed its juice with his hand, so that the citric acid,
by coming into contact Avith all parts of the internal surface,  would stimulate
the organic  contractility.   Or  that  of  M.  Desgranges, by introducing a
sponge dipped in vinegar, then squeezing out the fluid,  and abandoning it
in the  uterine cavity; having previously taken  the precaution of passing a
silk cord through it, by which it can  easily be withdrawn  when deemed
advisable.
   Again, some persons have suggested that a piece of ice be passed up and
left for a few moments in  contact with the uterine surface.   But the em-
ployment of this measure, as well as  the external application of cold, must
not be persisted in too long; because,  as Madame Lachapelle has judiciously
remarked, the prolonged application of snow, ice, cold irrigations, douches,
and sponging with very cold water, that has been so much vaunted by some 
            ARTIFICIAL  DELIVERY  OF  THE  PLACENTA.        891

 authors, is not unattended by danger to the patient; and, therefore, the use
 of cold  ought to be  restricted within moderate linits.  Most generally it
 becomes ineffectual in the course of five or six minutes; often, indeed, it
 proves positively injurious, either by reducing the woman to a state of mortal
 torpor, or by exposing her to a  violent inflammatory reaction.
   There are some cases of obstinate hemorrhage, in Avhich all the measures
 yet spoken of prove ineffectual.   For such cases other remedies have been
 recommended, Avhich now claim our attention.   These  are  the tampon, the
 introduction of a bladder into the Avomb, the approximation of the uterine
 walls  by immediate pressure, compression of the aorta, the use of ergot, of
 opium, and transfusion.
   1.  The Tampon. — Leroux reports quite a number of cases of inertia of
 the Avomb, in  which the tampon arrested the flooding where it seemed to be
 inevitably fatal.   But, as Desormeaux remarks, it often happens that men,
 even those Avho are otherAvise Avorthy of credence, are often more successful
 with remedies of their own  invention than any one else.  In fact, the only
 effect of the tampon in many cases is to convert an  external into an internal
 discharge.   In order to obviate  this disadvantage,  it has been suggested to
 combine its employment with compression of the uterine Avails, by means of
 the hands.  M. Chevreul, who is favorable to its use after the delivery, adds
 that it is necessary to irritate the organ externally as much as possible.   But
 in the cases mentioned, both by him and Leroux, where the tampon was
 apparently successful,  it was not, as M. Baudelocque avers, so much in pre-
 venting the discharge of blood, and determining its coagulation, as by irri-
 tating the internal surface of the Avomb, and thereby producing a retraction
 of its vessels, that the plug could  have had  a salutary effect.   The tampon
 itself, or rather the irritating substances M. Chevreul saturates it with, con-
 joined Avith external stimulation, may indeed  bring on the contraction in
 many cases; but  the mere plugging up of the vagina, as directed by Leroux,
 is useless, to say the least;  and therefore the introduction of some old linen,
 steeped in vinegar, into the  uterine cavity, is in reality the only efficacious
 part of the plan ;  but even this will prove still more beneficial Avhen accom-
 panied by compression of the hypogastrium, and by frictions and  stimula-
 tions of the organ above the pubis.
   2. The introduction into  the  womb of a hog's bladder, which has  been
 softened by holding it a short time in Avarm  Avater,  is even a Avorse measure
 than the preceding ;  and it is  really astonishing that Gardien seems to be in
 favor of its employment.  The presence of a bladder Avould evidently be a
 continual obstacle to  the retraction of the  Avomb.  Great stress has  been
 laid upon the compression,  Avhich it might  make  on the vascular  orifices,
 but to no purpose:  for, even were this a constant  result, which however is
 far from being the case, since Ave are never sure of filling the uterine cavity
 precisely, the difficulty Avould only be  delayed, as  the hemorrhage might
 reappear as soon as the  bladder  is Avithdrawn ;  and then,  after all, we
should have to fall back on the contraction of the organ.
  3. M. Deneux  conceived  the  happy idea  of pressing the uterine walls
together, in a desperate case, by means of a  folded napkin, which he ap-
plied over  the hypogastrium, and  retained  in  position by a tight body- 
892
DYSTOCIA.
bandage; this  arrested the discharge of the blood  completely.  Notwith-
standing M. Baudelocque has accorded the original suggestion of this plan
to M. Deneux, it Avas long since recommended,  particularly by the English
Avriters.  This procedure has been unjustly censured by certain practitioners,
since it  certainly may prove very useful  in  an extreme  case.   In  saying
that, from  the disposition of the posterior plane of the trunk, the uterine
walls can only be brought into contact with  each other at the point corre-
sponding to the sacro-vertebral angle, Madame Boivin has  evidently con-
founded the bare skeleton with the one still covered by its soft parts.
   4. Quite recently, M. D'Ornellas defended a thesis on  the compression
of the aorta as a remedy in uterine discharges, and  he brings fonvard
numerous cases in support of his  theory.  M. Baudelocque has assured me
that he  has several times succeeded in arresting a flooding in this Avay,
which  threatened an early fatal termination.   This gentleman, who dis-
putes Avith  Dr. Trehan the honor of its revival, appears to have great con-
fidence in the  efficacy of the measure;  and Ave  may add, that a very great
number of facts  noAV militate in favor of his  opinion.   He recommends
the compression to be made in the following manner: first, flex the patient's
superior  and inferior parts on the pelvis; then depress the abdominal Avail
immediately above the fundus of the Avomb with the  four  fingers  of one
hand, when the pulsations of the aorta will be more  distinctly felt than the
beating of the radial artery.  The compression may be kept up  for a con-
siderable time Avithout causing any particular inconvenience to the Avoman;
M. Baudelocque states that he has persisted in it for more than four  hours.
This compression, hoAvever, is only considered, even  by its  author himself,
as a mode of gaining time;  for he  administers ergot almost  immediately,
by the action  of  which the  uterine contraction is soon  established.  Com-
pression  of the aorta, though long since recommended,  had  been  gener-
ally proscribed  because the modes of effecting it Avere  very imperfect.
Thus, some  directed the pressure to  be made through the ventral surface
and  the  double uterine Avail;  Avhile others  introduced  the hand into the
cavity of the  uterus, and  then subjected the  vessel to pressure through the
posterior Avail  of this organ.  But both of these modes ought  to be rejected,
because they impede the retraction of the Avomb.
   NotAvithstanding the numerous successes Avhich have been attributed to
this  operation, several authors, amongst A\'hom  M. Jacquemier is conspicu-
ous, contest its utility, and even go so far as to  consider it injurious.   " In the
profuse  floodings following  delivery,  the blood AA'hich  escapes," says M.
Jacquemier, "  proceeds in great part from the veins, and compression of
the aorta could only favor  the reflux of venous  blood into the vena cava
and  the  branches which empty into it."  It is not to be supposed that the
utero-placental arteries could furnish the enormous amount of blood that
sometimes escapes in a few moments from a recently delivered Avoman, and
there can be no doubt that  a great part of it is discharged from  the large,
gaping venous  orifices left upon  the  internal  surface of the uterus  by the
detachment of the  placenta.   Though agreeing  with  M. Jacquemier as
regards this point, I cannot unite with the conclusion Avhich he draws from
it   Sucl , in fact, are  the relations between the aorta and vena cava, that 
           ARTIFICIAL  DELIVERY OF  THE  PLACENTA.        893

it is almost impossible, unless it be done expressly, to compress one without
compressing the other.  I am very Avilling to  admit that a  mistake may
have been  made in respect to the nature of the service thus rendered, and
that  all the credit hitherto accorded to  compression of the  aorta should
be transferred  to  the flattening of the vena cava; but of Avhat importance
is this as regards the  practical result, since the arrest of the hemorrhage is
no less the consequence ?  M. Jacquemier has done a real service in pointing
out a theoretical error, but I  Avould almost blame him  for it, should he
thereby deprive the  practitioner of  an  invaluable resource.  I  therefore
accept  his  theory, but shall  nevertheless  continue  to compress the aorta,
although convinced that I shall compress  the vena cava at the same time.
  Still another objection has been made to the proceeding.  Although com-
pression of  the aorta,  it is said, may prevent the blood from arriving by the
uterine arteries, it must necessarily increase the amount that passes through
the ovarian arteries, inasmuch as it is generally performed beloAV  the origin
of the latter. . . .  The objection loses much of its value from the fact that
the hemorrhage  is chiefly venous.   But of four arteries supplying blood,
two only are permeable after compression of the aorta; so far, therefore, it
is a marked advantage.
  M. Jacquemier also regards  the administration of ergot  during the com-
pression as useless and irrational.  " How shall Ave admit," says he, " that
this agent, Avhose effects are so prompt though evanescent, can stimulate the
uterus, since the arterial blood is cut off from it?"   It is by first acting upon
the nervous centres  and  stimulating the  excito-motor properties of  the
uterine nerves, that the drug exerts its special action on the uterus; there-
fore, to suppose that after having been absorbed by the stomach the medica-
ment can only act by being carried by the circulation into contact with the
uterine fibre, involves, I think, a physiological error.
  Hitherto, compression of the aorta has  been  recommended only for  the
purpose of  suspending the discharge of blood, and giving the measures for
restoring the uterine contractility time to act.  I  think that it is capable of
rendering great service even after the discharge is suspended and the Avomb
contracted.  The fact is, that Avhen  flooding has been profuse, all danger is
not at an end  from  the moment that Ave  have succeeded  in  arresting  the
hemorrhage and bringing about the contraction of the uterus; for although
not a single drop of blood  should be  discharged  afterward, the amount of
this fluid remaining  in the body is  no longer  sufficient to supply all  the
organs, and the brain at the same time, with the stimulus  necessary to the
maintenance of the integrity of  their functions; so that Avomen sometimes
expire'"Wo or three  hours after the arrest of the hemorrhage.  Death then
takes place, because the remaining blood, being equally diffused throughout
the entire extent of the circulatory apparatus, the brain, and especially the
spinal marroAV, receive too small a proportion of it, and consequently are
not sufficiently stimulated  to enable  them to support the respiration and the
movements of the heart.  This being admitted, it is easy to understand that
if, by compressing the abdominal aorta, Ave can prevent the blood discharged
by the left ventricle from  descending  into  the loAver parts  of the body and
inferior  extremities, it will necessarily be obliged to flow back toAvard  the 
891                           DYSTOCIA.
brain in  greater  quantity, and  thus secure for  this org*, n  the degree of
stimulus which it requires to enable it to react in its turn upon the functions
of the heart and lungs.
  The compression of the aorta may be assisted powerfully by placing ine
woman  on an inclined plane, so that the head shall be the loAvest part of the
body.
  I  think, therefore, that  compression  of  the aorta  and  vena cava is
useful Avhilst the flooding continues to be profuse;  but also, that Avhen the
patient  has lost a great amount of  blood, it should be continued for several
hours after the arrest of the hemorrhage and thorough contraction of the
walls of the uterus.   In the latter case, however, it is important to separate
the aorta  from the vena cava, so that the compression may act on the former
vessel exclusively.1
  5. Ergot has  been recommended, as stated  above, as a  means  of pre-
venting the occurrence of  hemorrhage in  Avomen who, by  their constitu-
tion and  previous  history, seem  to  be highly  predisposed to it.   This
remedy may also be resorted to in  the curative treatment;  unfortunately,
however, the time necessary for procuring it, and for the development of its
action, is ahvays too long to secure a sufficiently prompt effect;2 and hence,
in an alarming hemorrhage, one dependent on a complete  inertia of the
Avomb, for example,  the patient would certainly die before any benefit could
be hoped  for from its  employment.  Under such  circumstances, it would
prove highly useful  to compress the aorta in the meanwhile.   But with the
exception of these frightful cases, where a feAV minutes decide the woman's
fate, the secale cornutum ought to be employed ; and  its  use Avould be nearly
ahvays folloAved by success.   (See Therapeutics, article Ergot.)
  In  some females, the uterine  hemorrhages  haA'e  a marked  tendency to
relapse.    Consequently, a feAV grains of this substance ought  to be adminis-
tered as soon as it has occurred, Avhether it seems to be finally arrested or
not.   For, in the former case, it can do no harm, and, in the latter, it will
prevent a return of even a partial inertia ; which is not an indifferent matter
to a Avoman who is  already exhausted  from the  previous loss,  and who is
liable to  succumb  under  a  fresh discharge, however inconsiderable it
may be.
  6. The  English authors (Burns and others) recommend the use of opium
in full doses, both as a preventive and a curative remedy in cases of flooding
from  inertia.  They bring forward  some cases in support of their opinion;
but I do not deem them  conclusive; because, in  every  instance, they com-
bine the exhibition of opium Avith the employment of  those general measures
  1 Compression of the  aorta was once resorted to by M. Roux in the case of a wounded
patient, who was  exhausted by frequent hemorrhages.  I think, however, that I was,
myself, the first to suggest and  perform  it, in the floodings of newly-delivered females.
In the month of March, 1845, after stating the physiological principles upon which ]
based  my conclusions,  I proposed the operation in a formal manner,  in a communica-
tion to the Medical Society of the department of the Seine.   I am the more particular
in stating this fact, as the same suggestion  has been made in other quarters without
p ?knowledging my priority.
  2 Accoucheurs,  especially those who reside in the country, should always be carefuJ
to hnve with them a little ergot in the grain. 
            ARTIFICIAL  DELIVERY  OF THE  PLACENTA.       895

 just indicated as proper for arresting hemorrhage.  Besides, I cannot under-
 stand  how opium, when administered alone, can have any influence Avhatever
 over the contraction of the uterus, Avhich is here the only hope of safety.
   7. Transfusion, Avhich has  been so highly  praised by  certain English
 writers, in Avhose hands it seems to have succeeded quite a number of times,
 has not  been folloAved by the  same  success in France.  It is one of those
 extreme measures Avhich might be employed  in  desperate cases, though it
 cannot be relied  upon ; because  the extent of the flooding, the extreme
 debility of the patient, and the sloAvness of its operation, generally render it
 ineffectual; without referring to the  nervous and  inflammatory symptoms,
 and the phlebitis,  Avhich  very frequently succeed the operation.  Besides, it
 evidently could only be practised Avith any chance of success after the flood-
 ing had ceased, and the uterus was thoroughly contracted, and then I think
 that compression of the aorta would have almost all  its advantages Avithout
 any of its  numerous  dangers.  I once  saAv it performed at the Hotel-Dieu
 without any benefit Avhatever.  In some  of the reported cases, a notable
 improvement Avas  effected  by a moderate quantity of blood  (three or four
 ounces); in others, it Avas  necessary to inject as much as ten, and even as
 high as thirteen, ounces.
   In M. Nelaton's case,  he injected first six, and  five minutes aftenvards«
 eight, ounces of blood.  The operation was conducted as folloAvs:  The median
 basilic vein Avas uncovered  by an incision three-quarters of an.inch in length,
 then isolated, and raised by a loop of thread so as to  flatten it and stop the
 circulation in order to prevent any loss of blood.   The anterior wall  of the
 Arein Avas next seized Avith a pair of forceps,  and half divided obliquely from
 beloAV  upAvard, so as  to  form  a V-shaped  flap, which might  be raised or
 restored  at pleasure.   The blood draAvn from  one of the resident surgeons
 Avas received in a dish Avarmed to the temperature of 77° F., and  poured
 immediately  into a syringe heated to the same degree.
   Everything being thus  prepared, Avhatever  air remained in the syringe
 was expelled, the little V-shaped flap was raised Avith  the forceps, the tube
 of the instrument introduced into the vein beneath  it, and the injection per-
 formed sloAvly.  The second injection was made five minutes aftenvard, and
 the Avound in the arm closed  by means of collodion.
   8. AVe  have  hitherto  supposed  the  hemorrhage to come  on  after the
 removal  of the placenta;  but inertia  of  the  Avomb, and  the consequent
 hemorrhage,  often occurs  before this,  so that retention of  the placenta,
 under these circumstances,  is attended Avith some special indications  Avhich
 it is important to specify.   A\Thenever a hemorrhage  takes place, a more or
 less considerable portion of the placenta must evidently be detached;  some-
 times, even, it is wholly separated from the  uterine  Avail, being left free and
 movable  in the cavity of the organ.  The directions given by authors in
 this case are  very variable: thus, some  advise us to extract the secundines
 at once, together Avith any coagula the  uterine cavity may contain; others,
 on the contrary, to try first to remedy the inertia, Avhich is the sole cause of
 the accident.   We do not hesitate to recommend the latter advice Avhen the
hemorrhage is slight, because, if the placenta is partially removed, Ave  Avould
certainly augment its souj ces by completing the separation.  Hence Ave look 
896
DYSTOCIA.
 upon it as good practice not to attempt the extraction, and more particularly
 the detachment of the placenta, until  the accoucheur, by stimulating and
 irritating the organ with  his hand, has secured its diminution and contrac-
 tion to such an extent that it drives, as it were, the coagula and  after-birth
 beyond his hand.
  Should the adhesions of the placenta be unusually firm, the injections into
 the umbilical vein, spoken of in the last chapter, might be resorted to.
  But when the hemorrhage is profuse, and the placenta is completely de-
 tached, or adheres to the uterus by only a very small portion of its surface,
 it should be extracted together Avith the  clots Avhich may have collected
 within the cavity of the uterus.  Their presence there prevents an energetic
action upon the  Avails of the  womb, and  may impede their contraction.
Therefore, the best means of arresting  the flow of blood is  to  empty the
uterus of its contents as quickly as possible.
  When the physician has been fortunate enough  to overcome the  hemor
rhage by a resort to the various  measures just alluded to, he should  still
continue with his patient for several hours, carefully Avatching the character
and amount of the discharge from  the vulva, and occasionally placing  a
hand  over the hypogastrium, so as to detect any increase of volume in the
uterine globe.   Should the uterus become relaxed and groAV larger, Ave may
be certain that it is again  filled with coagula, and the hand should be again
introduced Avithout hesitation, notAvithstanding  the  patient's entreaties, and
the contents turned out; at the same time stimulating the organ by friction
upon  its internal surface.  The operation should be repeated  until the dis-
charge is finally arrested.  He ought also to take the precaution of applying
cloths steeped in vinegar or alcohol, or even in cold Avater, over  the belly,
and to  retain them there by  a  moderately drawn body-bandage.   Abso-
lute quiet is to be insisted on.  As nourishment, the  patient might have some
light cordial, broth, SAveetened Avine, &c, &c.
  Usually, the patient is put to bed  an  hour after her delivery; but after
severe floodings, she should be carefully  protected from any sudden motion
and it is often necessary to let  her remain  in the  same position for eight,
ten, or twelve hours.  The least movement might cause a mortal  syncope.
  After a  profuse hemorrhage, the patient is  naturally inclined to  sleep;
some  persons think it better to prevent her from slumbering, lest the dis-
charge be reneAved without her  knoAvledge.   But as this repose repairs the
exhausted forces, it ought not to be hindered; but she must never be left;
for the pulse, the uterus, and the vaginal discharge require a constant over-
sight.
  The patients are frequently tormented, after considerable  floodings, by
vomiting, or at least by sick stomach, nausea, and retchings.  Independently
of the pain they occasion, these gastric symptoms are not Avholly devoid of
danger ; for the vomiting, from the fatigue caused by the strainings to Avhich
the Avoman gives A\'ay, may produce a syncope, during Avhich the hemorrhagic
discharge may be reneAved  profusely.   If there are only the nausea  and
inclination to vomit, the Avomen are often so tormented  thereby as to Avear
out the little  strength they  have left;  and this  exhaustion of  musculai
poAver, at  a time Avhen the uterine contraction is so necessary, is  a very 
           ARTIFICIAL  DELIVERY  OF  THE  PLACENTA.         897

melancholy condition.  "Nothing tranquillizes  the  stomach under these
circumstances," says Dewees, " so far as I have observed, like opium, in the
solid form.   A neAvly prepared pill  of tAvo grains of opium, with a  very
small portion of soap, to facilitate its  solution  in  the  stomach, should  be
given every hour or tAvo, until the vomiting ceases, or the stomach becomes
reconciled.  I  have found a sinapism over the region of the stomach of great
service, and it  should be resorted to if necessary."
  The opiates, in a fluid form,  might also be used Avith advantage.  AVhen   '
after a profuse flooding  the patients are excited, uneasy, or  tormented  by a
feeling of extreme discomfort, a feAV dessertspoonfuls of the syrup  of diaco-
dion AviU generally serve to calm their anxiety,  and procure  the refreshing
sleep which they so greatly need.                      •
  [The danger is not over with the cessation of a profuse hemorrhage, for alarming
attacks  of syncope  are of frequent  occurrence.   Under these circumstances the
English practice ought to  be folloAved, which consists in the use of alcoholic drinks,
such as brandy, rum, Madeira wine, &c.   They may be  either diluted or  given
pure, and  a large amount can be taken without producing the least symptom of
intoxication.  A woman may thus drink from three to sixteen ounces of  brandy in
less than two hours, without the slightest inconvenience.  Brandy and water, with
a little lemon-juice, is often a very good  preparation, because  the pleasant taste
renders it agreeable to the stomach.
  Nothing  restores  more  rapidly  the exhausted strength of a woman enfeebled by
sudden hemorrhage, than  alcoholic drinks and cold broths ; unfortunately, however,
the stomach often rejects whatever is taken into it.   To quiet  this vomiting, frag-
ments of ice, ahvays taken Avith avidity, may be administered.  Should  the vomit-
 ing prove intractable, absorption by the large intestine, through the use of enemata,
may be attempted, and an injection given of broth and wine, Avith the addition of
from 15 to 20 drops of laudanum.   Dr. Charrier, former clinical chief at the hospital
 of the Faculte, published several cases which seem to prove the utility of these
 injections, and  I can myself bear witness to their  efficacy.  Therefore, in serious
 cases, they should not be  overlooked.]
   As the patient begins to recover from the extreme Aveakness Avhich imme-
 diately folloAArs a profuse loss  of blood, symptoms of febrile  reaction  begin
 to appear: the pulse is small and  rapid, sometimes hard, and  sometimes
 compressible; the heat  and dryness of skin are increased, the tongue is dry,
 and the features contracted : the patient is very thirsty, and feels disgust for
solid food: she is  startled by  the least sound, or by a bright  light: she
 complains of violent headache, and sometimes of palpitations and  dyspnea.
She is unable to sleep, or, if she dozes, is liable to be aAvakened by violent
startings.
   This condition evidently results from the excitement of the nervous system
occasioned by the  loss of  blood, an excitement which Ave should endeavor to
calm from the outset.
   Evidently, the first indication is to  repair the losses of the organism by
food  Avhich  shall  be easily digested, and  frequently administered in  small
quantities at a time.  Broths or light soups are eminently suitable.
   The  best  means of calming the excitability of the nervous system  are
perfect rest, cold aspersions upon the hands and face, but especially opiates.
given frequently and in small doses.
       57 
898
DYSTOCIA.
    § 2. Secondary Hemorrhage.
    In order to complete the history of puerperal hemorrhages, we have yet
  to speak of some accidents Avhich occur at a variable period after delivery,
  and Avhich o 1 that account have been styled secondary hemorrhages.
    These floodings, Avhich are so profuse as seriously to endanger the health
  and sometimes even the life of the patient, have been treated-of very imper-
  fectly in the most recent treatises, and Ave ourselves committed the ■'mistake
*  of passing  it over with a very slight notice in the earlier editions of this
  Avork.  Dr. Clintock has  recently performed  a valuable service in  calling
  attention to the various circumstances Avhich may give  rise to them.  Some-
  times these causes begin to act very shortly after the delivery of the placenta,
  and the thorough contraction of the uterus, sometimes not until after tAvo or
  three days, and  occasionally even  after three, five, or six Aveeks.   But at
  whatever time their influence is manifested, their mode of action is nearly
  ahvays the  same as at  the other  periods of the  puerperal  state;  and the
  hemorrhage may then be  accounted for either  by  secondary inertia, by a too
  active congestion, a real molimen  hcemorrhagicum, or, finally, by an altera-
  tion  of the blood, consisting in a great  increase of its fluidity.
     The hemorrhage, or rather the inertia which produced it, is not  confined
  to the period of  delivery, or to that Avhich immediately succeeds it; so that
  as regards the time of its  appearance, Ave may  distinguish a primitive inertia,
  Avhich is that just described, and a secondary, to  which attention  has been
  especially called'by Ramsbotham,  and  of Avhich Ave have ourselves observed
  several examples.
     A.  Secondary Inertia.—Some moments, hours, and sometimes even several
  days after delivery,1 the  uterus, Avhich had contracted properly and had
  remained so during all that time, may  suddenly become relaxed.  Its walls
  become softer, and it increases in size.   At the same time the patient grows
  weak and pale, the pulse loses its strength and quickens, and if the genital
  parts be carefully examined,  it is found that very little blood is discharged,
  and  that the clothes are but slightly soiled.    But if the uterine tumor be
  compressed slightly, or the organ be  incited to contraction by friction upon
  the hypogastrium, a considerable amount of  coagulated blood is suddenly
  discharged  by the vagina.  After this evacuation the size of the uterus is
  diminished, it is harder, and  remains  so, so  long as the hand continues to
  press upon it; but if the pressure  be removed, the softened Avails  are soon
  found to become distended afresh,  and then  contract again, driving out an-
  other quantity of clots, provided  the accoucheur renews the  pressure and
  frictions calculated to excite  their contractility.   This series of occurrences
  may take place several times, if the accoucheur relinquishes too soon the
     1 Mr. Fergusson reports (New York  Medical  Journal,  Sept., 1850) a case  of grave
  hemorrhage occurring thirteen days after delivery.  The cause was secondary inertia.
  The  author examined statistics in reference to this  subject, with the following result:
  out of 16,651 labors observed by Collins in the Dublin Hospital, there were 43 cases of
  hemorrhage immediately after delivery, and 40 twelve hours afterward.  The flooding,
  in one case, occurred only on the fourth, in another on the sixth, and in still another
  on the tenth day.
     Drs. -Clintock and ti ardy observed one on the seventh day, and Dr. Stimever another
  on the tenth. 
           ARTIFICIAL  DELIVERY  OF  THE  PI VCENTA.        899

use of the proper means for making the uterus  contract permanently; and
if the cause of the hemorrhage should not be discovered, it might cost the
woman her life.
   Noav several circumstances  are liable to lead  into  error.   In the first
place, the physician had previously ascertained the condition of the Avomb,
and it does not immediately strike him that it may have become relaxed in
a  secondary manner, after  having remained so long properly contracted.
Again, it frequently happens that the patient, exhausted by the fatigues of
the labor, falls asleep, and does not herself perceive her extreme Aveakness,
until her condition has become irremediable.
   Nothing but an examination of  the uterus is capable of clearing up the
diagnosis.  This organ is then  found  to be  much  larger  than  it Avas after
the labor, and the finger carried up to the internal  orifice, finds it blocked
up by a clot of considerable size.
   The accoucheur should use every effort to procure the contraction of the
Avails of the uterus, and  especially to render it permanent.  The best Avay
of accomplishing  this is, to continue  the pressure  himself Avhich Avas made
at the outset by the hand on the fundus of the womb, and  aftenvards substi-
tute for  it permanent  compression.   For  this purpose,  several napkins
folded on each other are placed on the  fundus  of the Avomb, and  by means
of a body-bandage tightly applied, the organ is held strongly pressed against
the opening of the superior strait.  I am in the habit of administering imme-
diately fifteen  grains of ergot, and of repeating it  every half hour or hour,
according to the degree of tendency to  relaxation, in closes of from six to
eight grains.
   B. Congestions  of the Uterus.— Under this title, Madame Lachapelle has
described a flooding, Avhich  comes on some time subsequent to  the parturi-
tion ;  and Avhich is  produced, as she supposes, under the influence of  a
peculiar  molimen hozmorrhagicum.  This variety is occasionally developed
even Avithout any inertia of  the Avomb.  " AVe have knoAvn," she continues,
" a Avoman to perish  seven or eight days after her  confinement,  from a pro-
fuse discharge of serous blood, Avhich transuded from all parts of the utero-
vaginal  surface, and saturated, by imbibition, the most solid tampon;  the
womb Avas soft, but not  distended Avith the  blood."  I have tAvice known
hemorrhage to take place after the delivery of  the after-birth, says M. Vel-
peau, although the Avomb had been contracted in  the one case for four and
in the other for seven hours.  He  further states that this accident is occa-
sionally manifested subsequent to the  first tAventy-four hours.
   These congestions, which in certain rare cases are  inexplicable, may usually
be attributed to certain easily detected, general, or local causes.
   We have already spoken (page 877) of the liability of the retention of  a
portion of the placenta to give rise to  these hemorrhages, and Ave Avould now
simply add that the presence of a  large clot within  the Avomb  might have
the same effect.   Both Collins and  Madame  Lachapelle report  cases of
flooding coming on eight and ten days after delivery, and Avhich ceased only
upon the artificial extraction of the coagula.
  The determination of blood may also be occasioned by the retention of  a
portion of the  membranes, as in the folloAving case. 
900                           DYSTOCIA.
  I was sent for  by a physician  to  see a lady living in hue Gros-Caillou
On arriving there, I found M. P. Dubois, Avho  Avas called at the same time,
but who  preceded me, engaged in extracting a considerable  portion of the
membranes, Avhich had been imprudently left  behind whilst delivering the
placenta.   The child was born at nine p. m., and half an hour aftenvards
hemorrhage came on, which could not be  arrested until half-past one in the
morning, at which time the foreign body was  extracted.  The  uterus had
remained perfectly contracted throughout.  (See  also page 879.)
  The extraction of the foreign body, in the latter case, generally dissipates
the symptoms;  in the former, a resort to revulsives to the upper part of the
body, to  cold applications, and even to venesection, is evidently indicated.
These Avill be materially aided by a regulated diet, and absolute rest in the
horizontal  position.
  Intra-uterine polypi have several times given  rise to mortal hemorrhage
tAvo or three weeks after delivery.  It has been  thought that these bodies
occasion the flooding only by preventing the contraction of the uterus.  AVe
are disposed to reject this opinion, because, as Oldham  observes, in these
cases  the  strongly contracted uterus  can  readily be felt above the pubis.
Besides, the cessation of the flooding  after ligation of  the polypus without
excision, justifies  the belief that the  latter does not act simply as a foreign
body; for Avere it so, the discharge Avould continue after the ligature was
applied.
  Irritation of the neighboring organs may give rise to hemorrhagic conges-
tion of the uterus.  M. Moreau mentions a case of hemorrhage which oc-
curred on the eighth day after delivery, and which he very properly attrib-
uted to a collection  of hardened faeces in the large intestine.   Injections
Avere used Avithout advantage, and he was obliged to empty the rectum by
using a sort of scoop.  As  soon  as this  was  accomplished, the discharge
ceased.
  For a long  time  after delivery the uterus  continues to be  a centre of
fluxion, toAvard which the general  disorders of  the economy seem to con-
verge.  There  appears  to be no other way of explaining such floodings as
are apparently  due to violent moral emotions, the abuse of stimulants, &c.
  c  Alteration of the Blood. — M. Blot also mentions, in  his excellent thesis,
the case of a woman yvhose uterus was firmly contracted, and Avho died in
consequence of a sero-sanguineous  discharge succeeding flooding  after de-
livery.  This hemorrhage, Avhich nothing Avas capable of arresting, is attrib-
uted by M. Blot to albuminuria and the consequent  impoverishment of the
blood.  I have already had occasion  to remark,  that new observations are
necessary to prove the correctness of this assertion.
  I cannot, hoAvever, agree with Madame  Lachapelle, who thinks that these
floodings are produced by an accidental congestion, a sort of molimem hozmor-
rhagicum.   I think,  on the contrary, that they are  the  result of a serous
condition of the blood, preventing the formation of obliterating coagula, and
allowing the fluid to exude from the  internal surface  of the  uterus.   This
sometimes takes place from the surface of wounds  in certain patients affected
with anaemia, scurvy, &c.  But to admit Avith  M. Blot that it is caused by
albwmi luria, would be going rather too far. 
           ARTIFICIAL  DELIVERY  OF THE  PLACENTA.        901

  The use of the tampon, assisted by compression of the uterus by means
of a bandage draAvn tightly around the  abdomen, would be proper under
these circumstances.  Ergot  has often  been used, without any advantage
Avhatever, in these dangerous  cases.   Some  English physicians approve
highly of styptics  taken internally.   In a case of flooding  occurring  nine
days after delivery, Mr. Clintock used the tincture of Cannabis Indica Avith
success.  Oxide of silver is also recommended, in the dose of from  half a
grain to a grain, three or four times a  day, in connection with a small quan-
tity of opium.   A large blister over the  sacrum  has also been applied suc-
cessfully.

  §  3. Hemorrhage  from the Umbilical Cord.
  In tAvin pregnancies, hemorrhage may take place from  the cut placental
extremity of the cord, after the first child is born.  For although no vascu-
lar communication habitually exists betAveen the tAvo placentas, yet the con-
trary has been too often observed to leave any doubt with regard to the fact
at the present day ; and hence it is admitted by most practitioners. Besides,
we find cases recorded  by Mery, Baudelocque,  and  Solayres, Avhich fully
prove  that, even  in single pregnancies, a hemorrhage  profuse enough to
endanger the mother's life may occur after the division of the cord,  as also
that the umbilical vein is  the sole source of this discharge.  " As regards
the bleeding from the placental end of the cord, other than in cases of tAvins,
I can aver," says M. Chevreul, " having observed it three times in Avomen
whom I had delivered Avith the forceps;  having  cut the cord in a hurry
Avithout applying any  ligature,  the  blood continued to Aoav abundantly
from that portion connected with the  placenta, whilst I Avas devoting the
necessary attentions to the child.  I resorted to all  the modes of irritation
advised in such cases, for the purpose of rousing the contractions; but the
discharge Avas only arrested by tying  the cord.   The delivery of the after-
birth shortly occurred, and Avas folio wed by no untoAvard accident."  Quite
recently, M. Guillemot  has met with a very similar case.  Dr. Albert, of
Wiesentheid, saw the  blood spring from the extremity of the cord, in a
stream as thick as a straAV.  The hemorrhage, which was considerable, could
not be arrested  except by pressure upon the umbilical vessels; and a  liga-
ture  had to be applied.
  By reflecting on  the  mode of vascular connection  heretofore studied in
the placenta, it really  seems impossible to understand) hoAv  the  mother's
blood, in a  natural condition of things, can pass into the ramifications of
the umbilical vein,  and thence  escape in such profusion.  But are we on
that account to reject  such  facts, advanced by  experienced  men of high
standing?  I think not; besides, the  explanation Avould be rendered  very
intelligible by supposing some vascular anomaly  in these exceptional cases.
I therefore consider hemorrhage from the placental extremity of the  cord
as possible, for I cannot question the testimony of the imposing authorities
just  quoted.  Under such circumstances,  ligature of the cord is evidently
the onlj resourt e.                 • 
902                           DYSTOCIA.
  § 4.  Inversion of the AVomb.
  This is an affection in which the fundus of the organ, being indented  ot
depressed, is more or less inverted  into  its cavity, or even passed  doAvn
through the os uteri into the vagina, or out at the vulva.
  Inversion of the womb exhibits many  different degrees;  from a simple
depression of the fundus to complete  inversion, in Avhich case the organ is
turned inside out, the internal or mucous surface becoming the external
one, and vice versa.  For the  purposes  of  description, Ave shall admit three
principal degrees :  in the first of which the fundus is simply depressed, ap-
proaching to, but not engaging in, the os  uteri;  the second is a  partial in-
version, in which the fundus actually engages  in the orifice, and protrudes
into the vagina; and the third is a complete inversion, in which the uterus
is turned inside out, appearing at the vulva, or even protruding beyond it.
  1. AVhen  the  depression commences at the fundus, a  concavity is pro-
duced  in the tumor above the pubis,  having its highest borders nearer  to
the latter than to the sacrum ; or it may commence at the sides; and  Avhen
it  is the front  one that is indented,  the posterior border is higher than the
anterior, but when  the reverse happens, the posterior is the  lower: again,
when it is  depressed laterally, the concavity in the top of the womb is in-
clined  toAvards  one of the iliac fossae.   If the placenta is still undetached,
the indentation  is augmented by pulling  on the umbilical cord.  Finally,
when the finger is passed  into the cavity of the womb, it finds  the fundus
within half an inch, more or less, of  the orifice.
  2. When the inversion is partial, Ave  can detect a hemispherical tumor by
vaginal examination, varying in its size, according to whether  the pla-
centa is detached or still adherent; the neck of the womb encircles this
tumor at its upper part like a collar.   The ball usually  formed in the
hypogastric  region by thf>  uterine globe,  is no longer felt on palpation; a
considerable depression being found in its  place.
  3. Where it is complete, the tumor may either fill up the vagina without
passing beyond  the  vulva,  or may  hang down  betAveen the woman's
thighs.  In  the  former case,  the  whole vaginal cavity is  occupied  by a
voluminous  tumor, the upper part of  which can  scarcely be reached;  in
the latter, Avhich is the most serious of all, the pelvic cavity is altogether
empty, and  nothing can be felt there by the hand; but a large tumor is
found between the patient's thighs, having the placenta attached, wholly  or
in part.  The top of this tumor is  either simply concealed betAveen the
labia, or extends up into  the vagina.  In some instances, the latter has also
been implicated in the  displacement, and  has been inverted  in a  great
measure, thereby giving a considerable length to the tumor.  " AVe cannot,
however, say that  the  inversion is strictly complete," says Burns, " for, in
most cases, the lips of the os uteri hang down, and the inversion terminates
at the lower part of the cervix."   Some writers assert, notwithstanding,
that the lips may be completely inverted.
  This accident is ahvays accompanied by general phenomena, which are
the more serious as it is the more considerable.  The patient not only suffers
from  pain, but  she is harassed by  a  constant  desire to urinate, and by
strainings at the close-stool, Avhich  are often sufficient to render an inversion 
           artificial  delivery  of  the  placenta.        903

complete, that would ofhenvise have only been  partial.   The pain becomes
excruciating, and  the  frightened  sufferer falls into a state of syncope;  the
pulse is feeble, and sometimes is nearly or  quite  imperceptible.   The inten-
sity  of these general  phenomena varies  with the  state of retraction  or
relaxation of the cervix, and Avith the degree of inversion.  For  instance, it
is much  less in a simple depression, than Avhere the inversion is  more com-
plete.  Furthermore, the pains and dangers are much greater in the latter
case, if the cervix  uteri is  firmly  contracted, than when it is dilatable.
Again, should the placenta be partially detached at the time of the accident,
there Avill be  a profuse hemorrhage; but, on the contrary, Avhen it is firmly
adherent throughout, no discharge occurs,  since the latter only begins Avith
the separation of the after-birth, and  increases as this progresses.   Lastly,
when the inversion is complicated by inertia, Avhich unfortunately is usually
the case, the flooding  is  frightful, and can only be  moderated  by the con-
traction of the womb.
  Inversion is  sometimes produced by attempting to  effect  the delivery
of the after-birth before it is entirely separated, by pulling imprudently on
the cord.   It may also result from a very  rapid labor, more particularly if
the Avoman happens to be standing at the  time Avhen the child is born; for
if the umbilical cord  is unusually short, or is wound around some part of
the child, the fundus  may be pulled down  by the strain on the cord, and
thus become  inverted.
  Inversion from this latter cause is far  more  unusual than  one  would
suppose; because  the  cord  is  generally broken under such circumstances,
incomprehensible  as the  fact  may seem, when Ave reflect on the amount of
force required to rupture  it.   The rarity of the inversion, however, is more
readily explained by the  poAverful contraction  at the instant the  foetus is
expelled, and by the difference in  the  line of axis of the two straits;  the
axis of the superior strait forming nearly a right angle Avith  that of the
inferior one,  or  rather Avith  that of the vulva.   In other Avords, the cord
passes around the posterior part of the symphysis pubis, as over a pulley;
and,  therefore,  the  greater amount of the tractive force  is spent  on the
symphysis before reaching the  fundus.
  It  may happen, from the uterus being  in a momentary state of inertia
after  delivery', that  the pressure  made  by the intestinal mass  indents  its
fundus like the bottom of a bottle.  Again, in  cases of complete  inertia,
should the placenta be attached directly to the  fundus of the organ, its
Aveight alone  might pull it doAvn.   Such accidents are usually corrected  by
the force of the  contractions;  though, should the operator pull  on the cord
before noticing the depression, he might increase the difficulty by converting
it into a. partial  inversion.1
  1 Although I am only treating of uterine inversion here, as a complication of the
delivery, I cannot refrain from  mentioning a very curious case, narrated by An6, at
the Societe de Medecine, of  a woman who had a complete inversion of the  womb twelve
days after the confinement, and which resulted in consequence of severe  strainings at
stool.  This  case,  which was confirmed by Baudelocque, who was called in consulta-
tion, can leave  no  doubt  as to the possibility of such  an accident, however  extraor-
dinary it may appear.  A still more wonderful case is related by Mr. Ebenezer Skae,
as occurring in a woman who suffered complete inversion of the womb tAvo days after 
904                          dystocia.
  Dr. Tydei  Smith  supposes that inversion of the  uterus  is  ahvays occa-
sioned by irregular  contractions of the organ; even in the cases generally
attributed to premature tractions on the cord, he considers,  that the pulling
does not  act  mechanically, but only  by producing an excitement of the
fundus of the uterus, where the  placenta is inserted, which  occasions  an
irregular  contraction, and consequently  a simple  depression.   This first
degree of inversion, according to him,  is immediately folloAved by a sudden
contraction of the fibres  above  the depressed point, which tend by their
action to expel the latter through the cervix, in absolutely the same manner
as they would act upon a foreign body.
  Dr. Smith's explanation  of  the mechanism of inversion  may be true for
some  cases; but when the Avails of the uterus are in a  state of complete
relaxation, it  is difficult to allow that violent pulling upon the cord of  an
adherent placenta should be incapable of producing inversion.
  When a simple depression occurs immediately after labor, it will scarcely
attract attention, unless the  placenta happens to  be  detached, and a hemor-
rhage is thereby developed.  It ought  to be reduced, as soon as detected, by
placing the patient on her back, and having the abdomen and  breech raised
higher than the  chest; the legs and thighs  are flexed and  held  apart, and
the head inclined forwards on the breast; then the operator  carries his. hand
into the uterine  cavity, and gently pushes out the fundus with  his fingers.
  M.  Chevreul sums up so well the indications presented by the partial and
complete inversions  of the Avomb, with  reference to the delivery of the after-
birth, that I cannot do  better than transcribe here his remarks on this sub-
ject.  He says: " A partial inversion is easily reduced when detected shortly
after its occurrence. Of course, the placenta may either be separated Avholly
or in part, or it may be still adherent  throughout to the womb, at the time
of the accident.  If wholly detached,  the hemorrhage is very profuse, and
requires  immediate attention.  The accident  is  remedied  by placing  the
woman in a suitable position, and then, introducing the whole hand into the
vagina, the fingers take hold of the inverted  portion of the Avomb and
endeavor to return it, by first pushing  up  the part  that came  down last.
Should the placenta be partially detached, and the remaining adhesions be
feeble, its separation ought to be entirely completed, by passing  the  fingers
between it and the  uterine wall;  after  which, the reduction is  to be effected
aborting in the fourth month of  gestation.  (The Northern Journal of Medicine.)  I
will further add, that the observations of Sabatier would  seem to prove that such an
inversion  may not only take place when the fundus of the womb  is  depressed by a
polypus, but also  in a state of perfect vacuity.  The responsibility of the assertion
must rest with the author.
  M. Roussel communicated a case to M. Martin, in which the inversion did not tnke
place until nine hours after delivery.  The patient had a frightful flooding at the time
of the extraction of the placenta,  which  M. Roussel arrested by the ordinary meas-
ures ;  after which, he  remained with her until fully satisfied of the  contraction of
the womb. It was then about eight o'clock  in the evening.   At five the next morning,
he was summoned in  great  haste; when it appeared  that the patient had got up to
evacuate her bowels, and the womb immediately fell down to the vulva.  On his arrival
B'he was senseless, and the pulse  imperceptible; the finger, passed into  the vagina,
found there a large tumor, formed by the inverted fundus, around which  the os uteri
had firmly contracted, and doubtless had thus contributed to the diminution of  the
tiemorrhage. 
            ARTIFICIAL  DELIVERY  OF THE  PLACENTA.        905

as in the former case.   But if it is still adherent throughout, the Avhole is
to be returned  together;  and then Ave may either  Avait  for the spontaneous
delivery of the after-birth, or Ave may attempt to  separate  it by the hand,
according to circumstances."
  Where the inversion has existed for several hours, it occasionally happens
that the protruding portion of the Avomb is strangulated, as  it Avere, by the
os uteri, Avhich constitutes a serious obstacle to  its reduction.  Under such
circumstances,  it is not advisable to use forcible attempts to surmount the
difficulty, lest some serious accident  might result; but  rather to have re-
course to venesection, to tepid  bathing, to fomentations, to  the use of the
ointment  or the extract of belladonna, and opiates; in a word, to all  the
means likely to'relieve the constriction of the os uteri, and  to  moderate
the force of the inflammatory symptoms.  The inhalation  of chloroform,
which has been used Avith such fortunate results in analogous cases by MM.
Barrier, \ralentin, Charles  AVest, and  G. Gonney, might here also be of very
great service.   But if still unsuccessful, the  patient  will have to endure
this disgusting infirmity for the remainder of her days.1
   AVhere the inversion is complete, and the placenta is detached,  Ave must
first apply a soft and dry napkin upon the tumor,  and then, having brought
the fingers  together in  the form of  a  cone,  depress its central  part with
their points, so as to make the fundus  and body of this viscus gradually pass
up through  its orifice, and thus regain its primitive position.  Should the
conjoined fingers prove too bulky, the stick proposed by M. Depaul might
be substituted for them Avith advantage.   AArhen the Avomb is once reduced,
the napkin should be AvithdraAvn. Should the placenta be partially detached,
its separation is first completed, and then the operation is terminated in the
same way.
   Again, if the adhesions  are  very extensive, or  if they exist throughout,
Ave ought to attempt the reduction of  all together, by proceeding as in  the
first case, excepting the use of the napkin; but if the orifice is not dilated
enough to permit the Avomb to pass  through Avith the placenta, it Avould be
necessary to separate the latter, and then reduce the former as promptly as
possible.
   AVhatever be the degree of  inversion, the hand is  always to be kept in
the Avomb for some time after the reduction, for the purpose of preventing a
return of  the accident, and for soliciting the contraction of the organ.  The
inertia, if present, must be remedied by the appropriate measures.
  It is  found  by experience that whenever  inversion  has occurred in a
former labor, it has a tendency to be renewed at the subsequent ones.  Con-
sequently, no tractions on the umbilical cord, with a vieAV of extracting the
  1 However,  two cases are reported, the one  by M. Delabarre (Ace. de Chir.), and the
other by Baudelocque, which fully prove that spontaneous reduction of the womb may
take place,  even after it has been completely inverted for a long time.
  M. Daillies  endeavors to explain this natural reduction, in his excellent thesis, by
the  tonicity of the Fallopian tubes, and of the  round and bi;oad ligaments: which,
after having been drawn down at the moment of the accident, will necessarily return
to their proper position in the  course of time; and thus, by acting on the organ that
involved  '.hem in  its  descent,  will gradually elevate and return  it to  its original
position. 
906
DYSTOCIA.
placenta, should ever be resorted to in Avomen who have previously suffered
from this accident.  In cases of this kind, many practitioners prefer the in-
troduction  of the hand into the  uterine cavity, so as to act directly on the
placenta itself.
  Such patients ought also to be advised to remain in bed for a  long  time
after their confinement;  and, by the use  of mild laxatives, to  obviate the
necessity of strainings at stool.

  § 5.  Rupture of  the AA^omb.
  Rupture of the uterus is one of the most terrible accidents that can occur
in the course of pregnancy or parturition.  But as  it only claims our attention
here, Avith reference to the difficulties it may create in the delivery of the after-
birth, we shall not revert to the minute detail already given in the Fifth Part
of this work.   (See p. 732.)   Several different conditions  may here be met
with; as, for instance, the child, having partially or Avholly escaped into the
peritoneal cavity, has permitted the organ to retract; and  this retraction of
its Avails may have driven the placenta into the vagina, and then beyond
the vulva ;*  or  the placenta may remain adherent to the internal surface of
the womb, the child having passed into the peritoneal cavity;  or again, it
as well as the foetus may have passed entirely into the cavity of the abdomen.
In the  former case, there is evidently nothing to be done.  In the second, if
gastrotomy is resorted to, and it is found impossible to withdraw the pla-
centa through  the double wound in the abdomen  and womb, OAving to the
closure of the lips of the uterine rupture, it would be advisable to cut the
cord as  soon as the child is extracted; and then, by means  of some long,
solid, and flexible instrument, to  bring doAvn the cord through the rupture,
the cervix, and the vagina, and out at  the  vulva; after Avhich the delivery
of the  placenta is  to be effected in the usual way.  In the third case, when
the after-birth has passed into the peritoneal  cavity along with  the foetus,
it ought  to be extracted  immediately after the latter, either by the natural
passages, if the child  is removed  in that way, or through the abdominal  in-
cision, if a resort to gastrotomy be deemed  necessary.

  § 6.  Eclampsia.
  For an account of convulsions occurring  during the delivery of the after-
birth, see the article on Eclampsia (p. 788).

  1 This spontaneous expulsion  may take place either immediately after the accident,
or not for several days ;  as occurred in the case reported by Saucerotte.   (Melangis di
Chirurgie, t. ii. p. 295.) 
PAET  VI.
                       THEKAPEUTIOS.

   J E have been careful, in the various chapters of the present Avork, to
      call attention to the medicines  best adapted to each particular case,
and thus have often had occasion to recommend the use of laudanum.  AVe
haA'e nothing now to add to what has already been said, but devote a special
article to ergot, so often advised by us for the purpose of exciting the Aveak-
ened or suspended  contractions of  the womb, and especially as an  heroic
remedy against hemorrhage.  Various substitutes, it is true,  have been pro-
posed for it; but as none can compare Avith  it in efficiency, nothing Avould
be gained by their enumeration.
  The first chapter will be devoted to the natural and therapeutic history
of ergot, and the second to the effect of a debilitating  medication and regi-
men upon the development of the foetus.
                           CHAPTER  I.

                                ERGOT.
   AVe shall first  study the nature and  physical properties of ergot, and
 finally its therapeutic action.

   § 1. Natural History  of Ergot.
   The ergot of rye, now so much used  in medicine, has ahvays been con-
 sidered as an alteration of that grain, the writers on the subject only differ-
 ing in opinion Avith respect to the causes which produce it.  Some think it
 depends on atmospherical or local influences, such as long-continued  rains,
 fogs, and  noxious de\Ars, or on too poor  or too humid  a soil;  Avhile others
 have regarded it as being produced by the puncture of certain insects ; this
 latter opinion has  even yet  a great number of advocates, although at the
 present day  it is most  generally considered as a fungus.  Paulet has classi-
 fied it among the clavaria, and De Candolle among the parasitic fungi,
 under the name of sclerotium  clavus, from its form;  and this Avas  the gen-
 erally received opinion until Dr. Leveille, in  a memoir published  in  1826,
 in the Annals of the Linncean Society of Paris, announced that the ergot was
 in reality an alteration of the grain; and that it Avas produced  by  the pres-
ence of a parasitic fungus, which he named the sphacelia segetum, intending
to satisfy by this title both the color of the diseased grain and the sad con-
sequences which result  from  its use  Avhen mixed with bread. The extended
                                                               907
W 
908
THERAPEUTICS.
observations of the author have satisfied him that this fungus appears chiefly
in the summer season, after heavy rains, and that it  is developed in  the
grain itself betAveen the integuments and the perisperm.   At first it is imis-
ible, but soon  increases in size, and breaks through the envelopes of  the
grain, Avhile the perisperm, Avhich Avas very small and Avhite, assumes  a vio-
let hue, then elongates, or grows, and becomes hard  and  brittle, escaping
from  betAveen the palese (the husk or chaff), and pushing before it the fun-
gus (sphacelia) found at its free extremity.  This fungus is soft and vcIIoav
of a disagreeable odor and a SAveetish taste; being formed  of several lobes
joined at their centre, its surface exhibits some small  undulations, similar
to the convolutions of the  brain.  If a  particle of it  be placed  in Avater,
under the  microscope,  it is found to become partially liquefied, and the
Avater holds  in suspension  an immense  number of little grains, or spores,
Avhich are oval, transparent, and  exceedingly minute in size.  These  facts,
which my learned friend, Dr. Leveille, has kindly made  me Avitness, leaves
no doubt on my mind as to the nature of this affection; and I am satisfied
that it is a true fungus, and a perfectly distinct part of the sclerotium claims.
This fungus is  rarely met with on the spurred rye found in the shops, as it
has probably been detached either by the threshing or by the friction of the
heads against each other.   As  this product  is soft and diffluent, it spreads
over the teguments and the spur, Avhere it becomes dried and cracked, and
forms a thin layer of a dirty Avhite or yelloAvish color, Avhich dissolves Avhen
throAvn into Avater.   Now, does the  ergot OA\e its properties to this fungoid
portion, or to its own proper substance ?   Experience has  not yet settled the
doubts of M. Leveille on this subject; but as, by the aid of this theory, we
can readily explain  why the ergoted rye so often proves  Avorthless Avhen
administered, we believe  the choice of this substance is not an indifferent
matter;  therefore, such grains as have a smooth  and  brilliant surface, as
well as those that exhibit numerous deep fissures, should be rejected, for the
one has been deprived of the sphacelated portion by friction, and the other
altered  by successive rains and heats.  The preference should  be given to
those Avhich still have the  fungus on their summits, and the surfaces of
which are entire, of a violet color and dirty  aspect, and covered, as it were,
with a powder.

  § 2. Therapeutical  Action.
  The action of this medicine  is  too well ascertained at the present time to
permit it to be any longer called  in question ; though Ave have only to speak
of it here in its obstetrical relations.
  Ergot is noAV recommended by accoucheurs for arousing or accelerating
the uterine contractions  during labor,  and for preventing or remedying
inertia of the womb  and the  hemorrhage Avhich so often  accompanies it,
after  delivery.   This action  is  prompt, and is recognizable  by the fol-
lowing  signs: the uterine contractions are observed to become  more active
in the course of ten to fifteen minutes after its administration, more frequent
and energetic if they were previously sIoav or feeble, and  reappearing  if be-
fore suspended.  Noav, we cannot believe, like the authors Avho proscribed
this medicine  as useless, that this is merely a simple coincidence, and that 
ERGOT.
909
the labor would  have been restored without  its use, foi  the thousands of
instances in Avhich its administration has ahvays been fohoAved by the same
uniform result, will  not permit us to consider the  latter as the mere effect
of chance; and, besides, all those who make use of this article knoAV full
Avell that the contractions which attend the exhibition of ergot have a pecu-
liar character that cannot be mistaken; for as soon as its action is felt they
become permanent instead of  intermittent; the uterine globe remains hard
and contracted, and  the pains are continual, though they are marked, it is
true, by exacerbations, or paroxysms, and there are moments, as in ordinary
labor, AA'hen the patient does  not appear to suffer  at all, and others where
she makes loud cries or bearing-doAvn efforts.  The periods of repose are,
hoAvever, only apparent, for the womb is constantly contracted on the pro-
duct of conception, and the hand, if  applied over the belly, always finds
this organ in a remarkable state of hardness; there is not that regular suc-
cession of  repose and  contraction Avhich is constantly observed  Avhen the
labor is spontaneous; and we  may further add, that the patients themselves
detect  a great difference betAveen the pains  excited by the medicine and
those previously felt in  the same or former labors, and they bear them, as a
general rule, more impatiently than  the latter, complaining  particularly of
the Avant of respite.  In an hour or an hour and a  half after the exhibition
of the ergot, ife action Avears aAvay and  soon disappears, so that, if there
is any necessity, it must  be again reneAved, or recourse be had to artificial
means for terminating the labor.
   The permanent character of the contractions produced  by ergot  makes
them very dangerous to the child when they are long  continued.   The vio-
lent retraction of the muscular fibres then  renders the circulation difficult,
and  sometimes even impossible, in  those A'essels Avhich  are distributed be-
tween their various  layers, and Ave may readily understand that the foeto-
placental functions  must  be  remarkably obstructed.   Therefore, it can be
prudently administered only Avhen a  prompt termination  of the  labor can
be predicted.
   This remedy is only  to be  given during  parturition, Avhen the pelvis is
well formed, the infant presenting by its cephalic  or pelvic extremity, and
of course Avhen the position is well ascertained; Avhere no serious obstacle
exists  at the uterine orifice, in the A'agina, or at the external parts;  that is
to say, Avhen the cervix uteri  is sufficiently dilated, or at least soft, supple,
and  patulous enough to admit of dilatation, or Avhere  the membranes  are
ruptured.  On the other  hand, its administration  ought to be avoided  as
much as possible in  primiparae, and, if it should become necessary in  them,
the perineum must be supported Avith the greatest care, lest it be exposed
to a considerable rupture should the delivery prove rapid ;  in very irritable
women, Avho may have had convulsions either during gestation, or in their
previous labors, because the ergot often produces a state of nervous excite-
ment in such persons, Avhich occasionally amounts  almost to mania;  in ple-
thoric patients, suffering from congestion about the head, Avhich is charac-
terized  by flushing  and turgescence of the face, by  injection of the eyes,
headache, Ac, etc.:  in  a Avord, in all  those cases Avhere venesection is obvi-
ously indicated; and lastly, in all those Avomen, where the womb, from being 
910
THERAPEUTICS.
endoAved Avith an acute degree of sensibility, is in a state of irritation, and
is habitually the seat of pains, or who, in a former labor, might have been
affected Avith an inflammation of this organ.
  The spurred rye has  likewise  been  employed successfully in the profuse
hemorrhages that  follow abortion,  which  are caused by  the retention  or
tardy separation of the placenta; as also for the floodings that take  place
after the  expulsion of  the  foetus, Avhether  before, during,  or subsequent  to
the delivery of the after-birth.   AAre  have  had occasion, in the article on
Hemorrhage, to refer to and insist on its  use under such  circumstances.
The question noAv  arises, can  the  ergot, Avhich  possesses in so high  a degree
the property of stimulating  the enfeebled  contractions, and of arousing them
Avhen suspended, — can it develop  them Avhere they have  not yet  existed?
If Ave might judge from certain experiments  made for this purpose,  by
Professor  Dubois,  in our  presence, at the Clinique,  in  1837, we should
ansAver this question in the  negative;1  but  it  must be confessed  that  those
trials were not sufficiently numerous to enable us to decide it positively ; and
although this article has seemed to possess the abortive property in some
instances, yet in many others it has  proved Avholly inefficacious.
  Again,  it  has  not been  observed that  abortions are of more  frequent
occurrence in those countries where  the bread of the inhabitants contains a
certain quantity of ergot; but habit,  perhaps,  might explain its  want of
action here.
  This medicine is employed  under  divers forms; and the powder,  the infu-
sion, the decoction, the  aqueous  extract,  or alcoholic extract, ethereal tinc-
ture, or the syrup, may be used, almost indifferently;  although  in France
scarcely any other preparation than the  poAvder, the infusion,  or decoction,
is ever employed.   Thus, it is customary to administer two or three  doses
of the poAvder, consisting of eight or ten  grains each, diffused, at  the time
it is given, in  tAvo  ounces of pure  or  sugared water, or a little Avine and
water, or some slightly aromatic infusion; and these doses are repeated at
intervals of ten minutes.  If the contraction is manifested after the second
close, as most usually happens, the third  need not be given.   Some accou-
cheurs administer  it in a small quantity of Avhite Avine or tincture of canella,
and  other  excitants; and it  has been advised to add a small quantity of
opium to prevent  the  medicine  from being  rejected, though,  Avhere the
patient either vomits or  seems disposed to vomit during the labor, it  is
better to administer it, as  M. Dubois recommends, by injection,  and the
dose might then  be increased a  little.
  The infusion is prepared  by diffusing tAvo scruples of the poAvdered ergot
in a glass  of water  for ten  minutes;  or, if the article is merely bruised,
without being poAvdered, three or four  scruples may be infused in the same

  1 Such also was the opinion, at the time, of the  honorable professor alluded to ; but,
since then, new experiments have somewhat modified his views; for we have  heard
him affirm, at the Academy of  Medicine (in M;irch, 1840), that, in certain  cases, the
ergoted rye might bring on the regular pains; and, in consequence, he classified thia
nudicine among  the measures  calculated to produce a premature  artificial delivery.
But this opinion  does not  appear to us to be based on a sufficient number of facts to
warrant its general adoption. 
EFFECTS  OF  BLEEDING.                   911
quantity of menstruum.  In conclusion, Ave shall not again repeat Avhat Avas
said in the commencement of this article concerning the physical characters
that  distinguish good and  genuine ergot,  but Ave will only add that the
apothecaries ought to be cautioned to ha\7e  the  drug freshly pulverized;
and as, notAvithstanding our earnest recommendations, they will not all take
the proper precautions, the accoucheur Avould do Avell to ahvays carry a few
grains Avith him, so as to have it at hand in case of necessity.
                          CHAPTER  II.

OF THE EFFECT OF BLEEDTNG  AND A DEBILITATING  REGIMEN UPON
                 THE  DEVELOPMENT  OF  THE  CHILD.

   As the foetus, during its intra-uterine existence, necessarily derives from
its mother the means of nutrition, it was natural to suppose that her emacia-
tion, brought about by restricted  diet and frequent evacuations  by blood-
letting or purgation, might have the effect to retard the development of the
child.   This supposition has not, however, ahvays been confirmed hy expe-
rience ;  for  Avomen, exhausted  by disease, or the  severest diet, have been
knoAvn  to have very large  and  robust children,  whilst others  Avho  had
become  stout and strong during  pregnancy, and  who  had  gained thirty
pounds  in Aveight, gave  birth to very medium-sized children (Baudelocque).
   This  observation of Baudelocque's, the truth of Avhich has been many
times proved, has dispelled  the idea of using purgation, bleeding, and diet,
as an obstetric means in cases of contracted pelvis.  AArith the exception of
M. Aloreau,  no  one in  France thought of having recourse to this method,
when M. Depaul published, quite recently, two very interesting observations
tending  to prove its efficiency. Fortunate  results had indeed been men-
tioned by others.  Thus DeAvees, who states that he had often seen mothers
in consumption  give birth to very  robust children, and avIio was not, there-
fore, a priori, favorably inclined towards the method, nevertheless quotes a
letter addressed to him  by Dr. Holcomb, in  which five cases are reported.
Four of these five Avomen had never been able to  have living children, and
one of the four had lost eleA^en.  These five Avere very early subjected to the
daily use of  purgatives, and Avere all delivered of living children.   Dr. Ritter
relates the case of a Avoman Avith a  contracted pelvis, avIio Avas several times
delivered of dead children, Avith great difficulty.   From the fourth  month
of her fourth and fifth pregnancies, she Avas subjected to repeated bleedings,
to the use of a slightly purgative mineral Avater, and severe diet,  composed
chiefly of a  small quantity of vegetables, milk, bread, and fruits,  Avithout
meat, eggs, or dried vegetables.  The  children, which were much  smaller
than usual,  Avere  extracted  quite  easily, but were still-born.   One, Avhich
presented by the feet, died Avhilst the head was retained by the contraction,
and Avas expelled spontaneously.  The other presented the arm, and had to
be turned; it Avas necessary to extract the head by the forceps.
  These cases, though certainly encouraging, are not sufficiently numerous
to establish the  value of this method. 
912
THERAPEUTICS.
  Admitting, for an instant, that a severe regimen, assisted by bleeding and
repeated purgation, Avould ahvays  have the effect upon the development of
the child, Avhich it appears to have had in the preceding observations, should
this method be preferred to the induction of  premature labor?
  The latter operation, though  almost  always  innocent as  regards the
mother, is frequently fatal to the  child: thus, of 225 cases mentioned by M.
Lacour, 37 of the children perished.   According to M. Stoltz, but half of
the children are saved; and  judging by my OAvn cases, and those which I
have witnessed, the mortality of the children is even greater.
  Unfortunately, we have not yet  enough cases in Avhich  the regimen has
been employed, to establish a comparison.   HoAvever, out of the  ten  cases
mentioned, Ave   have only tAvo  dead children,  and  this may  be partly
accounted for by the mode of presentation.   Therefore, this method appears
to afford greater chances to the children.
  It is greatly to be feared that  the  same cannot  be  said as  respects the
mothers.  It is, indeed, very difficult to suppose  that a pregnant woman,
who often has much greater appetite during than before her pregnancy, can
be deprived for five or six months of three-fourths of her usual alloAvance,
with impunity,  besides being subjected to more or less frequent bleeding or
purgation.   Is  it not to be feared  lest debility, and  the alteration of the
solids  and fluids  resulting  from such  a course, so long continued, should
predispose strongly to post-puerperal  disorders, and even have an unfavor-
able effect upon her future health ?  I  am well  aware that  nothing of the
kind is mentioned in the cases referred to; but these are yet very feAV, and
on that account no rule for the future.
  In giving preference to any  method, we should also take into account the
suffering to Avhich  it subjects  the patient.  That occasioned  by the induc-
tion of premature labor is almost  nothing, and lasts but a short time.   That
such is not the case as regards the prolonged  diet, even its partisans admit.
In speaking of  his first  patient, M. Depaul says, we may conceive what she
had to suffer, especially at the outset.   For the first two  months, he  says,
alluding to the  second, she suffered  much from epigastric pains, and a feel-
ing of  extreme hunger ; her strength gave Avay, so as to make her unable to
walk any considerable distance, or use any violent exercise.
  All  these sufferings would be readily endured, and, as M. Depaul remarks,
the woman would derive, from the ardent desire of maternity  Avhich controls
her, strength sufficient to brave everything,  could we only assure her as to
the result.   But as most authors  have regarded  this method as very uncer-
tain, as a large number of Avell-observed facts, though under other circum-
stances, tend to excite doubts as  to its efficiency, and  especially as, besides
it, there is an operation which in no  degree endangers the life and health
of the  mother, and saves the life of the  children  in nearly half of the cases,
I acknoAvledge that, had I to decide for my Avife or sister, I Avould prefer the
latter.
  Again,  to  Avhat cases of contracted pelvis is this  method  particularly
adapted ?   I have no doubt, says  M. Depaul, that it Avould be entirely suc-
cessful Avhenever the diameters Avere shortened to the extent of an inch and
a quarter; but I  would  not  venture to  affirm it, if the antero-posterior 
EFFECTS  OF  BLEEDING.
913
diameter was only from tAvo and three-quarters to three and a marter inches
in length.
  It is, therefore, to such pelves as present diameters of at least from three
and a quarter to three and a half inches in length, that M. Depaul restricts
the use of the debilitating regimen.  But, Avhen placed on this ground, the
question  changes its aspect, and  the results of the method are no longer
comparable  to  those  of premature delivery;  for the latter  operation  is
never practised  but for contractions of  a far  more aggravated character.
Accoucheurs are unanimous  in  considering the spontaneous delivery or
extraction of a child as possible Avhen  the sacro-pubic diameter  is at least
three and a half inches in length.   We have even seen that beloAV this limit
the expulsion of a living child is often possible; premature artificial delivery
ought, therefore, to be preferred.
  But if, alarmed  by the recollection of antecedent deliveries of the same
Avoman, you fear lest the child should have a large head  like  its predeces-
sors, and conclude to interpose, do not subject a poor mother to the martyr-
dom of the prolonged regimen.  Should the pelvis present three and a half,
four, or four and a quarter inches, you might defer much longer the period
at which premature delivery is effected; and instead of bringing on pains at
seven months,  or seven months and a half of gestation, you might Avait for
eight months, or even eight months and  one or tAvo weeks.  The operation
would then very probably afford a living child ; for it is likely to  support an
independent existence in proportion as its intra-uterine life has been pro-
longed.
   The mortality of the children, Avhich has been justly objected to the induc-
tion of  premature labor, diminishes  greatly as Ave approach  the  term of
gestation.  By this operation, you  spare the mother the long sufferings of
the regimen, and probably afford equal security to the child.
   BeloAV from two and three-quarters to three and a quarter inches, there is
nothing Avhich shoAvs any advantage in the plan of dieting, &c, over the
induction of premature labor.  But Avould  the latter operation afford more
favorable results if the mother Avere subjected to a severe regimen for a long
time  before practising  it ?  It is enough  to remember  that  the extreme
weakness of children born before term is the usual cause of their death, in
order to set aside a method the effect of Avhich is to weaken them still further.
I think, therefore, that in the present state of  our science, neAV facts are
required before adopting the dietetic regimen and bleedings.  HoAvever, in
order to enable the practitioner to judge  this question for himself, I think it
proper briefly to state the rules laid doAvn by M. Depaul for  carrying out
the plan.
  1. The greater the obstacle the more necessary is it to diminish the amount
of food,  and to bleed more frequently.  Thus, Avhen the pelvis  is contracted
by from three-quarters of an inch to an inch and a quarter, the method should
be put in full force.   (M. Depaul's first patient  had  her food regulated as
folloAvs :  Soups formed its basis ;  vegetables once a day ; meat once a week,
and in very small quantity; half a pound of bread daily, including that in
the soups.  The  first bleeding at three months, a second  at  six, a third at
eigh'., and the last one  at etg\t and a  half months.   Fourteen ounces of
      58 
911
THERAPEUTICS.
blood to be taken at each time.)  2. It should be commenced tOAva d  the
third or fourth month.  3. It Avould be Avell to diminish the amount of food
progressively.  4.  She should abstain from dark and very nutritious meats.
5.  The bleeding must be regulated by the constitution  and state of the  cir-
culation ;  it Avill be more  useful  in proportion  as practised in the latter
months.                               ,
  It is hardly necessary to add, that if the obstacle were  less considerable,
it Avould be proper to act Avith  less vigor, to begin the  treatment later, and
to  increase the amount of food in proportion to the object  to be attained.
  For the same purpose, M. Delfraysse, of Cahors, recommends the admin-
istration of iodine during the last tAvo months of gestation.  Besides experi-
ments made upon animals, the results of Avhich seem favorable to his proposi-
tion, he mentions the cases of tAvo Avomen.  One  of them,  Avhose pelvis Avas
rather less than three and a quarter inches in extent, had been  delivered
three times,  and very painfully, of dead children.   In the two subsequent
pregnancies, and  during the last tAvo months, she took, every morning, six,
and aftenvards eight drops, of the following mixture:—
         Iodine, pure,    .      .      .      .      .     .15 grs.
         Iodide of potassium, .      . #          .     .     30 grs.
         Distilled water,  ......  f^j.
  She was delivered spontaneously of living children, one of them weighing
twenty-two ounces and the other twenty-three less than their predecessors.
  Experience can  only decide the merits of this new method, which does
not appear to have  been injurious  to the mothers. 
PART  VII.
               OBSTETRICAL  OPERATIONS.

   THE indications arising from the various causes of dystocia just studied
    have been carefully pointed out, and each one, as seen, requires a differ-
ent operation.   This  seventh  part of the work is devoted to the operative
procedures.  The first chapter treats of the use of chloroform, which is an
invaluable adjuvant in most obstetrical operations.  In the second chapter
is described the  mode  of applying  the tampon,  Avhich, on  the ground of
utility, may be regarded as an important  operation.  Finally, Ave have  to
treat in the remaining chapters of the manipulations and operations, properly
so called.
                          CHAPTER  I.
     ON THE USE OF ANESTHETICS  IN OBSTETRICAL PRACTICE.
   In vieAV of the wonderful results obtained by the use of ether in surgical
 practice, it Avas altogether natural to inquire whether so efficient a means of
 avoiding the pain of  operations, might not  be employed  Avith advantage
 against the physiological pain Avhich accompanies labor in the human species.
 But before speculating upon the probable advantages to be derived from its
 use in this Avay, prudence  suggested  the endeavor to foresee the disadvan-
 tages also.   Might not  the torpid condition of the voluntary muscles pro-
 duced by etherization, extend to the muscles of organic  life, and might not
 that action of the Avomb which is indispensable to a prosperous  termination
 of labor, be paralyzed  thereby?   Supposing, even, that the  uterus should
 preserve  its contractile poAvers in the midst of the general paralysis, Avould
 not the want of that assistance which it receives  from the voluntary con-
 tractions of the abdominal muscles, and of that synergic action Avhich is so
 useful in the termination of labor, render  the  expulsion of the foetus very
 difficult,  or even impossible?   Might not the health and even the life of the
 child be endangered by the vapor  inhaled ?   And might not the  latter,
 which has occasioned some serious accidents in surgical practice, prove an
 addition  to the dangers Avhich threaten the female  during  labor and the
 lying-in ?  The previous solution of all these questions is of the highest im-
 portance, and Ave  may readily understand the effect they must have had in
 inspiring Avith prudence those Avho  were  the first to  employ  anaesthetics
 against the pains of childbirth.  Some of these questions are  capable of
elucidation byr the application of certain pathological facts; others could bo
solved only by experiment, and this experiment had yet to be performed.
                                                            915 
916
OBSTETRICAL OPERATIONS
  Professor Simpson, of the University of Edinburgh, was the first to ven-
ture upon the administration of ether in labor.  The opportunity presented
on  the  19th  of January, 1847.  The Avoman had a deformed  pelvis, and
having decided to turn, he thought the occasion a favorable one for  deter-
mining  the influence of inhalation  of ether  upon the contractions of the
uterus;  for, supposing the contractility of the organ to be paralyzed by the
anaesthesia, the introduction of the  hand and  evolution of the foetus Avould
only be facilitated thereby.  The result Avas  so satisfactory as to convince
Dr. Simpson that, notAvithstanding the complete abolition of sensibility, the
action of  the Avomb might continue intact.  Encouraged  by the  first trial,
he repeated the experiment in several cases of natural and of difficult  labor,
and on the 10th of February communicated the results to the  Obstetrical
Society of Edinburgh.
 . Almost immediately after  becoming acquainted Avith his observations,
several  English accoucheurs,  Murphy  (of London), Protheroe Smith, and
LandsdoAvn, administered ether Avith a like success.  Fournier  Deschamps
was the first to use it in France, and that only eight days subsequent to the
publication of Dr. Simpson's first observation.   In the month of February,
in the same year, Professor P. Dubois laid before the Academy of Medicine
the result of its administration in six cases of labor under his OAvn notice.
In  March, it was used by Stoltz, at  Strasbourg, and by  Delmas, at  Mont-
pellier.   In August, I made, in connection Avith Mr. Smith, some experi-
ments at the Clinique d'Accouchements, then under my charge, but the first
trials did not seem to me encouraging.  Still  later, MM. Chailly, Colrat,
Villeneuve, Roux, Male,  and several  others,  published their observations.
In  Germany, Professor Martin (of Jena), and  afterwards, Professors Siebold
and Grenser (of Leipzig), used ether in several cases of natural and of diffi-
cult labor.  Lastly, in America, Drs. Channing, Clark, Putnam, and others.
were the first to make knoAvn the results of their experiments.
   In November, 1847, the substitution of chloroform for ether, as  proposed
by Dr. Simpson, gave a fresh impulse to the use of anaesthetics in obstetrics.
The rapid action of the new preparation  and its easy administration, Avere,
perhaps, the occasion of a too ready forgetfulness of the dangers to Avhich it
might give rise, and Avere certainly the  cause of  its enthusiastic reception by
at least a large number of English accoucheurs.   At present, notwithstand-
ing some opposition, chloroform is employed almost exclusively in obstetrical
as well  as in surgical practice.
   Amongst the questions  Avhich would  naturally present  themselves  to the
mind of whoever  first entertained  the idea of  using anaesthetics in  labor,
there are  some, Avhich, as Ave have said, receive a degree of light from known
physiological and pathological  facts.  Of such are those having reference  to
the probable continuance of the uterine  contractions, notAvithstanding the
complete torpor of the voluntary muscles, and to the more or less important
assistance received from the abdominal muscles  in labor.
   Numerous facts at present authorize the belief that the momentary paralysis
of sensation and voluntary motion does not sensibly interfere Avith the  action
of the Avomb.
   Dr Simpson was acquainted with those cases of complete paraplegia,  in 
USE  OF  ANAESTHETICS.
917
which delivery had been effected Avith its normal regularity and aim ^t Avith-
out pain; nor Avas he ignorant of  the many instances in which won en have
given birth to children during the deep stupor of drunkenness ; he had often
seen labor terminated in patients affected Avith eclampsia, during the period
of coma attending or following the convulsive paroxysms, Avithout their
being in  the  slightest degree  conscious of Avhat  had  occurred, as also the
astonishment at their delivery manifested on the return of their senses.  Nor
are examples rare of the delivery of women, during a lethargy so  profound
as to be mistaken for death.   It is distinctly proved by all these facts, that,
notwithstanding the momentary or permanent extinction of volition, sensa-
tion, and  voluntary motion, the organic ^contractility may not only  continue,
but  be  equal  to the expulsion  of the foetus.   Hence it was quite  probable
that the condition produced by the inhalation, resembling as it does in many
respects the sleep of drunkenness  or the coma of eclampsia, might, like the
latter, have its influence restricted to sensation and to the muscles of animal
life.
   It Avas  to be  feared lest the anterior muscles of the abdomen should  be
paralyzed like those of the extremities, and that their inaction might some-
what retard the expulsive stage.   But the happy delivery of paraplegic
women, and of such as, notAvithstanding a complete prolapsus, of the uterus,
have, unaided, been delivered of the product of conception, naturally pre-
senting themselves to the mind, alloAved of no hesitation on the score of even
a probable paralysis of the abdominal muscles.  Besides, in the case in Avhich
Dr.  Simpson employed anaesthetics for the first time, version Avas to be per-
formed, and he  Avould be  able  to supply by tractions any deficiency of the
expulsive poAvers.
   More fortunate than Dr. Simpson, Avho at the time of his first experiments
had only the  rational inductions  afforded by  physiology and pathological
anatomy to support him, AA'e are iioav able to appeal to  experience.   Let us,
then, Avith the assistance of the  numerous facts  now on record, endeavor to
elucidate  the  various  questions connected  Avith the use  of anaesthetics in
obstetric practice.
   1. Of the Effects of Anozsthetics on  the Uterine  Contractions.—On this
point, as  on many others, accoucheurs entertain various opinions.  Some
regard neither chloroform nor ether as  possessing any power to suspend the
uterine action  ; others think that  the contractions are ahvays retarded, and
quite frequently even stopped  entirely.  Amidst these contradictory asser-
tions and facts, it  is, hoAA'ever,  possible to  discover the  truth.  A careful
reading of all the observations will sIioav that, with the exception of Paul
Dubois, almost all authors are  unanimous in the recognition of important
changes imjiressed by the inhalation upon the contractions.   These modifi-
cations are,  besides, very A'arious:  thus, whilst M. Stoltz  believed that he
had observed an increase in frequency and intensity, and Mr. Murphy, Avhilst
turning, declared that he had never before found the operation so  difficult,
although the patient avus under  the full influence of  the agent,  AA'e find MM.
Bovier, Siebold,  Montgomery, &c, asserting that it retards and sometimes
{■veil completely  suspends the labor.   Dr. Denham  also affirms, that  in  six
cases in which chloroform had been administered before turning, the  Dpera- 
913                  OBSTETRICAL  OPERATIONS.
tion Avas rendered easier, and that its happy effect was especially evident in one
case, where the introduction of the hand having been fruitlessly attempted
before inhalation, it was effected very easily after it.  AAre shall endeavor to
account for this dissidence hereafter.
  Whatever the exact truth may be, in an unprejudiced mind  no doubt can
exist of its being proved  by numerous facts, that Avhen chloroform is taken
so moderately as  to blunt and almost extinguish sensibility without entirely
depriving the  patient of the poAver of motion or of self-consciousness, it has,
ordinarily, no influence over the contractile power of the uterus;  but  that
Avhen carried  to  complete anaesthesia, the contractions  may be diminished
both in frequency and intensity to the point of complete extinction.  The
latter fact is acknowledged by Dr. Simpson himself, and he  regards it as of
possible occurrence in some .cases of moderate anaesthesia.   The degree of
the latter, he remarks, Avhich some patients  are able  to bear without the
womb being affected,  is exceedingly variable.   Some are throAvn into a pro-
found slumber without interference Avith the uterine action.   Others, on the
contrary,  experience  interruption of the  contractions  by a much slighter
degree of anaesthesia.  These individual  predispositions explain Mr. Mont-
gomery's  observations of the manifest diminution  of  the uterine contrac-
tions under the sedative influence of chloroform Avithout  the Avoman being
insensible to  pain.   Besides,  according to the majority of  English  practi-
tioners, the retardation or the suspension of labor  is the  indication  for the
particidar case, that  the  dose of the agent Avhich the patient might  have
supported Avithout  inconvenience has been exceeded, and the best  means,
according to Dr.  Simpson, of restoring energy to the uterus, is to cease the
inhalations for some moments and then resume them in more moderate pro-
portions, as soon as the  patient shall evince sensibility.   It is stated by the
Edinburgh accoucheur, that'the return of the contractions on withholding the
chloroform is delayed but a feAV minutes only ; such, also, is the vieAV of Den
ham, Murphy, and others.   Mr. Montgomery, hoAvever, has less confidence in
this prompt return  of the contractions.  In a very recent case  he Avitnessed
an interruption of the labor by so feeble a dose of the chloroform, that the
patient Avas all the while expressing with volubility the delicious sensations
she experienced; and notAvithstanding the suspension  of  inhalation, the
uterus remained  inert for some hours before resuming its original activity.
I have seen, says the Dublin professor, several similar cases.
  1. To recapitulate: In  the  majority of instances, the contractions  are un-
affected by the inhalation of chloroform.  2. AVhen the. anaesthesia is pushed
too far, the labor is  often  suspended.   3. In-certain individuals, the  same
result may be produced by moderate doses of the agent, and that before the
loss of sensibility and consciousness.
  This  difference in  the results, setting aside certain altogether exceptional
and as yet inexplicable  idiosyncrasies, is  manifestly due  to the extent and
duration of the etherization.  The various facts, says M. Bouisson, Avhich have
served  as a  basis to so many different opinions, are but the simple expres-
sion of  greater or less degrees of anaesthesia, and the phenomena presented
by the uterus in  regard  to  sensibility and contractility, are themselves in-
cluded  in the general laws of anesthesia.  We are, in fat t, perfectly Avell 
USE  OF  ANAESTHETICS.                    919
  iiAvare, that the participation of the organic movements  In  the  depression
  which the inhalations produce in all the powers of the economy, is to be
  reckoned amongst the ultimate phenomena of etherization.
    2. Influence of Anozsthetics upon the Contraction of the Abdominal Musclet.
  It is well knoAvn that in the last stage of labor the Avomb seems to call to
  its aid the action of the voluntary muscles, and that the efforts of the female
  assist in overcoming the obstacles to the passage of the foetus.   It Avould
  appear as though, being dependent upon the animal life, the action of those
  muscles Avhich accomplish the effort Avould  be destroyed by the ether or
  chloroform, as is that of the muscles of the extremities.   Noav, according to
  the majority of accoucheurs, such  is not usually the case, but that unless the
  anaesthesia be carried farther than  prudence would dictate, the auxiliary
  poAver of the abdominal muscles is not Avanting to the uterine  contraction.
  My friend  M. Longet thus attempts  to  explain this singular phenomena.
  He first calls attention to the fact, that in the  midst of the complete collapse,
  the respiratory movements are still  accomplished.   Noav the effort in  gen-
  eral, and that  yvhich accompanies labor in particular, are but a modification,
  a transitory change in  the respiratory act; it is a state requiring an ener-
  getic  contraction of the muscles  of  the  chest,  diaphragm, and  abdominal
  parietes.   Since  in etherization  the respiration is maintained  in  all its
  integrity, volition being  absent,  and the medulla  oblongata continues to
  excite all  the  muscles  that concur  in its accomplishment, the effort Avhich
  is the result of the action of these muscles, those of  the abdomen included,
  should also continue to be produced.  I Avould  also willingly add, Avith M.
  Bouisson, that since it  is at the present day demonstrated that the reflex
  or excito-motor poAver  of the  spinal  marroAV, Avhich produces movements
  Avithout the participation of  the Avill, is not  abolished by etherization
  except Avhen carried to  an extreme degree, the part Avhich is played  by the
  abdominal muscles in parturition may properly be regarded as reflex in its
  nature.  Their manifest relation with the viscera of the loAver part of the
  abdomen leads, naturally, to the supposition that the excitement emanating
  from  the uterus during the act, is directly reflected by the spinal marrow
  upon the muscular planes of the abdomen.  A\That tends to prove it is  the
  fact that the abdominal muscles  may refuse  the contingent of force Avhich
  they contribute to this act, provided the etherization be carried so far as to
  abolish the reflex power, Avhilst they continue to act,  though more feebly, it
  is true, as muscles of respiration (Bouisson).  I Avas, on one occasion, enabled
  to verify the correctness of this observation of the Montpellier professor.
    3. Influence of Anozsthetics on the Resistance of the Perineum. — One of
  the advantages usually  attributed to  the use of  ether or chloroform is such
h  a diminished resistance  of the perineum as to  facilitate the expulsion of  the
  foetus, and to prevent almost certainly the ruptures Avhich  it so often  suffers
  in labor.  AVere I to rely only upon my personal experience, I should find
  it difficult to arrive at a definite conclusion, particularly as I have Avitnessed
  very different  results.   Thus, like Messrs. Dubois,  Chailly,  and others, I
  liave sometimes knoAvn  the perineum yield and  distend Avith great facility.
  though more commonly,  even Avhen the anaesthesia Avas complete, it remained
  as resistant  as ever, and even, as in the case  reported by M. Villeneuve 
920
OBSTETRICAL  OPERATIONS.
(of Marseilles), in three instances, to be  ruptured very badly.1  On a still
more recent occasion, M. Danyau and myself Avere obliged to incise each
side of the vulvar orifice very deeply, the patient being completely under
the  influence of chloroform.  I  am  unable to say  why  these differences
should exist, because the anaesthesia was perfect in all the cases just men-
tioned ; so that different degrees of this condition cannot  be alleged in  ex-
planation.   Perhaps it Avill be Avell to remember  how  very variable is  the
resistance offered  by the perineum in different individuals, and hoAv very
difficult it is to foresee Avhat Avill occur in any particular case.  Every day's
practice sIioavs how liable our predictions are to be falsified by the event.
  Again, supposing that under  the influence  of  the pressure Avhich these
muscles have to sustain, the reflex action of the spinal marrow is unable to
produce their contraction in the efforts, involuntary though they be; sup-
posing, we repeat, that  they are paralyzed in the etherized female, it is not
to be credited that the entire resistance of the  perineum is on that account
ever suspended.   The fact is, that the resistance is ordinarily due  quite as
much to the aponeurotic planes of the pelvic  floor, and  to the sometimes
very large amount of fatty tissue situated between the different layers, as to
the muscular fibres themselves.   In those Avho  have borne children, and in
Avhom the perineum presents but slight resistance, the muscles of this region
are at least quite as fully developed and as strong as in primiparous females.
To what, then, can be due the facility Avith Avhich the foetus is expelled, if
not to the greater elasticity of the aponeurotic planes, which, having suf-
fered distention in previous labors, have their suppleness increased thereby?
Since the chloroform can have no effect upon them, it is no cause for aston-
ishment that after its administration the resistance of the  perineum should
continue.
  Hence we may conclude  that:  1. AVhen  properly administered and in
moderate doses, anaesthetic agents do  not  interfere Avith the regular course
of the uterine contractions; and  that whenever their administration is fol-
lowed by the cessation  or Aveakening of the efforts, the  effect ought not to
be attributed to the agent, but to the  abuse which has been made of it.- 2.
That it is  not  yet sufficiently shown that during the anaesthetic slumber,
the abdominal muscles  continue to aid, by their contraction, the expulsive
efforts of  the womb. 3.  That fresh  observations  are  necessary  to  settle
definitely the influence of chloroform upon the  resistance of the perineum.
  Before determining what cases indicate or confraindicate the use of chlo-
roform, it remains for  us to state Avhat is proved by experience regarding
the influence of  chloroform upon the health of  both mother and child.
  1. Effect  upon the  mother's  health. — Accoucheurs who  have often used
chloroform,  are  almost  unanimous in  the  declaration that it has never had
the least mischievous effect  upon the  mother's  health, Avhilst in all cases it

  1 Rupture of the perineum does not prove, however,  that the  resistance may not
have been lessened by the use of chloroform.   In two cases, indeed, it seemed to me
that the great rapidity with which the distention and thinning took .place  facilitated
the  rupture.  This  stretching, resembling precisely what a piece of India  rubber
would undei go, was effected so quickly by  the very strong pains, that there occurred,
first, a sort  f fraying, followed by extensive rapture of  the perineum.
||Mfe 
USE  OF  ANAESTHETICS.
921
has spared them the sufferings of the  last expulsive pains.  None of my
patients, srys Dr. Simpson,  have  been conscious  of them;  and  several,
through their confidence  in  etherization, have been spared the fears which
they usually suffered toward the end  of  their preceding pregnancies,  in
anticipation of the coming labor.  By exempting Avomen from the terminal
sufferings, the anaesthesia  husbands their strength, and avoids the  nervous
exhaustion Avhich folloAvs a painful labor.  Some, Avho Avere already mothers,
declared in grateful terms their condition to be incomparably better than
after their previous  labors.  Their recovery, continues the same author, is
more  rapid, and  consecutive inflammations are much rarer or less serious
than usual.
  I am not yet convinced, so far at least as regards natural labor, that this
last proposition is fairly demonstrated ;  and nothing in the facts yet knoAvn,
those  even of Dr. Simpson included, appear to me of a  cjjaracty to prove
its exactness.  In natural labor the fatigue is  moderate, ancTme  remem-
brance of it soon abolished  by the happiness of maternity.  The  lying-in
demands  always  the same precautions, Avhether chloroform be used or not,
and the time of getting  up is nearly ahvays  the same.  Finally,  in  an
epidemic of puerperal fever at Edinburgh, the Avomen who had used inhala-
tions Avere not more exempt from the disease than those who had not.
  I Avould even add, that  in tedious labors the gravity of cohsecutive acci-
dents  has not been sensibly diminished by the use of  chloroform.   Its only
incontestable effect is to abolish pain, and prevent the considerable  nervous
disturbance sometimes  consequent thereto.  This  result is,  doubtless,  of
importance, but,  except in some very exceptional cases, the pain is not fatal
of itself, and the nervous  shock is generally avoided.  Metritis, deep-seated
suppurations, inflammations,  and  gangrenous eschars of  the soft parts  of
the pelvis, are consequences of the violent uterine  efforts.  Noav, as Mont-
gomery has  shoAvn,  the only effect of chloroform  is to  remove the pain>
leaving intact all the other consequences of difficult labors.
  Another incontestable . advantage of  chloroform is that of facilitating
certain  obstetrical operations.   The uncontrollable and  disordered  move-
ments of the agonized female  hinder the  operator  greatly; but the sleep
which  she enjoys during  the inhalation, and the complete insensibility  of
till the organs, enable her quietly to bear the most painful operations.
  The annihilation of pain in all cases, the prevention of the nervous shock
which is sometimes the consequence of too painful or  too prolonged  a labor,
and the facilitation of obstetrical manoeuvres, are, therefore, the only indis-
putable advantages to be derived from the use of chloroform.
  Are not these advantages counterbalanced  by serious inconveniences?
Such is the opinion of some accoucheurs, though they have, in my  opinion,
exaggerated  both their frequency and  gravity.  AVe are noAV able to esti-
mate its power of suppressing the pains of labor:  prudently administered,
it in no respect alters the regularity and poAver of  the contractions;  but is
it altogether  the  same as  regards  the  contractility of the tissue, and may
not the retraction of the  Avomb after  labor be in some degree modified by
the previous use of anaesthetics?  I confess the Avant of an entire assurance
upon this point and  am  inclined to believe that they  have not,  in some 
922
OBSTETRICAL  OPERATIONS.
cases  at  least, been altogether without influence in the production of sub-
sequent inertia  and hemorrhage.  Tavo  cases of slight hemorrhage  are
quoted by Duncan, one of which, it is true, occurring in a twin labor Avith
extreme distention of the uterus, is thereby sufficiently accounted  for;  but
the other took place six hours after delivery, without any appreciable cause.
Dr. Channing has  met with  4 cases  of hemorrhage in  78 of anaesthesia.
In one case it was internal, and happened one hour after delivery; in an-
other, the Avoman half fainted immediately upon the termination  of labor
and he found the uterus much enlarged and filled with  clots, upon the re-
moval of Avhich, the organ  contracted, and there Avas no further loss.   In a
third  case, a serious hemorrhage occurred  immediately after delivery.   The
fourth observation  is less conclusive, on account of the patient having ex-
perienced losses after previous labors, and because the delivery of the pla-
centa  Avasjmade difficult by  adhesion.  Dr. Montgomery  declares, as his
personal  experience, that when the influence of the chloroform is kept up
until  the  labor is ended, the  patient is more or less exposed to hemorrhage
from inertia and to retention of  the  placenta.   The experience of several
9f my brother practitioners, he adds,  has been similar  to my own.
   I am Avell aware that in all  these instances the  hemorrhage may have
been  due to various circumstances,  and  there is  nothing  to show  that
chloroform Avas necessarily the cause; still, it is well to  be aware of them,
were  it only to excite  prudence  in the use of  the  agent; for, since by too
large  a dose the exercise of the organic contractility  has  sometimes  been
suspended, Avhy may not  the same dose diminish the contractility of the
tissue ?  In practice, these  facts ought  not to be lost  sight of, and I think
that, immediately  after delivery, it Avould be  prudent to administer some
ergot.
   In  certain surgical  operations, death has resulted immediately from the
administration of chloroform.  Is not the supposition both probable  and
reasonable, says Dr. Montgomery^, that a  similar misfortune might happen
to a Avoman in labor?  Doubtless it  is possible;  but happily, although a
great  number of Avomen have used inhalation,  not a case can be mentioned
in Avhich sudden death can be reasonably attributed thereto; for  I cannot
accept as such the  following related by Gream.  A young woman had just
been  delivered of  one  child,  and chloroform was  administered before the
expulsion of the second; death ensued in  half an hour.   No further detail
•is given.   In two other cases  mentioned by the  same author,  death occurred
at a still later period after  delivery.   The patients whom the surgeons have
had the  misfortune to lose, did  not die in this manner; for, in.their cases,
it was during the  administration of  the agent that life became extinct;  it
is, therefore, because in the observations of Gream a longer or shorter time
had elapsed between the cessation of inhalation and death, that I cannot
regard the chloroform as chargeable Avith the fatal result.
   AVith  still  less  reason  has it been reproached  Avith  the production of
eclampsia, by increasing  the cerebral  congestion,  Avhich  the exertions of
labor have of themselves a tendency to produce.  For, although AVood has
quoted a case of convulsions occurring in an etherized  woman in the last
stage of  labor  we are noAV in possession of enough  facts to prove that the 
USE  OF  ANAESTHETICS.
923
administration of chloroform during convulsive attacks, lessens  their fre-
quency, and sometimes puts an end to them altogether.
   Inhalation has also been accused of the production of insanity;  of Avhich,
says Channing, there is not a single Avell-established  case.   In reference  to
this point, he cites the folloAving observation by one of his countrymen.  An
insane woman  had in a preceding labor suffered from extreme  agitation,
Avhich Avas the  occasion of serious difficulty.   In her last  labor, ether Avas
administered,  thanks  to  Avhich,  the patient  was  perfectly quiet, and all
passed over admirably.
   2. Effect of Chloroform upon the Life and Health of the Fcetus.— AVhatever
difference of opinion may still remain respecting the influence of chloroform
upon the health of the mother, no one doubts its entire innocence as regards
the fcetus.   In the immense majority of cases, the  new-born child presents
its usual appearance ;  its cries are neither Aveaker, nor heard less  promptly,
nor does  its viability  appear to be in  any Avay injured.   Thus  have the
gloomy previsions of certain physiologists been falsified by experience.  The
conclusions Avhich M.  Amussat thought himself entitled to draw from his
experiments Avere contradicted by the ulterior researches of M. Renault.
   Indications.— In Avhat cases is  the accoucheur justified in the employment
of chloroform?  This  question is variously ansAvered  in different  countries.
Dr. Simpson, and Avith him quite a large number of his countrymen, recom-
mend it unhesitatingly in all labors, Avhether natural or difficult. In France,
on the contrary, it is confined almost exclusively to cases of difficult partu-
rition.  AVe adopt unhesitatingly the latter position, and  a few words will
suffice to explain the motives of  our preference.
   AVhilst regarding the use of chloroform as devoid of danger in the ma-
jority of cases, Ave cannot entirely forget the misfortunes of certain surgeons,
who had, nevertheless, taken the best precautions to avoid  them.  Noav,
though it be alloAvable to subject a patient to  some danger, in order to spare
him the intense suffering of an amputation or any other bloody  operation,
are we sufficiently authorized to do so Avhen the regular accomplishment of
a function is concerned ?  And, after all, is the suffering of child-birth,  in
simple cases, so grave and terrible?  Do Ave not see Avomen delivered almost
Avithout pain ?   To speak only of Avhat is  most common, do they not often
preserve their calmness and  gayety to the end of the labor ?  Do they not
often complain of the  repose  afforded  by  the  intervals between  the pains,
and ardently desire their return, in the conviction that each is a step toward
delivery?  Why, therefore, Avith  the simple object  of sparing them some
suffering, Avhich, after  all, they endure  courageously, deprive  them of the
caresses of the  husband, the  condolence of their relatives, and deaden the
imagination, already teeming Avith the joys of  maternity ?   AVhy, especially,
should thev be deprived of the ineffable happiness of hearing the first cry
of the neAV-born child ?  Instead  of the  pleasant chatting  in which Avomen
so often indulge, instead of those maternal aspirations and dreams of the
future Avhich soothe the young mother,  Avhat do we observe after  the anaes-
thetic  inhalations?  A deep  sleep,  resembling more  or less the coma of
inebriation, or concussion of the brain,  a complete annihilation of the  sen-
sorial and intellectual faculties, is the lot of the mother; an always increasing 
924
OBSTETRICAL  OPERATIONS.
solicitude that of her attendants.   Finally, we may add, that, supposing the
physician to be devoid of all fear, he is obliged to remain constantly by the
side of his patient to administer the  agent  personally, and to Avatch atten-
tively the state of  the pulse, of the breathing, and of the heart.
  As a justification of the use of anaesthetics in ordinary labors, it has been
said that they favor the dilatation of the mouth of the womb, and by lessen-
ing the resistance of the perineum  also shorten the period of expulsion.
We have already seen that the diminution of the resistance of the perineum
is  not  sufficiently proved;  and the  same may be said,  I believe, of the
rapidity Avith Avhich the dilatation of the orifice is effected.   HoAvever it may
be, upon consulting the published observations, it  is not discoverable that,
in the cases  in Avhich chloroform has  been employed, the duration of the
labors, as compared Avith preceding ones, has been sensibly shortened.
  Besides, the duration of a labor becomes  dangerous for either mother or
child only as it exceeds the natural limits, and of the  latter case only are we
Bpeaking at present.
  The case is different when some unfortunate complication disturbs or in-
terferes Avith  the course of nature.  It will have  been seen, on reading this
work, that we very often have spoken in favor of the use of chloroform, and
we shall noAV proceed to recapitulate the different cases in which we feel justi-
fied in recommending it.
  It may be especially useful: 1. In calming the extreme agitation  and
mental  excitement which  labor  often  produces in  very nervous women.
2. In those cases in which labor appears to be suspended  or much retarded
by the pain occasioned by previous disease, or such as  may supervene during
labor (vomiting, cramps, colic, compression of the sciatic  nerve).   Dr.
Montgomery, Avho certainly is no enthusiast, states that  he had witnessed a
case, in  Avhich he certainly  Avould  have used  chloroform had he  been
acquainted Avith it at the time: the sphincter ani muscle was affected with
so violent a  spasmodic pain  as  almost to deprive the patient of reason.
3. It seems to us particularly indicated by  those irregular or partial con-
tractions, Avhich, notAvithstanding the intense and almost constant pain Avhich
they occasion, have no effect to advance the labor.  AAre  might even think,
Avith M. Bele, that chloroform, Avhich must be exhibited in very large doses
to suspend the normal and rhythmical contractions of the uterus, would act
much more promptly in stopping the irregular contractions.  4. Spasmodic
contraction and rigidity of the cervix uteri have sometimes been favorably
affected  by  inhalation.  As this part  of the uterus  receives some  spinal
nerves, it becomes, to a certain extent, a portion of the muscular apparatus
of animal life.   Facts are, hoAvever, as yet too few to enable us to determine
the question.
   AVhen the last edition of  this Avork was  published, I Avas not sufficiently
informed in  respect to the usefulness of anaesthetics in  their treatment of
eclampsia.   Besides, having had  no personal experience, the cases I had
read of, those quoted so abundantly by Channing included, still  left me in
doubt as to their utility.  This being the  case, I came to  no definite  con-
clusion,  leaving the question for decision  in the future.  Since then, the
publication  of further observations, as Avell  as my OAvn experience, lead me 
USE OF  ANAESTHETICS
925
 to advise the use of chloroform.   It has seemed to me especially useful Avhen
 the  convulsions  begin during pregnancy, or  at  an early period  of labor,
 Avhen blood-letting, purgation,  revulsives to the skin, &c,  have all  been
 tried and the attacks continue as severe as ever.  The  same remark applies
 to their occurrence only after delivery, or Avhen, having begun during labor,
 they persist after the  child is  born.   Under the  latter circumstances,  how-
 ever, I think  it  important not to stop the  inhalations too  soon  after the
 attacks have ceased.   At  any rate, it Avere  prudent  to  stand prepared to
 recommence them should the convulsions be reneAved.
   Obstetrical  Operations. — Not only does chloroform abolish the great pain
 produced by various obstetrical operations and relieve the patient  from the
 dread Avhich they inspire, but by rendering her motionless, greatly facilitate
 the manoeuvre.  It is, therefore, no despicable auxiliary, provided the nature
 of the services  required of it be  well understood.  Turning, for  example,
 would certainly  be facilitated  by the immobility  and insensibility of the
 patient, but not at all by any fancied suspension of the physiological  con-
 tractions ; only the sensibility and irritability of the organ being destroyed,
 it is not irritated by the presence of the  hand, and the  usual spasmodic con-
 traction does  not occur.  To expect other assistance from the chloroform,
 to propose, for example, overcoming  by its  aid  the difficulties sometimes
 presented by a long and strongly contracted uterus, would be asking of it
 more than it can yield.
   If ever  symphyseotomy  or the  Caesarean  operation be decided upon, I
 should think  the administration of chloroform as  likely  to be useful as in
 any  other great surgical operation.  Finally, the difficulties attendant upon
 the delivery of the placenta from  its abnormal adhesions, and from  irregular
 contraction of the uterus,  sometimes require proceedings Avhich  are very
 painful to the female.   Anaesthetics may here render the  same services as
 in version.  It is, hoAvever,  necessary not to administer them  too freely,  for,
 independently of the dangers of Avhich Ave  have  spoken, it might be feared
 lest by paralyzing the  contractile poAvers of the womb, they should expose
 the patient to  inertia and consecutive hemorrhage.
   Before finishing the  study of the indications for the use of chloroform, we
 add a feAV remarks on  its administration to pregnant Avomen and nurses.
   During  Pregnancy. — Is  the  someAvhat free use of anaesthetics during
 pregnancy capable of  exciting premature contraction  of  the Avomb, or of
 exerting any deleterious influence upon the health or life of the child ?  In
 reference to this question, M. Blot mentions in his thesis three cases, two of
 Avhich came" from M.  Chassaignac : In the first case the woman had, three
 days after  the inhalation, uterine and lumbar pains Avhich yielded readily
 to opiates; the pregnancy, hoAvever, pursuing  its  regular course.   Another
patient, five months advanced, presented  nothing unusual.   The third ob-
servation,  borrowed from Robinson, had reference to a young woman Avho,
in the fifth month of her third pregnancy, breathed chloroform for the relief
of toothache, remaining in a state of demi-stupor for half an hour.  Shortly
after, abdominal  pains cam  on,  Avhich increased, and  in a few days ended
in abortion.  This last case is the only one  to which I attribute some im- 
926
OBSTETRICAL  OPERATIONS.
portance, and if it should recur in other instances, would show the impor-
tance of great caution in the use of inhalations during pregnancy.
   Whilst Nursing. — M. Blot also mentions in his thesis tAvo facts tending
to prove that the chloroform inhaled may pass into the secretions, and  that
occurring in a  nurse, for example, might have a bad effect upon the child
if sufficient time Avere not alloAved to elapse between the period of inhalation
and that of suckling.   A mother put her child to the breast three hours
after  breathing chloroform, and in  a  feAV moments  it fell into a profound
sleep, which  lasted for eight hours.  After the sleep, came on  a state of
excitement which  continued  for tAvo days (Scanzoni).  An analogous  case
is reported by M.  Chassaignac.  It would seem prudent, therefore, to delay
nursing in such cases for seven, eight, or ten hours.
  Mode of Administration. — The plan described by Dr. Simpson is the one
usually followed.  It consists, as is well knoAvn, in placing near the nostrils
and mouth a concave sponge, or a handkerchief folded  into a  cone, after
having poured  into the concavity a drachm or  two of chloroform.   The
handkerchief ought to be held rather above the opening of the nostrils, for
the weight of the  chloroform being  rather greater than  that of the air, it
would otherwise fall,  and not enter the mouth or the  nostrils.  The sponge
should be held  at  some distance from the face, so as to alloAV a free passage
to air, and prevent contact of the fluid Avith the skin and  mucous  mem-
brane.  If this precaution be not taken, little vesicles, and even small super-
ficial  eschars, will be formed.   During  the interval of the inhalations, the
evaporation of  the chloroform  is prevented by closing the hollow of the
handkerchief by the corners or with the hand.
  Dr. Simpson recommends beginning Avith a strong  inhalation,  and at the
outset, to cause  enough to be  breathed to produce  complete  somnolence.
He attributes  the loquacity, delirium, spasms, and  extreme agitation ob-
served in certain subjects, to beginning with too small a dose.   This advice,
which is very proper if ether be employed, is not of  equal value if chloro-
form  be used.   The  latter generally produces much  less excitement, and
throws the patient at  once into a tranquil sleep.  The cough and pulmonary
irritation which they sometimes occasion depend either upon the bad quality
of the agent or the holding of the sponge  too near the nostrils at  the outset,
thus causing too much of the vapor to be respired at  a time.
  AVhen  an  operation to last but  a few minutes is  to be  performed, it is
proper, as in surgical practice, to induce profound slumber, and to  continue
inhalation whilst the  operation is going on.   But if it be intended merely to
moderate the general excitability of the female, to abolish a pain Avhich  is
foreign to the labor, or to modify partial, irregular, or tetanic contractions,
it is necessary,  after quietness is obtained, to remove the  sponge in order to
alloAV of free respiration, and to be content Avith a few slight inhalations at
the beginning of every contraction.   Three or four pains may sometimes be
alloAved  to pass without  applying  the  sponge, having recourse  to it only
when the patient  complains  of  suffering.  These repeated inhalations are
sufficient to  keep the patient in a  state in which self-consciousness is lost,
and which may thus  be prolonged for several hours without inconvenience.
What we have to  avoid, adds Dr. Simpson, is  either  too  much or too little 
THE  TAMPON.
927
By too  large  a dose, the contractions may be  suspended;  by too small a
one, much excitement  is produced.   To calm the latter, increase the dose;
to remedy the suspension of the pains, withhold the  chloroform  for  some
time.
   It is  a singular fact, that large inhalations are less likely to suspend the
contractions in the second than in the first stage of labor, and,  consequently,
there is then less inconvenience in administering them to a smaller extent. Let
it not be imagined, however, that in order to produce complete anaesthesia,
it is necessary to carry the inhalations so far as to produce noisy respiration,
as in  surgical practice.  It is  rarely needful to go so  far.   The  amounts
required  to produce  sleep  and immobility  also vary  greatly in different
individuals.
   The  patients  are  calm during the  intervals between the pains ; at the
return of the contractions they indicate to the  accoucheur by more or less
motion, and by slight groaning, that sensation is not  completely abolished,
and that  it is proper to repeat the inhalation.
   So  long as the etherization is continued, the greatest silence  should be
maintained about the bed  of the  patient, for the  general excitement and
loquacity produced by the first doses are sometimes augmented by noise.
                           CHAPTER  II.

                              THE TAMPON.

   [The tampon is a sort of plug inserted in the vagina for the purpose of arresting
a flow of blood.  From  its simplicity, it might be regarded as a sort of dressing,
whilst  its importance justifies its being classed with the operations  proper, and
may be compared with the plugging of the nasal fossae.
   In several  passages of the present work, especially on pages 584, 778, 785, and
907, we have described at length the cases in which it should be resorted to, and it
now remains  to describe the way of  applying it.
i   Leroux (of Dijon), has the credit of introducing the  tampon into practice (1776).
His plan was, to fill the vagina with linen or tow, previously saturated with vinegar,
which  liquid, he thought, would cause the blood to  coagulate  more  quickly and
perfectly.  The  application  is now  generally made as folloAvs: enough charpie to
fill a common wash-basin is provided, the quantity, although apparently large, being
really hardly sufficient, on account of the loss of bulk by compression and the great.
distensibility of the vagina.  The charpie is formed into pellets  moderately com-
pressed, and each tied to the end of a strong thread for the purpose of withdrawing
it  readily when it is thought proper to remove it.
   When charpie is not at hand, tow or cotton may be substituted.  As time is always
consumed in the preparation  of a tampon, everything should be made ready before-
hand as soon as there is reason to suppose that a serious hemorrhage is likely to
occur.
   To apply it, the patient is placed  across the bed with  the seat at the edge of the
mattress and the limbs held  apart by assistants.  The pellets are then to be intro-
duced  successively into  the vagina.   The first  ones being applied directly to the
neck of the womb, where they are held  whilst the cufs-de-sac are filled compactly
with others.  The vagina is thus to be filled throughout its whole extent, taking 
928                  OBSTETRICAL   OPERATIONS.
care that no space is left unoccupied, for the plugging will not be well done unless
the canal be filled to distention with the compressed material.  Thick wads of the
substance used, are then to be applied to the vulva in order to support and retain
the pellet, and the whole to be kept in situ by compresses and a T-bandage drawn
tightly.
  I dwell purposely on these details, because a well-applied tampon is an heroic
measure in the treatment of certain  hemorrhages; but  if  badly or imperfectly
managed, it does not prevent the effusion of blood and occasions the  loss  of time.
The pellets may be introduced into the vagina in two different ways : sometimes by
means of a speculum, to the bottom of which the charpie is carried, whilst at others,
and, as we think, preferably, two fingers are introduced and  the pellets slipped in
upon them.
  The advice of Leroux, to saturate the charpie with vinegar, is now generally dis-
regarded, the pellets being lightly greased with cerate which facilitates their intro-
duction and makes them  less permeable to blood.   In case of insertion of the pla-
centa upon the neck of the womb it might be of advantage  to saturate  the  first
pellets in a solution of  perehloride of iron.  The use of the latter preparation is not
unobjectionable and will rarely be necessary when the tampon is carefully applied.
  The effect of the tampon is to arrest the blood, which then coagulates  progres-
sively up to the orifices  of the ruptured utero-placental vessels and thus soon checks
the hemorrhage.  It has also another effect: it irritates  the neck of the womb and
causes the organ to contract, which  may, on the one hand, assist in  arresting the
blood, and on  the other, conduce to the  expulsion of the ovum.  This would be an
advantage toward the end of pregnancy, but a serious inconvenience in the earlier
months.  On  this account, the tampon is more especially indicated when the foetus
is viable, and ought not to be used before then unless depletion of the womb seems
necessary to save the life  of the woman.
  The presence of the tampon occasions more or less discomfort.  Some women can
bear it for several days, whilst to others it becomes intolerable after a few hours.
These individual differences must be taken into account when it becomes a question
as to the time for its removal.   Still another effect of its application, may be reten-
tion of urine caused by pressure upon the urethra.   This must be relieved  twice or
thrice in the twenty-four hours by the use of the catheter, which requires, how-
ever, that the pellets nearest the vulva should first be removed, though they must
be replaced when the operation is completed.
  As a general rule, the  tampon may be alloAved to remain  for twenty-four hours
at least.  Then it ought to be removed for the  purpose of ascertaining the effect'
produced upon  the neck of the  uterus; and the opportunity may be taken to wash
out the vagina  by means of an injection.  Another tampon, prepared beforehand,
should replace the first one if deemed  necessary.   When labor  has begun, the
removal should be made rather oftener in order to watch its progress.   It sometimes
happens that the plug is forced out by the descending  head of the child, in spite
of the retaining bandage.  It is evident that when the expulsive stage begins, the
presence of the tampon will be more injurious than useful.
  In  most cases, it were  better to  allow the tampon to remain too long, than to
withdraw it prematurely.  Its removal is  effected by drawing  successively upon
the threads attached to the  pellets, beginning with the last  inserted.  It is very
readily done,  the only difficulty arising from the commingling of the threads, which
often makes several trials necessary.  To remedy this slight inconvenience, it was
proposed to make the tampon like the tail of a kite, attaching all the pellets to the
same thread at intervals.  When so constructed, it would certainly be more readily
withdrawn, but as it cannot be applied with the same facility, we prefer the common
method.
  In conclusion, I repeat that a well-applied tampon rarely fails to accomplish its 
VERSION.
929
object, but very often the  operation is badly performed.   To do it properly often
requires considerable time,  and the necessary material is not always at hand, in
which case something, else  must be substituted.  Chailly used for the purpose a
gum-elastic bladder which he passed into the vagina and then inflated so as to fill
and distend  the  canal.   The  bladder,  however, on  account of its rounded form,
adapts itself less perfectly to the inequalities of the os tincae and of the two culs-de-
sac of the vagina;  its polished surface,  also, is less favorable to the stoppage and
coagulation of the blood than  are the masses of charpie.   To meet this defect, the
English encase the bladder with a covering  made of sponge, — which, however
useful, is not absolutely necessary.  The advantage of the apparatus consists in its
ready application, whilst its management is so  simple that it can be explained and
put in charge of an  attendant at the bedside of a patient threatened with  hemor-
rhage.   On these accounts, we are  unwilling to reject it,  but recommend that in
making  a selection, preference be given to a globe  with very supple walls, which
should be made distensible by rubbing in  the  hands and successive  inflations in
order to  enable it to conform better to the shape of the vagina.  Finally, we prefer
the injection of water to inflation, because the air is too susceptible of compression.
Notwithstanding  all these precautions, it should be understood that we still prefer
plugging by means of charpie,  though recognizing the great advantage of the gum-
elastic globe  as a temporary tampon.]
                          CHAPTER  III.

                               OF VERSION.

   Version is an operation by which one of the tAvo extremities of the child
 is brought to the superior strait:  it therefore exhibits  tAvo varieties, in one
 of which the operator  proposes to bring  down the feet, and  hence this is
 called pelvic or podalic version ; Avhile in the other he attempts to deliver bv
 the head, Avhich  is on that account denominated cephalic version.
   Cephalic version Avas almost exclusively practised from the time of Hippo-
 crates until that of Ambrose Pare, that is to say, down to  the latter half of
 the sixteenth century.   Celsus advised that Avhen the child is dead, and the
 head cannot be reached without too great difficulty, the feet should be sought
 after.   iEtius  and  Paulus iEgineta  Avere  the  first among the ancients to
 recommend pelvic version Avhen the  child is living.   But  since the days of
 Pare, or rather since those of Guillemeau, his  pupil, the pelvic version has
 been  recommended as  applicable to  all cases; and the cephalic reduction
 was almost  entirely forgotten, until toward  the end of the last century, Avhen
 Flamand, and, somewhat later, Osiander,  exaggerating, doubtless, the  in-
 conveniences,  difficulties, and disastrous  consequences  resulting from the
 pelvic version, proposed a return to the precepts of Hippocrates ; and sug-
 gested the cephalic one in almost all  cases Avhere the hand  alone is sufficient
 to terminate the  labor.   The doctrine of the Strasbourg professor Avas favor-
 ably received in  Germany, but Avas too severely criticised by the school of
 Paris.   Indeed, Baudelocque scarcely speaks of it, and  Gardieu restricts its
application  to a very limited number of cases, Avhile Madame Lachapelle
formally rejects it.  But we shall see hereafter, when studying the respec-
       59 
980                  OBSTETRICAL  OPERATIONS.
tive  value of these tAvo  operations, that at the present day it avouIc".  be
improper to embrace either opinion  exclusively; for some cases  are better
suited to the cephalic version, while there are others, on the contrary, Avhere
the pelvic one is alone practicable; consequently, both operations should be
retained in practice, leaving to the judgment of the accoucheur to determine
the cases in which the one or the other ought to  be preferred.
  Both operations  may be  performed shortly before labor,  during labor
before the membranes are ruptured, or during labor but not until after the
membranes are ruptured.  In the latter case they almost always require the
hand to be passed  into the Avomb, Avhilst in the former this is very rarely
necessary, inasmuch as the  presentation can  be changed by placing the
woman in a suitable position, and applying pressure through the abdominal
walls.   This constitutes version by external manipulation.

                            ARTICLE  I.
                 VERSION BY  EXTERNAL MANIPULATION.
   Version by external manipulation was vaguely referred to by Hippocrates,
and  more distinctly advised by Jacob  Rueff and  Mercurius  Scipio, yet it
passed into oblivion until the commencement of the present century (1812),
when AVigand addressed  to the Academies of  Berlin and Paris,  a memoir
comprising a complete history of the operation.  AVigand's paper was prob-
ably lost in France, since it is mentioned  in none of our classical works, and
we remained ignorant of the wise counsels of the German  accoucheur.   I
ought, hoAvever, to  add, that,  in  opposition to the vieAvs of  Baudelocque,
Madame Lachapelle, Capuron, and others, M. Velpeau had indicated (1835)
the  propriety of performing cephalic version  in some  cases  by  means  of
external manipulation.   M. Lecorche-Colombe,  also  (1836), both advised,
and  several times executed this operation at the Clinique, and I  myself, in
previous editions of this Avork,  discussed more clearly than my countrymen,
the  cases in which  it seemed  to me that it  might be performed Avith ad-
vantage.1
   It should, however, be said that no one amongst us had treated the ques-
tion  as fully as M. Mattei, Avho, although  exaggerating the advantages of
the  operation,  and  needlessly multiplying  the  indications for  it, had  at
least the merit of again calling attention to a too much neglected subject. In-
deed, Ave probably owe to the exaggerations of our countrymen, the ability
to read in French, the excellent translation made by MM. Belin and Hergot
of AArigand's paper.   Two  pupils of the Paris  school, Drs. Ducellier and
Nivert, have, since then, made this  subject their  study in  their inaugural
thesis; so that, in consequence of all these labors and of the clinical instruc-
tions of Professor Stoltz, the teachings of the  Hamburg professor are noAV
well knoAvn.  Thanks to this translation, as well as  to the clinical teaching

  1 I am, therefore, astonished to read in M. Belin's translation, that  M. Cazeaux, in
his edition of 1853, leaves us ignorant of both when and how the operation ought to be
performed, and that I had been content with saying, in reference to cephalic version,
that  external manipulation, wisely conducted,  had quite frequently been successful in
changing the position-of the trunk,— this, too,  when no less than five pages of my book
are devoted to discussing the indications of  the operation. 
VERSION.
931
of Professor  Stoltz, the doctrines of the Hamburg professt r will  soon be
popular in France.
  External manipulation, performed  with the object  of bringing to the
superior strait one of the  foetal  extremities originally more or  less remote
from it, has been advised  :
         1. Before labor ;
         2. During labor and before rupture of the membranes;
         3. During labor and after  rupture of the membranes.
  A.  Before Labor.—Some accoucheurs have advised that external manipu-
lation be resorted to in the last fortnight of pregnancy, and Ave have ourselves
done so after the  example of M. Lecorche-Colombe.   M. Mattei, hoAvever,
advises, of late years, that the version be performed from the sixth or seventh
month.   AAre think this can readily be done in most cases, at least Avhere the
presentations are transverse or oblique, though Ave believe that generally the
operation will prove  useless.  When,  in  fact, the longitudinal  axis of the
foetus is replaced in the axis of the  superior strait, the form of the uterus,
which, as shoAvn by M. Hergott, is  very probably the cause  of the faulty
position of the child, remains unchanged, so  that the latter will gradually
resume  its primitive position; after a feAV days  the extremity, which has
been  brought to the  superior strait, no 'longer being found there.   I  have
seen  this  happen  several times.  Therefore,  as  the bandages  devised for
compressing the sides of the abdomen with the view of lessening its trans-
verse diameter and retaining the  fcetus  in the position given  it, would be
insupportable for two months, I agree with AVigand, that it is better to aAvait
the commencement of labor.  Still, I  Avould not  say that it Avere useless to
examine carefully all Avomen during the latter months of gestation, in order
to determine the form and obliquities of the womb, the position of the foetus,
the greater or less amount of fluid, and Avhatever other circumstances might
affect the presentation of  the child at the commencement of labor.  AVhen
carefully  performed, this examination  Avill rarely lead to an  immediate
operation,  but will often have the effect to aAvaken the attention of the
accoucheur to difficulties Avhich, at a later period, he may be able to correct
in time.
  Especially ought  such  an examination to be  made when a  faulty  pre-
sentation had been discovered in preceding pregnancies, for were this found
to be again the case, the Avoman would be advised to avoid all shocks or
great fatigue, Avhich might  lead to  premature rupture of the  membranes.
She ought to be  strongly advised to  observe the utmost quiet from the ap-
pearance of the first pain,  and to call her physician as soon as possible.
  In  case  of  considerable anteversion,  the  uterus  should be  kept raised
during the day  by a broad  belt  around  the  abdomen  supported  by sus-
penders, Avhilst, at night,  she ought to lie  upon the back.   When there is
lateral obliquity, the decubitus should be upon the opposite side.  AVe  have
nothing further to  say  in regard to version before labor.
  B.  During Labor  and before  Rujdure  of the Membranes.— Under these
circumstances is it, that version, by external  manipulation, has been  espe-
cially lauded by AAlgand  and German Avriters, and then only is it that it
stems +.o us to possess  incontrovertible advantages.   AVe may readily con- 
932
OBSTETRICAL  OPERATIONS.
3eive, that the mobility of the foetus at that time, immersed as it is in the
amniotic fluid, ought strikingly to  facilitate the movements  sought to be
executed; whilst, on the other hand, the possibility of rupturing the mem-
branes as soon  as  the  operation  has  succeeded, affords a  sure means of
avoiding a relapse.
  AVith the exception of some special cases, of which we shall have to speak
hereafter, it seems  to us  indispensable, as a general thing,  that the  mem-
branes should remain entire.   A second condition  regarded by AAlgand as
very important, is the persistence and regularity of the uterine contractions.
If too feeble, spasmodic, or irregular,  they ought, before anything else is
done, be stimulated in the first case, and made regular by opium or chloro-
form  in the second.   "I  recollect  several cases,"  he says, "in which the
head, after having been forced doAvn by the very violent contractions,  rose
again above the superior strait, until the very irregular contractions were
made regular by the use of opium."
 -  Contraindications.— Besides the irregularity of the contractions, Avhich it
is always easy to remedy, version by external manipulation is necessarily
excluded by all circumstances requiring a prompt termination of the labor.
Thus, hemorrhage,  convulsions, syncope, rupture of the uterus, prolapsus of
the cord, foetal monstrosities, Ac,  are so many  contraindications to the
operation.   The case is the  same Avith twin  pregnancies, Avhich makes it
very difficult to diagnose the presentation of both children,  and in Avhich it
is not always easy to knoAV whether the pressure is exerted upon both ex-
tremities of the same foetus.
  Positions  of  the Child, in which  Version  by  External Manipulation ought
to  be performed.— As was  stated on page  841 et seq., the presentations of
the vertex  and pelvis  are liable to certain irregularities  or  inclinations,
which, in the great majority of cases, are corrected spontaneously Avhen the
membranes are ruptured, but Avhich not unfrequently continue or facilitate
the production  of presentations more  unfavorable still.  In  this case, the
presenting part, head or pelvis, has  no  disposition to engage in the superior
strait, but strikes against one of its borders.  The longitudinal axis  of the
foetus is not in  the direction of the axis of the pelvis, but is more or less in-
clined to it.  At other times, Avhat is still more serious, it lies transversely,
so as to form a trunk presentation ; noAV, it is especially in  these oblique or
transverse positions of the foetal axis, that version by external manipulation
may be performed  Avith advantage,  and Ave shall borroAv from AVigand the
course to be pursued.
   1. Preliminary Measures.— The first precaution is to make as sure as pos-
sible of the position  of the child and  the exact situation of  the head and
pelvis.   AVithout entering into the details  already given whilst treating of
each  presentation,  Ave recall  briefly that the accoucheur ought to make use
successively of abdominal palpation, whereby he  recognizes the fcetal in-
equalities, of the touch, performed Avhilst  the patient is standing and whilst
lying on the back,  and finally, of auscultation.  He will take especial  note
of the form of the uterine tumor, of the greater or  less  protrusion  of the
bag of  waters, and of the impossibility of reaching any part of the child by
 the finger in the vagina.
• 
VERSION.
938
  The position the Avoman  should take varies according to circumstances.
Generally, sh  ought to lie upon the side in which is situated the part of the
child  Avhich it is desired to bring to the opening.   Thus, if this part be the
head,  and it rests upon the left ilium, the patient should lie on the left side.
The lateral decubitus ought  not to  be carried too far, but just so as to direct
the umbilicus  slightly to the left.   To give the abdomen a solid  support, a
thick  and  hard cushion,  or a cloth  several times folded,  should be placed
beneath, and against Avhich  the Avoman must be careful to press strongly, at
the same time assisting herself Avith her  hands.   The change of position
should be  made  betAveen the pains, lest the displacement of the  child in
connection with the uterine contraction should occasion rupture of the mem-
branes.
  If the diagnosis has not been clearly made out, the patient will  lie upon
the left side, this  being the  position  appropriate to the greater number  of
cases.
  Decided  anteversion, Avith the  head resting upon the crest of the pubis,
demands the  dorsal  decubitus,  the  pelvis  being  at the same time slightly
raised, and  the abdomen supported  by a  broad bandage in the hands of
assistants.
  The position of the accoucheur  will be various  and sufficiently indicated *
by the operation he is about to undertake.
  Both the  bladder and rectum ought, of course, to be emptied.
  Mode of  Operation.— In  some cases of simple obliquity of the child, the
mere  position, aided by the cushion placed beneath the side of the abdomen,
has proved  sufficient to accomplish the  reduction, though most frequently,
especially  in  transverse  presentations, external manipulation  becomes
necessary.
  The accoucheur ought ahvays to endeavor to cause that  extremity  of the
child  to descend into the strait which is nearest the  opening of the  pelvis.
Breech presentations  are not so unfavorable but that Ave may, in some cases,
give up the attempt to bring the head doAvn first, in order to avoid too long-
continued and perhaps hurtful efforts.
  Suppose, then,  the  child  to be  in  the left cephalo-iliac position  of the
right  shoulder.  The  operator, being  to the right of the  bed and Avishing to
depress the head, places his  right hand upon it, and Avhilst endeavoring to
make it descend, he, at the same time, endeavors to raise  the pelvis  by
pressing it upAvard with his  left. Acting thus in opposite directions with his
hands, and  endeavoring to  preserve accordance  in his motions, he makes
light frictions on the tAvo extremities of the child; if these be not success-
ful, he will press  more strongly, ahvays acting at the same time on both
extremities.
  As  soon as the  cephalic extremity is brought to  the  superior strait, a feAV
moments should  be  alloAved to pass, in order to  be  certain that it is Avell
fixed there; then the membranes ought to be ruptured, so  that the contrac«
tion of the  womb may keep the child in its  neAV position.
  When the head happens to be in the neighborhood of the uterine orifice,
as in oblique or inclined positions  of  the vertex, it will suffice to press with
a single hand upon the part  of  -e  abdomen corresponding with the breech. 
934:                  OBSTETRICAL  OPERATIONS.
 whilst tAvo fingers of the other hand, passed into the cervix, slide the  head
 over  the edge of  the  strait and  rupture the membranes  at  the proper
 moment.
   It  is easy to understand  the modifications required by  the operation,
 when it is decided to bring the breech, instead of the head, to the  superior
 strait.
   The change once made, the delivery is  left to nature, though, if difficulties
 should occur, the usual means Avill be employed for their removal.
   External manipulation may be practised Avith any amount of dilatation
 of the cervix, though it Avere best, in general, not to rupture the  membranes
 until  the dilatation is  pretty far adA^anced.  AAlien, at  the  commencement
 of labor, the accoucheur detects an oblique position of the head or breech,
 or a presentation of the trunk, he ought  first merely to put the woman in a
 proper position, and  by means of  a folded  cloth or hard  cushion placed
 under the side  of the abdomen, make  pressure upon the  part of the child
 Avhich he Avishes should engage.  At the same time, he insists upon absolute
 immobility, especially during  the  pain,  and if, after  Avaiting  five or six
 hours, these measures have not sufficed to change the presentation, he will
 have recourse to external pressure as already described.  AVhen  the conver-
 sion is effected, the membranes ought to  be ruptured  at once, provided  the
 dilatation of the cervix is advanced, but if otherwise, the woman should be
 merely kept upon her side and  proper pressure maintained upon the abdo-
 men.  Sometimes, notwithstanding  these measures, the child resumes its
 faulty position, and then the whole operation  has to be repeated, and the
 membranes broken immediately after.
  c. During Labor and after Rupture of the Membranes.—Under these
 circumstances, version by external manipulation is advisable only in oblique
 positions, Avhen the head or breech are very near the cervix, the membranes
 broken only a short time before Avith  a certain amount of Avater remaining in  -
 the uterus, and the child possessing considerable mobility.   Even  then, it
 Avere proper to be very careful  and not  continue too long attempts, whose
 least inconvenience Avould be the loss of precious time.  For my own part,
 I Avould prefer, if the dilatation of  the neck allowed it, to take advantage
 of the favorable conditions and perform the pelvic version.  For a stronger
 reason, would I be disposed  to  advise the same thing to be done in trans-
 verse  presentations of the trunk.
  Flamand did not restrict the rule to bring doAvn the head in  trunk posi-
tions to the cases just indicated ; but he was also in favor of the performance
of the cephalic version, even after  the rupture of the membranes and the
discharge of the amniotic liquid.  He has even gone so far as to point out
 the particular manoeuvre for each one of  the distinct presentations admitted
by him',  for  the  child's anterior, posterior, and lateral  planes.   (Journ.
 Complement,  des Sciences Medicates) ; but Ave deem it useless to enter  into
his  long  details, more especially since they may all be comprised  in this:
to grasp  the  presenting part, push it up  above the strait, and then  carry it
as far as  possible towards the side opposite to Avhere the head is found; and
aftenvards  get  hold of the head, and  bring it down, if the efforts made by
 the other hand through the abdominal Avails have  not  proved sufficient
 to make  it descend into the excavation. 
VERSION.
935
  Flamand himself acknowledges that this operation  seldom succeeds, ex-
cepting Avhen some region of the neck or upper part of the thorax presents
at the strait.   For  our own part,  we believe it would  be difficult, even
under such circumstances;  hoAvever, it is barely possible, especially if there
is still some Avater  in the uterus, and  the contractions are not very ener-
getic;  still, under the circumstances, Ave  should think it right to endeavor
to effect  the object.  But  where a long time has elapsed after the rupture
of the membranes and the total discharge of the amniotic liquid, and the
Avomb  is strongly contracted, Ave do not  hesitate to recommend the  pelvic
version in  preference; and particularly so, in those cases  in  which some
region of the loAver  half  of the trunk presents at the centre of the strait.
  In  common Avith many  of our contemporaries,  Ave had hitherto  advised
cephalic version in oases of contracted pelvis, from a fear of the difficulties
to Avhich  an arrest of the  head above  the superior strait would give rise.
An interesting memoir, by  Dr. Simpson, having again directed our attention
to the advantages  and  disadvantages  of pelvic version, we subjected the
knoAvn facts to a careful  examination, and uoav confess that the reading of
the memoir has greatly changed our opinion.   AVe are, at present, convinced
that the dangers of pelvic  version, in cases of contracted  pelvis, have been
much exaggerated, and do  not hesitate to  recommend this operation in pref-
erence to cephalic version, which would prove very difficult after a complete
evacuation of the Avaters, and, after all,  would require the forceps  to be
applied.
  Still more strongly Avould Ave prefer  pelvic version, if the pelvis Avere one
of the kind in Avhich the  narroAving affects  one side  much more than the
other; that is to say, one in Avhich the sacro-vertebral angle, though pro-
jecting strongly fonvard, is, at the  same  time, turned to one side, as  in the
oblique-oval pelvis of M. Naegele, for it Avould enable us the more easily to
direct  the  back, and the  large occipital  extremity  of the head toward the
most roomy side of the pelvis.
  AVhen a trunk presentation is complicated by the  descent of an arm, the
cephalic version, recommended by Ruffius  (humeri repellendi ut cadet caput),
Rhodion, and  others, should, in my estimation, be  wholly rejected; since
the necessity of a previous return of the arm would  then render the version
by the head exceedingly difficult, if indeed, as before stated, the premature
rupture of the  membranes did not constrain us to abandon it altogether.
Consequently, the pelvic version would appear to  be far preferable  in cases
of this kind.
  Presentations  of  the Pelvic Extremity. — " Partisans, as  we are,  of the
version by  the head," says Flamand, "we are not prepared to  propose it in
these  cases indiscriminately,  notwithstanding we are that way  inclined.
But after  a consideration of the following suppositions, we do  not doubt
that every unprejudiced accoucheur will follow  our  advice, and  attempt
this operation.
  " Supposing that a monstrosity Avere to present Avithout any loAver extremi-
ties whatever, or one having only a couple of little stumps near the buttock,
too  small to furnish a  sufficient hold for the accoucheur's hand to draw
down the breech, and at the same time the mobility of the fcetus indicates, 
936
OBSTETRICAL  OPERATIONS.
 the possibility of bringing down the head, avIio would  hesitate to attempt
 the operation?"  For ourselves, Ave should not hesitate to leave the deliv-
 ery entirely to the poAvers of nature; for Avhat would be gained by drawing
 on  the pelvic extremity?  Have not the precepts of Madame Lachapelle,
 of Desormeaux, of Dubois, and  others, taught us, that all tractions on this
 extremity are more hurtful than beneficial ?  And would not some of those
 disadvantages that  Flamand and his followers refer to the delivery by the
 breech, and on Avhich they rely for advising the cephalic version,—would
 not they result in consequence  of such  imprudent tractions ?
   " Supposing a woman has but three inches and three lines in her sacro-
 pubic diameter, and that in former labors she has lost several children that
 were delivered by the breech ; and besides, that the foetus appears sufficiently
 movable at the time when, or shortly after Ave  are obliged to rupture the
 membranes—an attempt to effect the version by the head is warrantable."
   AAre likeAvise believe that, in such a case, the accoucheur would be justi-
 fied in making this attempt before the membranes are ruptured ;  but after
 the discharge of the waters, it  appears to us that this  operation must be
 impracticable in a large majority of cases ;  and we should then prefer Avell-
 conducted tractions on the trunk of the child, using every exertion to keep
 up the flexion of the head at the moment when the latter reaches the supe-
 rior strait.  The observations of Madame Lachapelle, and  those published
 more recently by Dr. Simpson, afford a satisfactory reason for our preference,
 even in  those cases Avhere the pelvic  contraction results from the direct
 for\A'ard projection of-the sacro-vertebral angle; and this precept Avould be
 still more applicable, if one of  those pelves described by M. Naegele, under
 the name of oblique-oval, Avere to be met Avith.   For the tractions then made
 on the breech would  have  the effect of turning the child's back, and, as a
 consequence, the large occipital  extremity of the head, toAvards the Avidest
 part  of the pelvis.
   To recapitulate: Version by external manipulation ought to be attempted,
 in oblique or transverse positions of the body of the child, only during labor,
 and, if possible, before the membranes are ruptured.  Should, hoAvever,  but
 a few moments  have  elapsed  since  the rupture took place  and  a certain
 amount of Avater remain in the  Avomb ; if,  in short, the child is still movable,
 and the part to be brought  doAvn very  near the cervix, some attempt may
 yet be made with this  object; but, should difficulty be met Avith, pelvic ver-
 sion must be employed instead.
   If the faulty position of the  child has been discovered before labor, the
 preventive measures already mentioned should be had recourse to, and ex-
 ternal manipulation left imtil labor has begun.


                           ARTICLE  II.
                          OF PELVIC VERSION.
   This is an operation whereby the pelvic extremity is brought to the supe-
 rior strait, from which it had been more or less removed.
   As stated in the preceding article, this result may be obtained by external
manipulation  perfoi ned before tlie membranes are ruptured.  We gave  a 
version.                            937
 formal statement, hoAvever, of contraindications for this method, even though
 the membranes be intact.  It frequently happens that the accoucheur is not
 called to the patient until long after the Avaters have  been discharged, and
 then first discovers  the faulty position of the  child.   As  in all such cases,
 pelvic version  by internal manipulation is indispensable, we shall have  to
 study  the subject Avith the greatest care.
   In the first place  will be given  the general  rules  applicable to all  cases
 of this operation, and afterward the peculiarities presented by each of the
 presentations of the vertex, face, and trunk.   Before operating, it  is well,
 hoAvever, to observe certain precautions Avhich may  facilitate the process  at
 a later period, and especially is it necessary to bear  in mind the conditions
 necessary for the performance of the operation.

   § 1. Precautions to be  observed.
   Before studying the general  rules for the performance of pelvic version,
 we Avill point out briefly certain precautions to be observed by the operator,
 and Avhich apply to all cases.
   1. In the first place, the  accoucheur ought to apprise the patient of the
 operation he is about to perform, to make her understand as clearly as  pos-
 sible the necessity for resorting to it, and to calm her anxiety, and to remove
 any fears as to the unfavorable consequences  it may have either upon  her-
 self or the child.
   2. As soon as the Avoman  shall have consented to the operation, she is  to
 be placed in a suitable position, Avhich position varies very much in different
 countries, and  even  according to individual accoucheurs.   The folloAving  is
 the one generally preferred in France :  the Avoman places herself across the
 bed, one side of Avhich rests  against a Avail or  some tall piece of furniture;
 several pilloAvs are  then piled up under her back, so as to  keep the upper
 part of the body moderately elevated ;  and that the sacrum, by resting on
 the free side of the bed, may leave the vulva and perineum entirely exposed.
 The loAver extremities are moderately flexed, the feet resting on two chairs,
 and supported  by two assistants standing on the outside of the limbs.  AVhen
 the patient is  very  intractable, or fears that she cannot control her move-
 ments, another assistant holds the pelvis in a fixed position by grasping the
 iliac crests.
   In England, women  are usually delivered on the side; and they are placed
 in the same position Avhenever it becomes necessary to resort to any opera-
 tion ; the precaution being taken, however, to bring the breech to the side
 of the  bed, and  to  place a cushion between the  knees, for the  purpose of
 keeping them apart.
  It were Avell  worth Avhile, in some cases at  least, to adopt this  position.
 AVhen, for instance, the dorsal region of the foetus is directed backAvard, the
lateral  decubitus sometimes allows the hand to reach the  feet with greater
facility;  in  the dorso-anterior position, on  the  contrary, turning is re
easily effected whilst, the patient lies upon the back.
  3. As the little bed on which women are delivered is often too  Ioav, and
therefore incommodious for the operator, some practitioners direct a mattress
to be placed on a bureau or any other article of furniture of a proper height. 
938
OBSTETRICAL  OPERATIONS.
 to which  the patient is to be transferred.   In most  cases, the accouchtur
 will, no doubt, be obliged to go doAvn on his knees, or sit on a  Ioav chair.
 which  position  is often inconvenient, and  obstructs the operation.  AVhen
 the bed is too Ioav, it should be raised by means of a folded mattress, or else
 the woman may be  placed upon some higher piece of furniture.   Generally
 it is only necessary  to turn the bed  in  such a way that one of its sides will
 be supported against the Avail, and to place the woman crosswise on  it, tak-
 ing the precaution,  if necessary, to elevate her breech by slipping a pillow
 under the first mattress; this is such a simple affair that she Avill scarcely per-
 ceive it, and it will  not disturb her  in any Avay.
   4. The accoucheur ought to throAv off his coat, as the forearm  has to  be
 introduced into  the parts  as  far up as the elboAv.  He will also  have a
 proper number of napkins prepared and placed at the foot of the bed to
 wipe his hands, and  to envelop the body of the child as it shall be extracted.
   5. Before operating, he  should again ascertain the  child's  position.   We
 need only refer here to the diagnostic signs  in each presentation, that have
 been pointed out in  describing natural labor.
   6. The position being clearly recognized,  it will be necessary to decide on
 the choice of the hand by which the version  is to be  performed.   In the
 presentations of the  vertex, face, and breech, we introduce that hand Avhich,
 being held michvay betAveen pronation and supination, has its palmar surface
 turned towards the child's anterior  plane;  while, in those of the trunk we
 introduce  the hand having the same  name as the presenting  side of the
 foetus (the right hand for the right side, and the left hand for the left  one),
 whenever Ave intend to perform the  pelvic version.  As to the cephalic ver-
 sion, it is difficult to lay doAvn  any general  rule for the particular  hand to
 be used, since this varies according to the particular case.
   The hand and forearm chosen  are then covered by some fatty substance,
 with a vieAV of facilitating their introduction, and, at the same time, of pro-
 tecting them against  the  contagion of any diseases the woman  might  be
 affected Avith. Care  should be taken to grease only the dorsal surface of the
 hand, which alone conies into contact with  the mother's parts, the palmar
 face having to apply itself to those of the fcetus which are too slippery already.
   7. In those cases in which the version is rendered indispensable by  some
 accident that threatens the life of  the mother or child, and, consequently,
 where  it is not possible to choose our own time, Ave evidently have to operate
 as soon as the gravity of the case renders it advisable ; but in those in Avhich
 a malposition of  the infant constitutes  the whole difficulty, as in the trunk
 presentations, for example, the operator (if attendant on the patient  from
 the commencement, of her labor) should bear  in  mind  that,  Avhen  the bag
 of waters is still intact, or else so recently ruptured that a considerable
 quantity of water still remains  in the uterine cavity, the introduction of the
 hand and the evolution of the fcetus  are much easier than at any other time;
 and, consequently, he ought to select that moment  for operating, provided
 always the os uteri is sufficiently dilated.

  § 2.  Necessary Conditions.
  In order to perform the pelvic version, it is requisite that the os uteri be
dilated or dilatable; that the presenting part be not engaged too deeply in 
VERSION.
939
the excavation, and  more  particularly that it has not cleared the neck of
the uterus; finally, except  in trunk presentations, most authors require that
no disproportion exist betAveen the size of the head  and the dimensions of
the pelvis.
  1. It  is necessary, Ave say,  that the os uteri be  sufficiently dilated or
dilatable to permit the ready introduction of the hand, and the free passage
of the child.  The neck may be considered as being properly dilated, when
its orifice offers nearly two inches in  diameter; but it may be much less
open, and yet the version be still possible, because it is then often sufficiently
dilatable.  In the latter case, the cervix is  thick, soft, supple, and easily
distended; it is neither tense nor contracted, and the finger, on being  passed
over the divers points of its circumference, finds that it does not re.-ist in the
least, and that it admits of being readily enlarged.   This dilatability of the
uterine orifice is particularly apt to be  met with, Avhen the presenting part
cannot engage in the os uteri after the  membranes are ruptured, on account
of its volume or bad position; because, being no longer sustained, the mar-
gins then relapse tOAvards its centre, and thus  diminish its  size.
  2. The second condition is,  that the presenting part be not too  deeply
engaged in the  excavation, and more  especially that it has not cleared the
cervix.   It will  presently be  seen that, before endeavoring  to  enter the
uterus, the hand of the accoucheur ought to push the part, Avhich  is already
more or less engaged in thq excavation, above the  superior strait. Now, it
is evident that if this part  had cleared the os  uteri, it could not be returned
without the Avomb being pressed back at the same  time,  and  consequently
Avithout exposing the utero-vaginal attachments to laceration.
  3. AVhen  the pelvis  is  contracted,  most French  accoucheurs proscribe
pelvic version.   Although  Ave  also at  one time  adopted  this view, we now
think that it should  be-reserved for those cases only in which the  narroAving
affects all the diameters of the pelvis,  or in Avhich the sacro-pubic diameter
is excessively shortened.   An attentive examination of  this  question has
convinced me  that  Madame Lachapelle, Dr. Simpson, of Edinburgh, and
Mr. Radfort, of Manchester, Avere right in preferring pelvic version to the
application of the forceps in some cases.  AA'e shall discuss this  important
practical point in the folloAving chapter, but Ave feel justified in saying at
present  that version  maybe practised Avith  advantage:  1, in the oblique-
oval contractions of  M. Naegele; 2, in  those antero-posterior contractions of
the inferior  strait complicated Avith a considerable  narrowing of the sub-
pubic arch.   (See Forceps.)
  Below two inches, the antero-posterior diameter of the pelvis  is so short
as to render it impossible to introduce the hand.  A contraction so great as
this, makes it unnecessary  to insist much upon attempts at version.

  § 3. General Rules of the Operation.
  The operation, in  the performance of podalic version, is composed of three
principal stages, namely, the introduction of  the hand, the evolution of the
child, and the extraction of the latter.
  1. Introduction of the Hand.—-The patient having  been properly placed,
the operator sits down or rests on one knee before her, then presents his hand 
940
OBSTETRICAL  OPERATIONS.
at the entrance of the vulva,  and endeavors to introduce it  by pressing
gently from before backAvards,  and slightly from above dowmvards.  If the
vulva is very large, the fingers are held  together and introduced, flat first,
taking care to depress the  anterior-perineal commissure Avith the cubital
border of the  hand; but if  the vulva is very narrow, the fingers  are  intro-
duced one after another, and then brought together in such a way as to  form
a kind of gutter, in AA'hich the thumb can slip along their palmar concavity,
and  thus  enter  imperceptibly.  The hand  thus  forms a cone, the base of
which is still at  the exterior, while  its  apex endeavors to penetrate up into
the vaginal cavity.  The wrist  is then slightly depressed, in order to accom-
modate the  direction of the hand to the line of axis  of the inferior strait;
and, as the fingers penetrate deeper, it is depressed  more and more, so  as to
make the hand  describe a curve Avith its concavity anterior, corresponding
to the pelvic axis.  The introduction is facilitated by gently and moderately
rotating  the  hand on its OAvn axis,  Avith a vieAV of effacing the folds of the
vagina.
   AArhenever possible, the introduction  into the vulva must be made during
the interval between the pains.  Ant.  Dubois gave a different precept, and
taught that it was preferable to make the introduction Avhile the pain lasted ;
for, said he, the  woman, being engrossed Avith the uterine pain, will not per-
ceive that caused by  the entrance of the  hand.  But every one who has
attended a female  in labor, and has made the vaginal examination during
the contraction, must be convinced of the error of this celebrated accoucheur.
   The fingers, having reached the upper part of the vagina, may find the os
uteri either freely dilated or sufficiently dilatable.   In the former case they
can be made  to  penetrate into the organ Avithout any difficulty, by placing
them betAveen the internal surface of the uterus and the presenting part of
the child; but, in  the  latter,'they are to be introduced one after the other,
in such a manner as to form a cone, the extremity of Avhich is entered in the
orifice.  Then the hand is ptished along, imparting to it at the same  time
some gentle rotatory movements, and separating the fingers a little  from each
other, so as to make a moderate and uniform' pressure on the various points
of the periphery of the cervix.   AVhen the  services of an assistant  can be
obtained, he should be directed to place both hands over the fundus of the
uterus, in  order to prevent it from  being pressed up by the efforts made to
introduce the hand ; if there is no assistant, the other hand of the accoucheur
is placed over the fundus to  perform the same office.   AVithout this precau-
tion, there Avould be danger  of  lacerating the vagina at its point  of attach-
ment with the uterus.
   The os uteri ought to be  entered during  the interval of the pains.  As
soon as the hand has reached the cervix, it is necessary to ascertain that we
have not been mistaken about  the position ; and in  case an error has been
committed and the Avrong hand has been introduced, it should be withdraAvn
at once, and replaced  by the other, if there is  reason to anticipate  much
difficulty in the version ; that is to say, if the membranes have been ruptured
a long time, the  pains are strong, and the Avaters are Avholly discharged; for
we ought  not to add to the  difficulties that already exist  by the choice of
the wrong hand.   But, under opposite circumstances  we might use the hand 
VERSION.
94]
first introduced, so as to spare the patient the  pain and repugnance which
the introduction of a second one ahvays occasions her.
  AVhen the hand arrives at the os uteri, the membranes may either le still
intact, or  they may have  been ruptured for a long time.  Supposing  the
former to  be  the case, the question arises,  are they to be ruptured  before
passing  any further?  It is far better to insinuate the hand between  the
external surface of the membranes and  the internal one of the womb, and
thus get it up to the  point where, from the child's position, we know the feet
ought to be found; and only rupture the membranes at  the moment when
the loAver  extremities are seized, or at least not until  after the Avhole hand
has penetrated into the uterine cavity.  Both  processes have their advan-
tages : the first is the most expeditious and does not, whatever may be said
to the contrary, permit a too rapid discharge  of the Avaters, for  the  simple
reason that the presence of the forearm  in  the mouth of  the Avomb stops it
almost  completely.  In the second, by  leaving the membranes  unbroken
until  the  feet are grasped, Ave have the great advantage of reaching  the
fundus  uteri  much more easily, of turning  the feet more  promptly, and of
practising the second stage or evolution of the  fcetus more  readily, the latter
being yet  mo\rable in  the surrounding Avaters.   If  the hand  finds the pla-
centa attached to one side of the organ,  as  it advances between the internal
surface  of the Avomb  and the external one of the membranes, it is very neces-
sary to  avoid its detachment, Avhich might be done  by passing around its
margin; and where  this  is impracticable,  to rupture the membrane at the
inferior border of the  placenta.1
   The introduction of the hand is far more
difficult when the membranes are broken,
for the presence of  another foreign  body
stimulates the contractions still more, and
it were  folly  to endeavor  to overcome them.
It is therefore  advisable  to suspend  all
attempts,  and only  renew  them  Avhen  the
pains are  a little calmed.   The first step in
the process is to get hold of the presenting
part,  and push it  up a little  above  the
superior  strait;  then  it is to be carried
toward  one of the iliac  fossae, where  it is
sustained, first  by the palm of the hand,
and  afterwards by  the anterior surface of
the forearm.  This  pressing back, which is
easy Avhen the foetus is still someAvhat mov-
able,  becomes impossible when the Avaters
are  entirely  discharged;  in this case  our
efforts  should  be  limited to  gliding  the
hand betAveen the neck and the presenting
part.    The mode of reaching the feet varies
  i This plan is recommended by Peu, Smellie, Deluerye,  Hamilton, Boer, N^gele, and
Madame Lachapelle.   The latter has even been careful to suggest another precaution;
namely,  to  rupture the membranes during the relaxation of the uterus, lest its contrac-
tion drive  out a large portion of the waters.
 In this figure the head has been pnehed
up into the left iliac fossa, and one hand
gets hold of the feet while the other sup-
ports the organ externally. 
942
OBSTETRICAL  OPERATIONS.
according to the particular position.  Some  accoucheurs have laid it down
as a general rule to pass  the hand around the side of the child that ia
directed towards  the mother's  loins, and then slip it along its  back and
breech, and doAvn along the posterior surface of the loAver extremities to the
feet.  For, by folloAving an opposite course, and laying it flat on the anterior
surface of the foetus, and thus guiding it directly to the feet, nothing would
be easier than to mistake  the hand for a foot, or an elboAv for the knee, in
the folded-up condition of the superior and inferior extremities.   There are
some cases in which this direction may be folloAved, but in many others it is
useless or impossible to take  this  precaution: useless, Avhen a considerable
quantity of water still remains in the cavity  of the uterus; and impossible,
where  the membranes have been ruptured for a long time, and the uterine
Avails are forcibly retracted on the  child's trunk ; for then we must be con-
tent Avith slipping the hand flat along the anterior plane of the fcetus, being
careful not to confound a foot with  a hand.
  2. Evolution of the Fcetus.—Having succeeded in  finding the  feet,  the
hand grasps them in such a Avay, that the  index finger is placed betAveen
the two internal malleoli, the thumb on the external surface of one leg, and
the three fingers  on the external  side of the other.   Such at least is the
direction given by many medical authors, but in practice Ave cannot ahvays
do Avhat we Avould, and it is only necessary to  be certain that Ave have a firm
hold of them.  (See Fig. 120.)  It is sometimes  difficult to seize  both feet
at the same time; and Ave must then be satisfied with a single one,  provided
the search after the second is attended Avith considerable difficulty.   The
                                   feet are then draAvn upon in such a Avay
              FlG-121-               as to  double up the foetus on its anterior
                                   plane.  During the performance of this
                                   evolution, which  is ahvays to  be  done
                                   during the interval betAveen the pains,
                                  the other hand should be placed over the
                                   part of the abdomen Avhere the head is
                                   found,  and by pressing up, the latter
                                   should endeavor  to  make  it ascend
                                   towards the fundus of the Avomb.  It
                                   sometimes happens, as just stated, that
                                   only one  foot can be brought doAvn into
                                   the vagina, and if this is the anterior or
                                   sub-pubic one, the operation might be
                                   terminated without going  in  search of
                                   the other;  but if, on the contrary, it is
                                   the posterior foot, we should, after hav-
  The same position, in-which the version is com-  jn~ seCured it  with a fillet,1  introduce
     mencod by drawing down the feet.       °                 ir>n    ,   •
                                   the hand aneAV, and follow the internal
  1 The fillet usually consists of a piece of tape, one or two fingers' breadth wide and
a yard long, made into a loose slip-knot, which is applied above the ankle; when the
foot is still in  the vagina, the knot is placed  on the dorsal surface of the hand, and
then, by grasping the  foot, it is slipped  over it above the  malleoli, and afterwards
tigktenee1 by drawing on the two extremities of the tape that hang down at the vulva 
VERSION.
943
border of the limb  already extracted, up to the root of  the  opposite leg;
Avhence by tracing out the  latter, Ave finally get to the other  foot, which is
to be brought down in a line of abduction.   It is to be understood, how-
ever, that it is possible and often easy to turn Avhen  the posterior foot only
can be got hold of;  in Avhich case, the course to be pursued will be pointed
out hereafter.
  In some cases, it is much easier to seize the  knees Avhich present to the
hand of the accoucheur, and they might then be drawn upon Avithout incon-
venience for  the  purpose  of  effecting evolution, but relinquished Avhen
brought doAvn far enough to allow him to get hold of the  feet.
  3. The extraction is the only stage of version performed during the uter-
ine contraction.   In fact, as the  latter facilitates the tractions made on the
pelvic extremity, and likewise serves to keep the head flexed on the chest,
the accoucheur Avould be justified in terminating the  labor, Avithout waiting
the return of the pain, only Avhen there was a complete inertia of the Avomb
conjoined Avith some accident requiring a prompt delivery.
  At first, we  must draAV on the sub-pubic limb as much as possible, because
Ave thereby encourage the rotation of the anterior plane of the child toAvards
the mother's loins, and we are better enabled to press the parts backAvards ;
that is, to get  them in the direction of the axis of the superior strait, Avhich
they have to  traverse.   If the posterior foot  is the one brought down, the
version  may be completed  successfully with it  alone.  In order to accom-
plish it, the limb should be rotated  to the right or left Avhilst being draAvn
upon;  the  breech, generally following  the movement thus  communicated,
will descend  Avith  its greatest  diameter  corresponding  to the transverse
diameter of the pelvis.   Continued traction in the  same direction finally
brings under the pubis the foot which at first Avas behind, and  the operation
is completed as under ordinary circumstances.
  As the loAver extremities are delivered, the whole extent of the disengaged
parts are grasped by the two hands, taking care to place the thumbs on the
posterior part  of the limbs, the index and medius on their external surface,
and the  ring  and the little fingers on  their anterior surface.  AVhen the
breech appears  at the vulva, it  is necessary to ascertain the state of the
cord; for that  purpose, a finger is to be slipped up to  its umbilical insertion,
when, if it be found tense, the thumb is joined to the  finger,  and  by making
a gentle traction on its placental extremity, by both, the  loop it forms will
be enlarged (Fig. 123).   If the cord  has slipped over one leg, and got into
the fissure between the thighs, it will  likewise  be necessary, after having
drawn slightly on it, to disengage the child's posterior limb, and place the
cord in contact Avith the perineum.
  In case the version  has been demanded  by an unfavorable position, and

When the foot is high up in the vagina, it is oftQn very difficult to apply the fillet:  in
this case, M. Van  Huevel proposes -substituting for it a long forceps, the  upper ex
tremity of whose branches terminate in a half ring placed at right angles upon the
stem.  When the forceps are closed, we have a complete ring, by means  of which the
leg is seized above the malleoli.  But why should instruments be so multiplied without
absolute necessity ? 
944
OBSTETRICAL  OPERATIONS.
the child has been restored to a natural one by the pelvic evolution, the rest
of the travail is left to nature; provided ahvays the force and frequency of
FlQ. 122.                             Fio. 123.
 The version is here completed, and the occi-
put, which was placed in the left iliac fossa, at              Management of the cord.
the commencement of the operation, will now
come down behind the right acetabulum.
the pains are such as to give us reason to anticipate a speedy delivery.  But
if the uterine contractions are feeble or sIoav, or if the severity of the symp-
toms endanger the life of either the mother or the child, the tractions must
be kept up, and  the patient  be encouraged to aid them with all her remain-
ing strength.   The hips,  loins, and lower part of the chest soon come down ;
and as this delivery progresses, the accoucheur's hands ought to  embrace as
many parts as possible, constantly seizing those that are nearest to the vuhra,
and taking care  always to act on the bones, not on the soft parts.  The arms
are apt to become stretched out  along the  sides  of the head, and  thus
descend with it  into  the excavation ; when their disengagement must  be
effect,1;] in the  following manner: Ave  commence  with the posterior one,
Avhich has only the resistance of the soft parts  of the perineum to overcome,
and therefore will offer  less difficulty than the sub-pubic  arm.   The same
hand is again used by placing its index  and  middle fingers on the posterior
and external side of the arm, just beyond the humero-cubital articulation,
while the thumb rests on the anterior internal  plane of the humerus, Avhere
it acts like a splint;  the axillary space is thus found lying in the  interval
that separates the thumb from the tAvo fingers (Fig. 124).  The trunk hav-
ing been enveloped in  a napkin  is next carried up in front of the pubic
symphysis, either by the.other hand, or  by an  assistant.  Then the fore and
middle lingers, acting over  the whole  extent of the arm and a  part of the
forearm, bend the latter down over the side of the head and face  towards 
version.                            945
Fig. 124.
 the chest, on the side of Avhich it is ultimately placed after its complete dis-
 engagement.  The sub-pubic arm is next delivered by supporting the child's
 trunk upon the  other  forearm, and  depressing it
 towards the anus, Avhile the hand, not the one en-
 gaged in the previous operation, is introduced in a
 state of forced pronation; that is, turned over on
 its radial  border in such a Avay that the thumb
 can be still applied on the internal, and the index
 and middle fingers on the posterior surface of the
 arm ;  and  then this is brought down over the side
 of the  head, face, and  front of the  chest, as Avas
 the posterior arm.
   In ordinary cases, the head descends flexed into
 the excavation, the occiput being turned towards
 some point adjacent to the symphysis pubis, and
 the disengagement is effected spontaneously if the
 pains  are  tolerably strong and frequent; and  if
 necessary to facilitate it,  we have only to carry
 the trunk  up in front of  the  symphysis.   But
 should it happen that the expulsion of the  head
 is SOmeAvhat delayed, we must aid it  by introduc-   Delivery of the posterior arm.
 ing tAvo fingers  on the sides of the nose,  and tAvo  others on  the occiput,
 and  then,  by means of the latter,  the operator pushes up the occiput,
 while  he  draAVS  down, on  the  contrary, Avith  those  implanted  on  each
 side of the  nose,  and thus determines  a  movement  of flexion Avhich
 secures the delivery of the head.  The difficulty Avould be much  greater
 if the face Avas  turned forward, and the occiput backAvard; though  even
 here, if the head  is not  very voluminous, and  the pelvis is large, Ave might
 effect its delivery by depressing the trunk on the perineum, and by draAving
 doAvn the face in the pubic arch, with the  fingers planted on the  sides of
 the nose, so as to  flex  the head; or, on the other hand, by carrying the
 trunk up in front of the pubis, we might, in some exceptional cases, succeed
 in delivering the  occiput  first at the anterior perineal  commissure.  (See
 Mechanism of  Labor in Breech Presentations.)

   § 4.  Of the Difficulties that may be met with in performing the
 Pelvic Version.
   In common  simple cases, the manoeuvre is accomplished in the Avay Ave
 have just described; but it frequently happens that the  operator encounters
 difficulties in its performance, dependent either on the mother or on the child,
 which  next claim our attention.  Those which the mother's organs  may
present are, a  very small vulva, obstinate resistance  of  the uterine  orifice,
spasmodic contraction, and mobility of the body of the Avomb, and insertion
of the  placenta over the os uteri.  Those appertaining to the foetus are,
shortness of the umbilical  cord, unusual size of the  shoulders, crossing of
the arms behind the neck,  and extension of the head.
  a.  Smallness of the Vulva.— Unless the1 smallness of the vulva results
from the persistence of old adhesions, it is seldom  so  great, even in  first
       GO 
946                  obstetrical  operations.
pregnancies, as to constitute a serious obstacle to  the introduction  of the
hand.  The only precaution to be taken is to  pass in the fingers o.ie after
the other, and to make the hand enter gently and carefully.
  B. Resistance  of the Uterine  Orifice.— The causes and  principal indica-
tions of the resistances which  the uterine  orifice  may offer to the sponta-
neous expulsion of the child, have already been studied (page 698, et seq.);
and it is possible that these same difficulties  may  be  met with in  the  per-
formance of the version.   Here, also, the retraction may be seated  at the
external or internal  orifice of the neck.   Two conditions may be met Avith
when the external is the only one  affected ; that is,  the pelvic evolution  may
be necessitated, either by  a trunk presentation, or else by some  accident
Avhich, by compromising the life of the  mother or child, renders a prompt
termination of the labor imperative.  In the former case, Avhatever  be the
cause of the contraction, or of the  non-dilatation of the orifice, all the means
calculated to facilitate the dilatation will be brought into use ; such as vene-
section if the patient is plethoric,  tepid bathings, fumigations, and unctions
with the extract of belladonna on the periphery of the cervix;  and, Avhere
these remedies have  been employed Avithout success, we should act as in the
folloAving case.  In  the latter  case, the  necessity of terminating the labor
promptly does not permit us to rely on the employment of the  means just
enumerated, because their action is not developed for some time; and our
only resources are in a forced introduction of the hand, or multiple incisions
on the neck.   AVe have hitherto stated that, as a general rule, the repeated
incisions of the cervix appear  decidedly preferable  to a forcible introduction
of the hand, Avhich latter is ahvays a slow, difficult, and very painful opera-
tion, Avhilst the instrument is not  even felt by the  patient; besides, it is not
dangerous, and its results can be  more certainly relied on.  It is, hoAvever,
very necessary to take in  consideration  the nature of the accident Avhich,
in  this state  of the cervix, demands the intervention of art;  for, in  this
respect,  hemorrhage or eclampsia may  present very different  indications.
In  the former, it is very probable  that the contraction of the orifice is slight,
and capable of being  overcome Avithout much difficulty;  besides, should it
fail, the attempts at forcible  introduction would  have the effect to irritate
the organ and  excite the contraction of the  fibres  of  the fundus, whose
inertia had probably caused the flooding Avhich demands the termination of
the labor.  But, during an attack  of eclampsia,  there is every reason for
supposing that the contraction of the orifice is due to the convulsions, with
Avhich every muscle of the body is affected.   Hence, it is not of a character
to yield readily to attempts at introduction, and, in case of insuccess, it may
be feared lest, by irritating the very sensitive fibres of the neck, they might
have the effect to increase the general convulsions which we wish to remedy.
Therefore, we should, in this case, give preference to incisions.
   AA nen the spasmodic contraction is confined exclusively to that portion of
the uterine Avails which constitutes the internal orifice  in  the non-gravid
state, the hand, after  having  penetrated  the external one Avithout difficulty,
 is suddenly arrested by an obstacle that it cannot surmount.   This retraction
 is apt to take place, in  the presentations of the cephalic extremity, around
 the child's neck after the head is free,  but it is oftener observed in trunk 
version.
947
presentations.  The measures that we shall presently point  out  for combat-
ing the spasmodic contraction of the body of the Avomb, are et ually appli-
cable in cases of this kind.
   c. Insertion of the Placenta on the Neck of the Uterus. — As is Avell knoAvn,
this circumstance is an habitual  cause of hemorrhage, and often  requires the
pelvic version.  AVhen the placenta is only attached by one margin to some
point of the uterine neck, the hand is introduced at the part Avhich is not
covered, and the version presents nothing peculiar.  But a  different course
has been advised  relatively to the introduction of the hand,  Avhere the inser-
tion takes  place, centre  for centre, and  no portion of the circumference of
the placenta is detached.  Thus, it has been recommended  to perforate the
centre of the after-birth, and introduce the hand through this opening; but
this appears to us  a  difficult and  dangerous process, because:  1st, a great
number of umbilical ramifications  are then necessarily torn, and a hemor-
rhage produced Avhich may speedily prove fatal to the child; 2d, the force
necessary to effect this perforation is sometimes sufficient to drag upon, and
then detach, the periphery of the still adherent placenta; and, 3d, the central
opening made in the after-birth will seldom  be spacious enough to permit
the child's  trunk  and  head to pass  freely; Avhence  it may happen  that the
frictions made by the movable parts of the  foetus against the margins of this
opening, will facilitate a displacement of the arms and an extension of the
head.  Consequently, unless the patient's strength be already exhausted by
the flooding, or the placental adhesions be very strong, we would  rather
detach some point of the circumference of the  placenta, and thus  get the
hand betAveen its  external face and  the  internal Avail of the uterus.  True,
by operating in this manner, Ave should lacerate a certain number of utero-
placental vessels, and  thereby add  to the sources of hemorrhage, but  Ave
would succeed in saving the child's blood;  besides Avhich, the hand  and
forearm, at first, and then a little later the trunk of the foetus, by becoming
applied over the mouths  of these vessels, Avould compress them like a tam-
pon, and thus  put an end to the hemorrhage.
   D.  Violent Contraction of the Body of the Womb. — This is  a condition that
ahvays makes the  version very painful and  very difficult, and, in  certain
cases, may  even render it impossible;  it is, therefore, a sufficient reason for
preferring  an  application of the forceps Avhen the  cephalic extremity pre-
sents.  But, in a  case of trunk presentation, version would be the only
practicable measure;  and even  that might be rendered Avholly impossible
by the retraction of the uterus.  I  have succeeded very well in such cases
by introducing the hands one after the other several times, and using gentle
efforts to pass them deeply into the uterus.  The muscular fibre of the organ
being thus  fatigued, sometimes relaxes, and uIIoavs the feet to  be reached.
Here, likewise, venesection and  tepid  bathing prove very useful;  and the
employment of opiates is  particularly indicated, for  the aqueous  extract
of opium, when administered in injections, or by the stomach,  in  the dose
of three-quarters of a grain to tAvo grains, or an equivalent quantity of lauda-
num, is usually found sufficient  to  overcome the resistance of the  body of
the Avomb.   Under such circumstances, Dewees highly extols  a resort to
general bleeding,  carried to sy ucope;  and he makes the patient stand  up 
948
obstetrical  operations.
during che operation, whenever  possible, so as  to produce this effect m >re
speedily.
  I had an opportunity of putting the advice of the American accoucheur
into practice, for the first time, on a lady in the Rue du Four-Saint-Germain,
to Avhom I was called in consultation  by Dr. Treves.  The child presented
by the left shoulder ;  notwithstanding  which, ergot had been administered,
in consequence of an error of diagnosis, and the uterus was so contracted on
the trunk of the child that an introduction of the  hand Avas altogether im-
possible.   I made the patient get up, and had  her supported by  tAvo assist-
ants ; the vein Avas opened, and I permitted the blood to run until the Avoman
fainted;  when  she  was  immediately replaced on her  bed, and the version
Avas effected without difficulty.
  If these measures fail, and the child be still living, there is evidently no
other resource than to wait and hope for a spontaneous evolution from the
expulsory efforts of the uterus.  If it be dead, the section of its neck, a ccord-
ing to the plan of Celsus, and a separate extraction of the trunk, and after-
wards of the head, ought to be immediately practised, with a vieAV of sparing
the patient the disastrous consequences of a prolonged and usually a use-
lessly prolonged labor.  (See Embryotomy.)
  Again,  the contraction of the  uterus very frequently renders the  efforts
made during the version to turn the  anterior plane of  the  foetus backwards
ineffectual; and Avhere this is the case, it is not advisable to operate on the
trunk, by pushing it back and draAving it down alternately, endeavoring to
impress a slight rotation on it each time, as certain accoucheurs have recom-
mended ; for that Avould very often be impossible, and, besides, by being carried
too far, it Avould Avring  the  child's neck; for the head, being held by the
contraction of the fundus uteri, might not participate in the rotation im-
pressed on the trunk.  It is much better, therefore, to renounce it altogether
and permit the face to come above.
  Inhalations of chloroform have been  recommended by some  persons as
possessing  the immense advantage of quieting these spasmodic contractions
of the uterus, and of rendering versions easy, which Avere previously impos-
sible.  I have no personal experience in this matter, but upon interrogating
that of others, I find that they have obtained very different results.  Thus,
whilst M. Stoltz thought that he had remarked an increase in the frequency
and  force of the contractions, and  Mr. Murphy states that he had never
before met Avith so much difficulty in a case of turning, although the patient
was  completely under the influence of  the chloroform, Ave  find Dr. Denham
affirming  that in ten cases in Avhich  chloroform had been administered pre-
vious to the version, its  use had facilitated the operation, and that its happy
influence  was especially remarked in  the  case of a  Avoman  in  Avhom the
introduction of the hand, though attempted,fruitlessly before the inhalation,
was effected Avith the greatest ease immediately afterward.
  The facts as yet known are too contradictory to enable us to judge of the
efficacy of cl iloroform in these cases.   For even in those in Avhich its use was
folloAved by a  relaxatiqn of the  uterus, is it  certain  that this  occurrence;
AA'hich often  takes  place spontaneously  and suddenly, was anything mor6 
VERSION.
949
 man a simple coincidence?  There seems some reason for thinking so, when
 Ave recollect the cases in Avhich it  produced no  effect,  It is, therefore, an
 undecided question.   However, I should hasten  to add, that Mr. Simpson,
 and other most conscientious men, admit that  the inhalation of chloroform
 must be pushed to its fullest extent, and be continued for a long time, before
 it affects the muscles of organic life.  Mr. Simpson attributes the suspension
 of normal labor to the abuse and excess of inhalation.  If such be the case,
 is it not reasonable  to suppose that it would be necessary to carry the use
 of chloroform beyond the limits of prudence, in order to terminate  the ab-
 normal and almost tetanic contractions, and then is there not cause to  fear
 the occurrence of one of those terrible misfortunes Avhich some surgeons have
 had to deplore ?
   e.  Mobility of the Body of the Uterus.— According to M.  P. Dubois, suffi-
 cient stress has not been laid upon this difficulty; because, if unattended to,
 it may absolutely prevent the introduction of the hand as far as the fundus
 uteri.   That is, the hand, being wedged in between the uterine and foetal
 surfaces, attempts in vain to get at the feet, since the womb, the hand, and
 the trunk of the child  then  form a whole which turns on itself, but the
 hand does not progress into the interior of the  uterine, cavity.   To remedy
 this  obstacle, it is only necessary to have the fundus of  the  organ kept
 steady, by directing an assistant to place both hands over its superior and
 lateral parts.
   f. Shortness  of the  Cord.— AVhatever be the  cause, the  cord Avhen very
 short may become stretched, during the tractions on the pelvic extremity,
 and even to such an extent as to occasion  its  rupture.   This  accident is to
 be prevented by cutting the cord, when the tractions made on its placental
 portion are not sufficient to relax it.
   G. Large Shoulders.—As the loins become free at the vulva, the shoulders
 engage at the superior strait; when it happens, in certain cases, that the
 tractions, Avhich up  to that time had been efficacious, cease  to be  so  any
 longer, and some resistance is experienced in completing the delivery.  This
 resistance is dependent solely on the fact that the bis-acromial diameter of
 the shoulders corresponds to the diameter of the superior strait; and conse-
 quently, from its Avidth, encounters some difficulty in  clearing the latter.
 But  this is  easily relieved  by  imparting some oblique movements to the
 portions of the child  already disengaged, Avhich carry the breech successively
 to\;ards the groin of one side, and the sacro-sciatic ligament of the opposite
 side ; whereby the bis-acromial  diameter is inclined, and its two extremities
 are made to  engage in the excavation one after the other.
   H. Crossing of the  Arms behind the Neck.— It sometimes happens that one
of the arms (ordinarily the sub-pubic one) is found crossed behind the neck,
 when about to be delivered.  We have  advised that an attempt be made to
bring the child's posterior plane around in front; but in  order to accom- ■
plish this, it is necessary to make the trunk undergo a considerable revolu-
tion, during  Avhich the  arms, that are not involved  in the movement, might
be displaced by rubbing against the Avomb, and thus become crossed between
the neck and the poster or face  of the  symphysis pubis.  It  is  highly iin- 
950
OBSTETRICAL  operations.
portant to  bear in mind that, according to the observation of Duges, this
crossing of the arms may take place in two ways: namely, they may be
crossed  behind  the neck, after having been first raised up on the sides iff the
head, and then the overlapping is effected from above dowmvards and from
before backwards, relatively to the foetus; or it  may occur from below up-
Avards, the  arms then mounting up along  the  child's posterior plane, and
becoming placed  under the occiput.   This  latter circumstance may be pro-
duced in the folloAving way: as the arms are usually located on the sides of
the thorax, they may not participate in the movement of rotation impressed
on the trunk, in making an attempt to bring the anterior plane of the fcetus
tOAvards  the mother's loins; and, consequently, one or both of them may
thenceforth be  found placed on the child's dorsal plane.   Then, supposing
the tractions on  the breech  are continued, the arm will  become arrested
against  the symphysis pubis, Avhile the trunk  descends or is extracted, in
such a way as to be still there when the back of the neck reaches that  point.
These tAvo cases can be distinguished  from  each other  by remarking that,
when the crossing of the arms has ta*ken  place from above doAvmvards, and
from  before backwards, the inferior  angle of the scapula is removed to a
considerable distance from the median line of the spine; while, on the con-
trary, it Avill be quite close to it when the crossing has occurred from  below
upward along the back of the foetus.  The diagnosis is important, since the
disengagement  of the crossed arms evidently cannot be effected in the same
manner in  both cases; because, as a general rule, the arm has to be brought
down in an opposite direction to the course  it folloAved in becoming dis-
placed.   Thus,  in  the latter  case, it  must  be made to  descend along the
back, by hooking the elboAv Avith one or tAvo fingers ; in the former, it Avill be
first brought over the occiput, and then down  along the  side of the head,
face,  and sternum.  This latter  disengagement is  sometimes exceedingly
difficult, for the  occiput, being strongly pressed  against the symphysis,
seldom leaves free space enough between it and the os pubis for the  opera-
tion.  AVhen this  occurs, it has been recommended to press up  the  chest
forcibly, Avith a vieAV of making the occiput go upwards, and thereby releas-
ing the  arm.   It  would  certainly be better, after having disengaged the
posterior arm, to  impress a movement of rotation on the whole trunk and
head of the foetus, on its longitudinal axis, which would carry the occiput
and the arm to  be disengaged into the hollow of the sacrum.
  I. Arrest of the Head.— Both contraction of the  pelvis and extension of
the head may render difficult the delivery of the cephalic extremity.  But
as we have already pointed out Avhat  is proper  to be done in  the former
case, we need not  revert thereto again.
  AVhen the expulsion of the foetus is  left to the powers of nature, the head
descends, moderately flexed, into the excavation, and most generally its dis-
engagement presents no marked difficulty.   But Avhen it becomes extended
in consequence  of improper tractions  on  the breech, its long diameters are
brought into correspondence Avith the diameters of the pelvis, and its further
delivery is  thereby rendered impossible.  Of course, in this  state of  extern
don, the occiput may either be found  in front, (though this seldom  happens,) 
VERSION.
951
or it may be found behind, the face being above, Avhich is by far the most
common.1
   When the occiput  is in front,  the  flexion of the head is effected Avithout
trouble ; for it is generally sufficient to place two fingers on the sides of the
nose, or else on the lower jaw inside of the mouth, and then depress the chin
by a moderate traction on this part;  Avhilst tAvo fingers of the other hand
              Fig. 125.                                        Fig. 126.
At ilc of flexing the head by drawing down
  tlie chin and pushing up the occiput.
Mode of rotating the face into
 the hollow of the sacrum. '
are passed in under the symphysis and implanted on the  occiput, so as to
press up the latter above  the superior strait.   (Fig. 125.)  AVhen this ma-
noeuvre does not prove successful, it  has been recommended, before having
recourse to the forceps, to introduce the hand into the hollow of the sacrum
and grasp the face Avith its  palmar  concavity, in  order to bring  down  the
head into its normal position by effecting a forced flexion.
   When  the  occiput is behind, and its delivery  is not  possible,  either by
flexion or extension, (see Fig.  126,)  it is  advisable, says  Madame Lacha-
pelle, to change the position of the  head and  carry the  face back into  the
hollow of the sacrum ; and, for that purpose, to introduce that hand into the
sacral concavity whose palm Avould embrace  the  occiput more easily; (the
right, when the face is a little to the right, at  the same  time that it is in
  i The extension of tlie head, during version, is far more common in those cases where
the occiput is turned towards the sacrum.  The reason of which will be readily under-
stood by giving attention to the following circumstances, namely :  ihe tractions are
naturally made downwards and forwards, while the os uteri, which  has  a constant
tendency to retract, is directed somewhat downwards and  backwards; whence it results
that the anterior lip of the womb presses strongly on that portion of the child which
is turned towards the pubis.  Consequently, when the occiput is in front, the resist-
ance offered by this lip has a tendency to flex the head still more: but, on the contrary,
when it is behind, the chin is  almost inevitably caught by the anterior lip, and the
head is thereby extended. 
952
OBSTETRICAL  OPERATIONS.
front;  the left, when it is someAA'hat to the left; though, if the  face were
entirely above the pubic symphysis, the choice of the hand would  be a mat-
ter of indifference;) then  the fingers, after having passed behind the head,
are slipped over one side of it, and pushed forward as far as the mouth, by
gliding along the nearest cheek (Fig. 126).   The  hand is then forcibly in-
clined  on its cubital border, having the palmar  surface in front;  next, it
draAVS the parts on which the extremity of the fingers is  applied,  that is  to
say, the face, dowmvards and backAvards towards  the coccyx, when nothing
further remains than to flex the head and extract it as in ordinary cases.

   § 5.  Appreciation of  Version.
   Version, Avhen  performed  under favorable circumstances, that  is to  say,
when the membranes are intact, or have been ruptured Avithin a short time,
and the child, surrounded  by a considerable amount of fluid, still possesses
a certain mobility, is, in general, an easy operation, and but slightly hazard-
ous either to  the  mother  or the foetus.   Unhappily, it  must  be  confessed
that these fortunate conditions  are rarely met with in cases wherein we are
obliged to perform the operation.
   AVith the exception of shoulder presentations, none of the malpositions of
the child require the intervention of art, until, after waiting for a longer or
shorter time subsequent to the rupture of the  membranes and the complete
dilatation of the cervix, it is ascertained that the  natural efforts are insuffi-
cient.
   Shoulder  presentations  themselves are rarely detected certainly before or
very shortly after the rupture of the membranes, so that  unless an experi-
enced accoucheur should have attended the Avoman from the commencement
of the labor, he is not called in consultation until after the Avaters have been
discharged for a long time.   It is, therefore, mostly necessary to  act under
unfavorable circumstances.   Noav, it should'not be forgotten that  the requi-
site manoeuvres, Avhich are serious as regards the  maternal  organs, are
especially fatal to the child.  AVhilst pelvic version proves  fatal to one
Avoman out of 10'4 according to  Kiecke, and to  one out  of 11*4  according
to Hiiter, the  mortality of the children is  very much greater.   Thus, the
statistics  of  Madame Lachapelle represent the loss of one child out of 3"96,
and those of Carus,  Osiander, Michaelis, and  Khvisch more than one-half;
whilst Hiiter states the mortality at tAvo-thirds.  This mortality of the chil-
dren is truly frightful, and yet, considering  the accidents which, in  certain
of the cases, necessitated the version, and Avhich of themselves destroyed the
foetus, I think that  these results are correct,  so far as the  influence of the
mere operation is  concerned.  I have often heard  the venerable Capuron
say, that in  difficult cases, two-thirds, and perhaps even three-fourths of the
children  perished ; and the results of my OAvn practice correspond  fully  Avhh
his observation.  Churchill, avIio states 542 cases of version, gives a mortality
tff 1 in 3 for the children, and 1 in 15 for the mothers.   It is true, that he
makes  no distinction between difficult cases and others.
   The  above-mentioned difficulties, Avhich, unfortunately, are very common,
explain sufficiently this result.   AVith experience, and especially with great
care, it is always  possible to overcome them,  and, at the same time, spare 
VERSION.
953
 the mother the grave lesions of the vagina and of the body and neck of the
 uterus which an unpractised and brutal hand often occasions ; but Ave cannot
 ahvays prevent the violently contracted  organ from being exceedingly irri-
 tated by the forcible introduction of the hand, nor the irritation from becom-
 ing the starting-point of puerperal inflammations, nor the physical and moral
 shock to the patient from being so great as to terminate her existence.
   It is only necessary to have folloAved  the  manoeuvre in difficult  cases to
 understand the dangers to Avhich the fcetus is  exposed.   Throughout  the
 operation, the umbilical cord is liable to be compressed  more or less severely,
 and the efforts required to disengage the upper and loAver extremities, expose
 them greatly  to fracture.   Finally, the  tractions exerted upon the pelvic
 extremity, Avhenever an obstacle prevents a  ready engagement of the head,
 may very easily give rise to lesions of the upper part of the neck and  the
 medulla  oblongata incompatible with the regular  establishment of extra-
 uterine respiration.
   It  is very difficult, from an  examination of the  published statistics, to
 form  an exact idea of the frequency of  the cases in which version  may be
 required.   These cases, in  fact, are  not the  same in all countries, nor  for
 every accoucheur in the same country.   Besides, as the statistics Avere  for
 the most part  collected in hospitals,  it is evident that we would have a very
 incorrect proportion by deciding upon a mean  from the figure of  the ver-
 sions  performed in any one institution, because this figure represents  not
 only the versions required by the patients already admitted into the estab-
 lishment, but  also the difficult cases brought there at the last moment from
 the city.
   The following resume, to which, hoAvever,  I attach but  a very secondary
 importance, will at least serve to  show the differences in  the statistics ac-
 cording to localities.  Thus, whilst in England  but 145 cases of version
 are mentioned for 39,539 deliveries, or 1  in 269,  the French practice  gives
 400 versions for 37,479, or 1  in 934, and the Germans have  performed it
 337 times in  21,516, that is to say, in one case in 63f.

   § 6. Of  Version in Vertex,  Face, Breech,  and Trunk Presen-
 tations.
   After the minute detail into which we have just entered in describing the
 general precepts that  are  applicable to  all cases of version, it will only be
 necessary to point out the peculiarities attending this operation  in each of
 the ten positions admitted by us.
   Presentation of the Vertex.—AArhenever  the vertex presents, the child will
 be placed  in  such a way that its occiput is  directed either toAvards one of
 the points on  the right lateral half, or towards one on the left lateral half
 of the pelvis;  that is, either in the left or the right occipito-iliac  position.
   1. Left  Occipito-iliac Position.— In conformity Avith the precepts above
 given,  we would here introduce the left hand; yvhich, after  having reached
the os uteri, is to grasp the head in such  a manner that the palmar face of
the four fingers shall be applied on its posterior (left)  side, and the thumb
on its  anterior one, the  sinciput being  lodged  in  the palmar  concavity.
Then, during the interval betAveen the pains,  the  head  must be  pressed  up 
954
OBSTETRICAL  OPERATIONS.
towards fate left iliac fossa; after which, the thumb is brought alongside of
the index, and the hand is passed successively along the  left side of the
head and neck, and behind the shoulder and  elboAv; in a Avord, it is made
to traverse the whole left  lateral plane of the fcetus down to the breech.
AVhile this movement  is being effected, it is advisable to keep the  head in
the iliac fossa Avhere  it was originally placed,  by constantly pushing it up,
first with the thenar eminence of the hand, and  afterwards Avith the front
surface of the forearm.  Having  gained the nates, the hand, which up to
that time had been kept in a state bordering on supination,  is  changed into
one of pronation, in order to pass around the breech; when it descends on
the posterior aspect of the loAver  extremities, extends the legs, and reaches
the feet, which it seizes as firmly  as possible.  Or, as stated above, Ave might
guide the hand along the anterior plane of the foetus, and thus get  directly
at the feet.   (Fig. 120.)
   In drawing down the feet, we must be careful to curve the  child's trunk
in the line of its  natural flexure; Avhilst the  other hand, placed over the
left iliac fossa, pushes the  head toAvards the fundus uteri,  and thus facili-
tate* the  evolution of the fcetus.   This evolution being once  effected, the
left occipito-iliac  position is  found  to be converted  into a right lumbo-
iliac one.  The subsequent progress  of the delivery offers no  special indi-
cation.
   2. Right Occipito-Piac Position. — In this case, the  right  hand Avould  be
chosen in  preference, by which the head is to be grasped, as in the preced-
ing case, and then to be  pushed up towards the right iliac fossa; the hand
traverses the right lateral or posterior plane of the foetus, and after having
seized the feet converts the  second position of the vertex into a first of the
breech, or, in other Avords, into a left lumbo-iliac one.
   The rapidity with which the extraction is  to be effected  must depend
upon the gravity of the accident which has rendered it necessary.
   Presentations of the Face. — In  the  face presentations, Ave use  the left hand
in the right  mento-iliac, and the right one in  the left mento-iliac positions.
The four fingers are to be applied on the posterior cheek, the thumb on the
anterior one, and the face Avill be lodged in the palmar concavity; the head,
after having  been pushed above the superior strait, will be carried if pos-
sible toAvards the left iliac fossa in the right mento-iliac, and  towards  the
right iliac fossa in the left mento-iliac positions; and then the evolution will
convert the former of these positions into a right lumbo-iliac, and the latter
into a left lumbo-iliac position.
   Presentations of the Pelvic Extremity.—When the pelvic extremity pre-
sents,  and any circumstance whatever demands a prompt termination of the
labor, it  is  not, properly speaking,  a version  that the accoucheur has to
practise,  but rather a feAV simple  tractions on the presenting part.
   If the feet  or the knees offer at the uterine orifice, or hang in the vagina,
the accoucheur merely seizes and draAvs  on them, conforming to the rules
above  given; but where the loAver extremities are stretched out along the
child's anterior plane, and the  breech alone presents, the course to be pur-
sued varies a little, according as this part  is  more or less engaged in the
exe?V0tion.  Thus, when the nates are still  above the superior strait, or at 
VERSION.
955
Fig. 127.
least are so little engaged that it is easy to press them  up, we mu»t  act in
the following manner:  taking care to introduce the left  hand  in the  left
lumbo-iliac positions, and the right hand in the opposite ones, the buttocks
are first seized by the whole hand, and gently pushed up into that iliac fossa
tOAvards Avhich the child's  back is  turned ; then the feet are sought out, by
folloAving the posterior aspect of the lower extremities, and they are brought
down so as to draAV upon them and terminate the third stage of the version.
AATien the nates  have reached the pelvic floor, the index finger of one hand
is  placed in the posterior  groin, and the same finger of the other hand in
the anterior one, and then, having both fingers curved like a hook, Ave draAV
on the buttocks until the feet are entirely clear.   Lastly, if the breech is so
far engaged  as to be no longer capable of being  pressed above the superior
strait, and, nevertheless, has not yet descended low  enough to be caught by
the fingers, a blunt hook is employed,  Avhich is to be applied from Avithout
inwards on the anterior groin, if it is possible to make it slip up betAveen  the
anterior hip and the symphysis pubis (Fig.  127); in the contrary case, it is
passed between the tAvo thighs, and made to penetrate from Avithin outAvards
on the  internal  part of the limb ;  but in this  latter case it is necessary to
protect the genital  parts,  the scrotum in par-
ticular, by one or  more fingers previously in-
troduced, lest  they become  embraced by the
concavity of the instrument.  (See also For-
ceps.)
  Presentations of the Trunk. — AVe have fre-
quently repeated that the trunk presentations,
of themselves, require the intervention of art;
and that it is  requisite to change the position
of the child as soon as the conditions necessary
to this evolution are met Avith.   In the pre-
ceding article we endeavored to point out those
conditions under which we think an attempt
to effect  the cephalic version ought to be re-
commended ; notAvithstanding Avhich, the pelvic
version is very often practised, either because
such attempts have proved ineffectual or be-
cause it is deemed  advisable not to resort  to
them.                         »
  Nevertheless,  before laying doAvn the rules
of the  operation,  Ave  must  remark that the
accoucheur  only resorts to  pelvic version  in
these eases  in order to remedy the defective
presentation ;  and  consequently that, as  soon
as  he shall have converted this latter  into one of the breech, he  should
abandon the rest of the labor  to the expulsory efforts of the uterus, unless
some accident, serious enough to threaten the  life of either the mother or
the child, should  require  a more  rapid delivery.   As before  stated,  the
trunk presentations are two in number, and each side  iff the foetus may  pre-
sent at the superior strait in two different positions: in  the first of each,
Mode of using the blunt hook in
      breech positions. 
956
OBSTETRICAL  OPERATIONS.
the head is m the left iliac fossa, and in the  second it is in the right iliac
fossa.
  The rule heretofore followed in the choice of tne hand is  not applicable
to the trunk presentations; for here we would introduce the  right hand in
the positions of the right lateral plane, and the left in the positions of the
left lateral  plane; after which the operation is conducted in the following
manner:
  A. First Position of the Right Shoulder (left cephalo-iliac). — The right
hand is to be introduced into the parts in a s'tate of supination, Avhen, after
having endeavored to push the shoulder above the superior strait, and  a
little toAvards the left iliac fossa, it is directed towards the right sacro-iliac
symphysis, above which the child's feet  are found ; the  latter will then be
seized and brought down into the vagina.   In doing this, it is not necessary
to bend  the fcetus  in the line of its natural flexure, as in the vertex  and
face positions,  but  we may draw immediately on  the feet and bring them
into the  excavation; for  this  lateral evolution, or  bending on the side, is
much more speedily accomplished, and is not  attended Avith  any inconven-
ience.  The feet being once in the vagina,  the  operation  is  terminated as
in all other cases.
  B. Second Position of the Right Shoulder (right cephalo-iliac). — Here,
likeAvise, the right hand is introduced in a state of supination.  The shoul-
der is seized and pushed up toAvards the right iliac fossa, and  then the hand
traverses the posterior plane of the foetus, by passing backwards and to the
left; when it reaches the nates, it gets around them by being changed into a

       "    Fig. 128                                        Fig.  129.
 The introduction of the hand in the second                Mode of seizing the feet in the same
      position of the right shoulder.                              position.

state of pronation, and then comes fonvard and to the left to grasp the feet,
Avhich are next brought  down into the A'agina.   (Fig.  129).
  c. First Position of the Left Shoulder (left cephalo-iliac).—The left hand
is introduced in a state of supination, and then, after  pressing the shoulder
upwards and a little to the left, it is directed along the child's back toAvards
the right posterior part of the  pelvis, where it  is passed around the breech
 
VERSION
957
Fio. 130.
Mode of seizing the feet in the second
    position of the left shoulder.
  by turning to a state of pronation, and is next brought forward and to the
  right, so as to seize the feet.
    D.  Second  Position  of the Left Shoulder
  (right cephalo-iliac.) — The  left hand, in-
  troduced  in a  state of supination,  pushes
  the shoulder above the  superior strait and
  somewhat to the right;  and then, passing
  toAvards the left side and  posterior part of
  the uterus, it goes  in search  of the feet,
  which are found there.1
    Trunk  Presentations  with a Descent of
 the Arm.   (Presentations of  the  arm or
 hand,  of  authors.) — AVe  have heretofore
 stated that the descent of  the hand  in the
 shoulder presentations  is nothing more than
 an attendant circumstance of these  latter.
 Consequently, Avhether the hand has  been
 carried along by the gush of waters which
 escaped Avhen the  membranes were  rup-
 tured, or whether it  has been drawn doAvn
 by the accoucheur himself, in order to make out the diagnosis, it constitutes
 an obstacle of minor importance, and even  one which may render the pelvic
 version more easy; hence,  so  far from attempting to push back the arm into
 the uterus, we ought to  apply  a fillet on- the wrist, not for the  purpose of
 drawing upon the latter, but to prevent it  from returning  whilst searching
 after the feet in the ordinary Avay.

   1 As the  reader will see, this operation  is very simple; though it must be acknowl-
 edged, however, that, in those cases in which the dorsal plane of the foetus is directed
 forwards, it renders this plane liable to be turned backwards after the evolution of the
 child.   Consequently, when we cannot succeed in turning the belly posteriorly during
 the traction, it gives rise  to all the  inconveniences  hitherto pointed out as  occurring
 in those instances in which the face looks toward the pubis.
   In  order  to  remedy these difficulties and their attendant dangers,  M. Velpeau
 recommends that the  positions in which the back  is  in  front (the first of the right
 shoulder, and the second of the  left) be  converted into the dorso-posterior positions
 before attempting the evolution.   Thus, he would endeavor to convert a second posi-
 tion of the  left  shoulder into  a  first of the  left, by making the head  pass  above the
 pubis or above the promontory of the sacrum, according  to whether it was originally
 placed nearer to the anterior arch of the pelvis,  or to the right sacro-iliac symphysis ;
 lie would then terminate  it, as if it had  primitively been a first position of the left
 shoulder.  " Should the membranes have been long ruptured," adds M. Velpeau, " the
 womb strongly contracted,  and the child not to be moved but with very  great difficulty,
 there is a third manoeuvre that  ought  then  to be  preferred ; it consists in pushing
 the shoulder up with the  right  hand from behind  forwards, as if  to  make the spine
 turn upon its own axis;  then  trying  to reach the  right side by  passing along the
 front of the  chest, while the womb  is forcibly pushed backwards with the left hand;
 lastly, in taking hold of the feet, the right one first, so as to bring them down in the
 first position."-—Mi'igs1 Translation, p. 447.
  We have alluded to this manoeuvre, only because the author's name might give it
some importance in the eyes of young practitioners.  But in our estimation it ought
to be  rejected altogether.  In fact, one of two ihings  must then happen; for either 
<
958                 OBSTETRICAL  OPERATIONS.

  " Our  object  in applying  this fillet," says Madame  Lachapelle, " is to
keep the  hand at the exterior, lest the arm should take a Avrong direction;
as also lest, being stretched out as it is, it will not folloAv the rotation that
turns the sternum of the foetus  posteriorly, Avhen, by being arrested by the
pubis, and by ascending along  the  child's back, it  might  become crossed
behind the neck."   Finally, let us  add, that the hand, or  rather the arm,
materially aids in accomplishing the rotation of the trunk, since it offers an
additional hold for the tractions  made  on the body, and obviates the neces-
sity of delivering one shoulder, Avhich is very often painful.
  After Avhat has just  been said, the reader will doubtless be astonished in
looking over the older  Avriters,  to observe the alarm occasioned by the so-
called  presentation of the hand or arm, and he Avill be still   more surprised
at the barbarous procedures employed by  them for its management.   They
Avere evidently mistaken with regard to the cause of the difficulties that are
often met Avith  in the  performance of version  under such circumstances.
However, it must be acknowledged that, although a presentation of the hand
is nothing more than a variety of the shoulder presentation, yet the descent
of the forearm, and  more especially of the arm, beyond the vulva, consti-
tutes an exceedingly  unfavorable complication.  Because, Avhere this hangs
down at the exterior, or nearly so, it must necessarily happen  that the pre-
senting shoulder is already  forcibly engaged in the excavation;  an engage-
ment that can  only  take  place when the Avhole of  the  Avaters  have been
discharged  for some  time, when the uterine contractions have been exerted
for a long Avhile on the body of the child, and Avhen  the walls of the womb
have become firmly retracted on the surface of the  foetus.   Moreover, the
prolonged contact of the foetal  inequalities  is then  very apt to bring on
spasmodic or .tetanic contractions of the body and the neck of the uterus,
Avhich  are justly considered  as  constituting one of the  most serious com-
plications ;  for they equally prevent the  return of the presenting part, the
introduction of  the hand, and the evolution of the foetus.
   Consequently, Ave' are not  to  operate on the part that  may present in
these difficult cases;  for a return of the arm into the  uterine cavity is then
impossible, and of little service; to  draAV on  it strongly, under  a hope of
engaging the doubled-up trunk in the excavation, and of making it perform
a kind of artificial evolution, is to commence a manoeuvre that cannot be
carried through, and which must greatly augment the existing difficulties;
to go in search of the other arm, so as to subsequently  pull upon it Avith a
vieAV of making  the descended shoulder return, presupposes  an introduction

the uterus is  forcibly retracted (when this  conversion, if persisted in, appears to uh
impracticable and dangerous), or else the womb is inert, and  it would  therefore be
useless.  As we have already  stated, the reason for dreading  a persistence of the
ehild's anterior plane in front, is not because  it cannot be turned backwards during
the traction, but  because  there is reason to fear  lest  the head,  by being arrested
by the contraction at the fundus of the uterus,  may not follow the movement of rota-
tion impressed on the thorax, whereby a torsion of  the neck might result.  Again, if
the organ is inert enough to admit of the preliminary conversion advised by Velpeau,
it. would doubtle93 be sufficiently so to enable the accoucheur to direct his tractions in
such a way as to bring the occiput in front, and the face into the hollow of the sacrum,
without hazard. 
THE  FORCEPS.
959
of the hand, which would be almost as difficult as searching after the feet;
and, lastly, to scarify the arm or amputate it, is a barbarous measure Avhen
the child is living, and generally useless when it is dead.
  AVe repeat, it is not there that the genuine obstacles to the delivery are
to be found;  but  it  is rather against the violent contraction of the body
and occasionally of the neck of the womb, that Ave are to act, by employing
the measures  recommended above.   Should these fail, the course to be pur-
sued will necessarily  vary, according to Avhether the foetus be living or dead.
If still living, and the mother's condition does not  absolutely demand a
prompt  delivery, we should  hope,  and wait for  a spontaneous  evolution.
(See Natural Labor.)   But  if her life is seriously  compromised,  though
the child  be  yet alive, its viability may be considered  as destroyed, and
embryotomy be resorted to.  (See Embryotomy.) The reasons for this course
will be still more  urgent Avhen there is a certainty of its death.
                         CHAPTER  IV.
                          Or THE FORCEPS.
  The forceps is a kind of pincers composed of tAvo blades, very similar to
each other, and Avhich are specially intended to be applied on the head of
the fcetus.
  The honor  of inventing this instrument has been attributed to several
persons;  but,  at the present day, it  is clearly established that the forceps
was invented  by a member of the family of the Chamberlens, avIio, during
the first half of the seventeenth century, pursued  the censurable course-of
holding it as a secret, by the aid of Avhich they promised to  terminate the
most difficult labors.  It Avould appear, ho av ever, that it soon became knoAvn
to some of the English practitioners; for DrinkAvater, Avho practised the art
of midAvifery from 1668 to 1728, made use of instruments Avhich, if Ave may
judge  from the  description given of them by Johnson, closely resembled
those employed by the Chamberlens.
  In 1670, one of the Chamberlens came to Paris for the purpose of selling
his  secret; since, according to the account of Mauriceau, he had  proposed
to the king's chiefphysician to make known his instrument for a remunera-
tion of ten thousand croAvns.  As  Chamberlen believed his  process was
applicable to  all cases, he unfortunately promised to effect  delivery in a
Avoman Avhose pelvis  Avas deformed  to  an extreme degree, and  on  whom
Mauriceau had  deemed the  Caesarean  operation to be  necessary.  Conse-
quently, as the French accoucheur had  foreseen, all the attempts of Cham-
berlen  to accomplish the delivery proved ineffectual, and he  returned to
England, abandoning all  the  glittering  hopes of  fortune that he had ex-
pected  to realize on arriving at Paris.   It Avould  seem that he  aftenvards
made  a journey  to Holland, about  the  year  169o, and communicated, or
rather sold, some of his instiuments to  certain accoucheurs there, among
whom Pioonhuysen, Puysch, and Bockelman  are particularly mentioned. 
960                  OBSTETRICAL  OPERATIONS.
 In fact, it is almost  certain  that  the famous lever of the  former of these
 physicians had no other origin, and was only a slight and defective modifica-
 tion  of the  instrument he obtained from Chamberlen.  However this may
 be, the forceps Avas likewise held as a  secret for a long time in Holland, and
 it was not until sixty years  aftenvards, that is, about the year 1753, that
 Visscher and Van de Poll brought Roonhuysen's  lever into general notice.
   Palfyn, an accoucheur of Ghent, has also been  incorrectly considered as
 the  real inventor of the forceps.   He made several trips  to  London and
 Germany, Avith a vieAV of finding out  this wonderful secret;  which, accord-
 ing  to  Mauriceau, had furnished  Chamberlen an income of  more  than
 thirty thousand livres per annum (an enormous sum for that period); and
 it is  probable that it Avas in  consequence of the  information  obtained in
 these tAvo  countries, that he designed  the instrument for draAving upon the
 head (tire-tete), subsequently presented by him to  the Academy of  Sciences
 at Paris.2
   Chamberlen's forceps underwent a number of modifications after it became
 public property, that Avere generally unimportant; and  fortunate indeed
 was  it Avhen  the so-called improvements did  not  render  it  more awkward
 and  dangerous than  before.   But  the  middle  of the eighteenth  century
 opened  a neAV era in the history of this instrument; for, about this period,
 tAvo illustrious obstetricians, Levret in  France,  and  Smellie in England, Avere
 struck Avith the necessity of accommodating the  shape of  the forceps to the
 direction and form of the  pelvic  axis ; and, as a  consequence, they thus
 enlarged the field of its application.  Chamberlen's forceps Avas straight,
 and therefore only applicable when the head  was  low down in  the excava-
 tion,  and close to the  perineum ; but both of these  gentlemen endeavored to
 render it capable of being applied to the head Avhen still above  the  superior
 strait;  and for that purpose they gave it a curve in the direction of its long

  1 We may remark that the instrument described by these last-named authors, under
 the title  of Roonhuysen's lever,  was  not the  one  which the latter had bought of
 Chamberlen, for it is oomposed of a single curved iron blade.   In 1747, Rathlauw
 published a description of an instrument that he had received from Vander Swam, a
 pupil  of  Roonhuysen, which was  composed of two blades, having fenestroe  in them,
 and joined at their extremity by means of a pin.
  2 This presentation, made at a time when  Chamberlen's  forceps were scarcely known
 in France, unjustly obtained for Palfyn the reputation of being its inventor.  But, in
 our day, the question can no longer be considered doubtful, for,, independently of the
 numberless proofs that establish  the claims of the  Chamberlens, they have recently
 been confirmed,  says Dr. Edward  Rigby, by a discovery made in the county  of Essex.
 It appears that Dr. Peter Chamberlen purchased, towards the end  of the seventeenth
century, the estate of Woodham,  Mortimer  Hall,  near Maldon, in Essex, which con-
tinued in the  family till about 1715, and was then  sold  to  Mr. Wm. Alexander, who
bequeathed* it to the Wine Coopers' Company.   About the year 1815, the tenant in
occupation discovered, in the floor in the uppermost of a series  of closets, which are
built over the entrance-porch, a trap-door.   In the space between the flooring of this
closet  and the ceiling below were  found, among a number  of empty boxes, a cabinet
containing a collection of old coins, divers trinkets, many letters from Dr. Chamberlen
to different members of  his family, ami some obstetric  instruments.  These instru-
ments, which were given  to Mr.  Carwardine by the lad}' of the mansion, and described
by Rigby, exhibit the successive attempts mad** by the Chamberlens, before they suc-
ceeded in perfecting their forceps. 
THE  FORCE r'S.
961
Fio. 131.  Fig. 102.
axis, so that the anterior border presented a concavity and'the posterior one
a convexity.
  It is impossible to ascertain Avhich of the tAvo had the priority in originat-
ing this important modification  of the forceps; for, though it is certain that
Levret  had such a curved instrument  in  1747, and that Smellie did not
.innounce his  until  1751, yet the  latter expressly declares that he had in-
dented it several years previously;  hoAvever,  as  his invention had not been
made public, the merit of priority7  belongs to Levret.
  Hundreds of modifications have been proposed since the days of Levret
and Smellie, nearly  all of Avhich have fallen  into oblivion; some of them
Avere quite ingenious, but they imperfectly attained the end their authors had
in vieAV ; and others were really destitute of value or utility.  Consequently,
Ave shall restrict Avhat Ave had intended to say concerning its history to these
feAV lines, and shall only describe the forceps noAV generally used throughout
France, which  is none other than that of Levret, very slightly modified.
  The forceps  is composed of two branches, each of which may be divided
into three parts, namely:  the blade, the handle, and the point of junction,
or the lock. The blade is intended to be introduced into the mother's parts,
so as to embrace the head of the foetus; presenting, therefore:
  1. A curvature on its flattened aspect, the internal concavity of which is
destined to be applied to the side of the foetal head, Avhile its external con-
vexity slips along  the concave Avails of the
pelvis.  2.  A  curve on  its edge,  having  the
concavity anteriorly, Avhich is  made for  the
purpose  of accommodating  the form of  the
instrument to the direction of the pelvic axis;
and to  render  an application of  the  forceps
practicable even when  the  head  is  retained
above the superior strait.   The blade is usually
provided Avith a fenestra, Avhich serves to dimin-
ish  the size and weight of the instrument, arid
has the  further  advantage of permitting the
parietal  protuberances  to engage  in  the AToid
thereby produced, Avhich engagement compen-
sates, to  a  certain extent, for the thickness of
the branches.   The old forceps  Avere provided
with a kind of  bead  around the  periphery,  and \-S,
the internal face of the blades, Avhich Avas made isi. The male branch. 132. The female
                    .,    j  j  .    1  -j. x„  +i „    branch.  133. The forceps locked.
quite prominent, Avas intended to obvitute  the
slipping  of the  head.  But the contusions of the scalp,  produced by this
raised border, have led  to its removal, and  those now in  use have the inner
surfaro of the blades polished down with a file.   Both handles of the instru-
ment are usually bent to a slight degree at their extremity, in the form of
a hook.  One of them is much  more curved than its fellow, and has, near
its end, a hollow button, which- unscrews and serves for the lodgment of  a
sharp hook, while the curve of  the other scarcely reaches a right angle, so
that we  find the forceps, a blunt  and a sharp hook, included in the same
instrunien . The handles and blades are just alike on both branches, which
      61
 
962
OBSTETRICAL  OPERATION'S.
differ from each other only at their  middle or articular part, Avhere one of
them is provided with a pivot and the other with a  mortise, made either in
the middle or  on the side of the instrument, by means of Avhich they  can
be firmly locked after their application.   The branch bearing  the pivot  has
received the name of the male (Fig. 131), and the other, having the mortise,
that of the female branch,  or blade  (Fig. 132).   The delicacy of certain
accoucheurs has  been  shocked  by  these  denominations, and they  have
endeavored to  substitute for them the  titles of the left and the right blades;
but I cannot understand why the old names of the pivot blade and  the mor-
tise blade should not  be  retained ; though I Avould willingly accept those of
the left and the  right ones if it  were clearly understood which ought to be
called the left and Avhich the right.  But unfortunately such is not  the fact,
for M. Velpeau designates that blade as the right one which Madame Lacha-
pelle has called the left, and vice versa.   This discrepancy of  terms creates
great confusion in the mind of the reader, Avhich we shall endeavor to  avoid
by retaining the names of the male and the female blades.

  [Of all the parts of the forceps, the articulation has,  perhaps^ been the most  fre-
quently altered.   In Levret's" instrument  the mortise is  placed lengthwise in  the
centre of the female blade.  In the articulation, the  female blade has to be raised,
in order to allow the pivot to  pass through the mortise, Avhen a turn of the pivot
makes all  secure.  If the fingers are unable to  turn  it, a key made for the purpose
may be used.   (See Fig. 132.)
  In Siebold's forceps, the place for the pivot is a notch  in  the side of the female
blade, and the articulation is effected by simply bringing the  two blades  together
anc1 screwing down the pivot after it has entered the  notch.  This kind of articula-
tion is the one now generally used.
  The articulation of Brunninghausen's forceps resembles the preceding, with the
exception  that the pivot is a simple pin, which enters the lateral notch and  holds
the blades with sufficient firmness Avhen the attempt is made to bring them together.
The articulation of Smellie's  instrument  is effected  by a sort of interlocking, the
left blade  having a notch which receives the articular part of the right one.
  The  branches  of the forceps just described  cross each  other, and can only be
articulated Avhen the male blade  is below the female one, so as to allow the pivot
to enter the notch.  To avoid this inconvenience, Avhich, after all, is not so great as
has been represented, a forceps, described by Thenance in 1801, was invented, the
blades of which are parallel and articulate at their ends by means of a hinge fast-
ened with a pin ; besides  which, they are pierced  at their centres with an oval
opening intended to receive  a band which  secures  the  articulation by tying  the
blades firmly together.
  The latter instrument is still much used in the  middle of France, where it is
knoAvn as  the Lyonese forceps.   Taking it as a model,  my colleague, M. U. Trelat,
had a forceps made of the  same form, but of reduced size, and remarkable for  the
flexibility  and elasticity of its blades.
  The wish to avoid the uncrossing of the branches when the male  blade happens
to be placed above the  female one, led Dr. Tarsitani to devise his  instrument, the
I ranches Of which are crossed like  Levret's forceps, whilst the pivot projects on
either side of the male blade.  It will be seen  that  this arrangement makes  it a
matter of  indifference whether the female blade be above or below, and the articu-
lation is as easy in one case as in the other.  As, however, the branches were no
longer  parallel,  it was necessary to break one of  the branches and supply it Avith
a hinge joint, which allows that  handle to be depressed at will, in order to restore
the parallelism. 
THE  FORCEPS.
963
  The forceps, besides grasping the head of the child, subjects  it to compression,
and if the operator uses too much force, or presses the handles too strongly U gether,
the  compression may be  dangerous.   To avoid this  risk, Petit  had a stop  put
between the handles of  his forceps, which limited the extent to Avhich they could
be closed, and measured, as it were, the degrees of pressure to which the head was
subjected.  Lauverjat, and other accoucheurs, devised similar arrangements, which
from time to time have been resuscitated,  and deserve, perhaps,  to be added to our
modern instruments.  Doubtless, with the same idea,  M. Mattei  within a feAV years
past invented  an instrument to Avhich  he gave the name of leniceps.  The blades
resemble those of Levret's forceps, but the usual handles are cut off at the  point of
articulation, and their place supplied by  a transverse one, which is furnished Avith
notches at intervals, so  arranged as to allow the blades to be separated or brought
together.  The chief advantage of this instrument is its transverse handle, which
fits  Avell the operator's hand, and prevents too great compression of the  head.  Its
disadvantages are, that  it affords a less secure hold than Levret's forceps ; and as
the degree of separation of the blades is predetermined by the notches of the handle,
it is impossible to regulate exactly the application of the blades to the sides of the
head. In this respect, those forceps are preferable which are provided with a movable
stop or a screAA', which allows the degree of approximation to be regulated at will.
  In cases of contracted pelvis, the necessary application of the  forceps to the sides
of the cavity causes the  head to be compressed laterally, and consequently lengthens
it in the  direction of the antero-posterior diameter.  In order to avoid this incon-
venience, Baumers (of  Lyons) invented  a  forceps curved in  such a way that one
of the blades could  be applied directly in  front, behind the  pubis, and the other
directly back.  It was with the same idea,  doubtless, that Leake devised an  addi-
tional branch  to the common forceps, which Avas capable of being applied directly
in front.
  Within a few years past,  Dr. Chassagny (of Lyons), and our colleague M. Joulin,
Adjunct  Professor  to the Medical  Faculty of Paris, conceived  the idea that there
might be an advantage  in cases of difficult labor, in the substitution of an apparatus
for  producing steady traction, for the muscular effort of the accoucheur.
  M. Chassagny's plan was, after applying his forceps, to attach one end of a cord
to two hooks placed at  the junction of the  handles Avith  the  blades, the other end
being fastened to the middle of a metallic bar placed in front of the woman's knees
which  gave it a fixed  support.  The cord  being then draAvn upon by means of a
screAV, brought aAvay the  forceps and  child  together.   Chassagny's apparatus has
the merit of priority, but  has also the inconvenience of requiring a special addition
to the forceps.
  The principle of M.  Joulin's instrument, which he calls an aid-forceps, is the
same as that of M, Chassagny.  It  consists of  a padded  metallic  bar. Avhich  is
placed, not upon the knees, but against the woman's ischia, the thighs being mod-
erately flexed.   The common  forceps are then applied, and a  band being passed
through  the fenestras, is attached  to a drawing-screAv with which  the bar is  pro-
vided.   The traction made  upon the band by turning  the  screw Avithdraws the
forceps and head of the child.  As the  band passes through  the fenestrae of tlie
forceps, they have a direct tendency to approximate the blades with a force propor-
tionate to the resistance, and  thus increase the firmness of their hold.  By means
of a small dynamometer the force used is indicated in kilogrammes (a kilogramme,
about tAvo pounds), so that there is no occasion for exceeding the limits of a prudent
intervention.  Chassagny's and Joulin's instruments both act by effecting mechan-
ical traction steadily and progressively applied, a form  of power which  had not
before  been utilized in  obstetrical practice.   The question now arises, Is this kind
of force likely to be useful or injurious?   It can only be replied at present, that, not-
withstanding the laudable experiments of some accoucheurs at  Lyons, nothing has 
964
OBSTETRICAL  OPERATIONS.
yet. appeared to demonstrate the utility of machines of the kind described, and thai
our colleague and friend, M.  Bailly, Avho has learnedly compared their ad rantages
and disadvantages, condemns them.  (Bailly,  Thesis for the Concours, 18GG.)
  In concluding the description of the forceps, Ave would add, that all  instrument-
makers noAvadays  construct  them so as to allow the branches  to be taken apart
about their middle.  It is a true step  in advance in the cutler's art,  making the
forceps much more portable, at the same time  taking nothing from its strength and
solidity.]
   Some  time since, Dr. Simpson proposed a new forceps, which deserves
mention, if only on the score of its  originality.  Every one has  seen  those
circular  pieces of leather  Avith Avhich children  lift bricks, by first wetting
them and then pressing them strongly upon the  brick.   Now,  the ingenious
Edinburgh professor conceived the idea of applying a nearly similar piece
of leather to the convexity of the child's head projecting into the excavation,
and  producing its adhesion to the scalp by exhausting the  air  from between
them by means of a pump, the body of the pump also serving as a  means
of traction and draAving the  head outside of the  genital parts.
   This instrument is very ingenious, but I doubt much whether it will ever
come into general use.  When the head is in  the cavity of  the pelvis, I
think that the common forceps Avould be  applied much more easily ;  Avhen
it is high  up, the application of Dr. Simpson's instrument Avould be very
difficult, besides which, its form Avould give  an  improper direction  to the
first tractions.  I Avould also add, that if violent tractions were necessary, it
might cause a separation of  the scalp and a dangerous effusion of blood.
   We shall divide our remarks on the subject of the forceps into three dis-
tinct articles: in the first of  which Avill be found the precautions  that ought
ahvays to be taken before proceeding to an application of this instrument; in
the second, we shall point out the general rules applicable to all cases; in
the third, the directions peculiar to each position; and shall close the Avhole
by some general considerations on its employment and mode of action.

                            ARTICLE I.
                       PRELIMINARY PRECAUTIONS.
   The Avoman is to be placed in the position before  recommended for the
performance of version ; the  loAver extremities being supported by tAvo assist-
ants standing on the outside of the limbs, and having the pelvis firmly held,
so as to prevent her from  giving Avay to  any involuntary movements  that
might annoy the operator; of course, the breech ought to be brought to the
edge of the bed.   The patient  should  be placed in this position whenever
nothing  particular prevents, and more particularly Avhen the head is high
up, though it is not so necessary Avhen the latter is at the inferior strait.  In
fact, if she found it impossible to change  her posture,  Ave might  permit her
to remain horizontally on the bed; but it Avould  then be requisite to employ
the old straight forceps, or else resort to Smellie's, wdiich  is very short, and
the blades slightly curved.   The English  practitioners place the patient on
her left side, the position  in Avhich the women of their country are usually
delivered, taking care, however, to bring the pelvis nearer to the edge of the
bed  th*,n usual.   An assistant, standing  on the opposite side of the  latter; 
THE  FORCEPS.
965
a olds the patient steady, Avhile another  raises up  and supports the right
knee and thigh.   But whatever be the position, one attendant is particularly
charged Avith the duty of preparing and handing the blades to the accoucheur,
as he may Avant them.
  In order to spare the female the disagreeable sensation  produced by an
impression of cold, it  is customary to Avarm  the  instrument by dipping it
into hot Avater.   Some care is requisite  not to leave it there too long, and,
before using, it should  be passed through the closed hand so as to be certain
there is no danger of its burning the  soft  parts; the external surface of the
blades should then  be smeared Avith butter, cerate, or  oil, Avith a vieAV of
rendering the  introduction more easy.  Baudelocque has laid down a pre-
cept that has been followed by most succeeding  authorities, and to which it
is advisable to conform ; namely, to exhibit  the forceps to  the patient, con-
cisely explain to her its use, its object, and its mechanism,  and to make her
understand its harmlessness.   " It has  not been my fortune," says Madame
Lachapelle, " to meet  with  any one wlio  was not tranquillized by such an
explanation, and  I have often knoAvn persons in their second labor to solicit
their application from having experienced  the relief they afforded  in the
first."
  Everything being prepared for the operation, Ave must next ascertain the
position of the head Avith the greatest possible care;  for even though it had
been recognized  at  the commencement of the  labor, the  former diagnosis
ought  to  be confirmed by  a fresh  examination, lest the  head may have
changed its position since then.   By  this  exploration, the  size of the  head,
its reducibility, and its softness,  the perfect or defective conformation of the
pelvis, the degree of contraction, if any exists,  &c, will be made out as far
as possible ; and as the dilatation or  the dilatability of the os uteri is even
more indispensable here than in the case of version, we must be certain that
this condition exists.   After  which we are to  proceed to the introduction of
the blades.
  "We shall pursue the course followed in studying pelvic version, first stating
the general rules of the operation, and treating in  another  article  of the
peculiarities presented by each particular case.

                          ARTICLE  II.
                            GENERAL  RULES.
  1. The instrument ought only to be applied on the head of the fcetus, Avhether
the latter be flexed or  extended, that is to say, in the vertex and face pre-
sentations ; or Avhether it alone remains behind, presenting  by its base after
the delivery of the  trunk.   Certain obstetricians have recommended the
instrument to be  applied  on the pelvis in the presentations of the pelvic
extremity, Avhere from any cause it may be desirable to  terminate the labor
promptly.   But the bones of the pelvis  are too deficient in solidity, and
their articulations offer too  feeble a resistance to be able to support the
pressure made by the forceps Avithout hazard.   Besides, it would be difficult
to get the breech  in the hollow of the blades, Avithout carrying their points
above the  iliac crests  against the soft Avails of the  abdomen, thereby pro-
ducing a more  r less serious contusion  of  the abdominal  organs.  As a 
966
OBSTETRICAL  OPERATIONS.
general rule, the breech presentations do  not appear to me to Avarrant the
use of the forceps.   I am aAvare, hoAvever, that M. Stoltz recommends its
employment  under  such circumstances, and I am induced to believe that
M. P. Dubois Avould not hesitate  in  resorting thereto, in  some cases Avhere
direct tractions on the pelvic extremity might be difficult.
   2. The blades should be applied as nearly as possible on the sides of the head,
in such a way that the concavity of their margins shall be directed towards that
part of the head which is to be brought under the symphysis pubis.— This rule
is  not always feasible, for it Avill be  seen  hereafter  that  it is impossible to
carry it out in some cases of transverse positions, in AAhich Ave are obliged to
seize the head over the forehead and  occiput;  but these exceptions are rare,
and the operator should endeavor to follow the rule in all cases.   When the
forceps is thus applied, each blade bears on the lateral parts of the cranium;
the parietal protuberances are found  in  the opening of the fenestrae, at the
point where the blades are the most Avidely separated from each other; and
the occipito-mental diameter corresponds very nearby to a line draAvn  from
the extremity of the blades tOAvards the pivot.
   3. As a general rule, the posterior  blade  ought  to be introduced first.—As
the head is placed in a transverse  or diagonal position in  a vast majority of
cases, one  of its sides  will look  forwards and the other  backAvards, and,
therefore, one of  the blades Avill be at the fore and  the other at the  hinder
part of the pelvis, since Ave have just seen that it is requisite to apply them
on the sides of the head.  Now it is the one that goes to the back part of the
pelvis that we recommend to be generally introduced  first.   In theory, this
is  even admitted as the absolute rule, since it is considered to  be the most
generally applicable;  for everybody acknoAvledges that  the positions  in
which  the occipito-frontal  diameter corresponds  to the left  oblique one of
the pelvis are the most frequent of all.  But it must be borne in mind, that
in practice there  is no invariable law, and the one Ave lay doAvn is subject to
very numerous exceptions.  If desirable, however, to establish a universal
principle for the operation, Ave might  say, that the blade,  the application of
which presents the greatest difficulty, ought to be introduced first.   After
all, it must be left to the skill and tact of  the  accoucheur to decide at the
bedside of the patient Avhich branch must be introduced first, for it is out of
the question to anticipate, in a book,  or even to imitate on the manikin, all
the peculiarities that may there influence his decision.  For  instance, when
the head is high up in the excavation, it would sometimes  be better  to re-
verse the rule, and introduce the anterior blade first.
   4. The male blade is always to be held in the left hand,'and is to be applied
at the left side of  the pelvis; the female  blade is to be held in  the right hand,
and is always to be applied at the right side of  the pelvis.
   M. Hatin has lately suggested a method which  bears considerable resem-
blance to that employed by Flamand in some exceptional cases.  It consists
in the introduction  of both branches by the same hand.  The left hand
preferably, is carried to the fundus of the uterus, or at least to the parts to
which the forceps are to be applied.  The  first branch having been  intro-
duced along the hand  which serves as a guide, the  latter, Avithout quitting
the head of the fcetus, passes around it, and places itself on  the opposite side,
to receive and guide the second branch of the instrument. 
THE  FORCEPS.
967
  This  process, represented  by M. Hatin to  be the easiest, and especially
the least dangerous  for both mother  and child, does not appear to me to
possess all the advantages claimed for it by Flamand and M. Hatin.  As
M.  Stoltz judiciously remarks, it can have no advantage except Avhen the
head  is  movable, or previously rendered so, above the  superior strait, in
which case Ave  have already seen that pelvic version is preferable, even
though  the pelvis be  slightly contracted.
  When the head is wedged  in the
superior strait, or more or less en-
gaged in the excavation, it  seems
to me that the ordinary process is
incontestably superior.
  5.  The free hand,  or the one not
engaged in holding the blade, should
always  be  introduced first, so as to
direct the latter. — When the head
is at the inferior Strait, it is usually
sufficient to  insert  two  or   three
fingers  betAveen  the side of the
head  and the pelvis (see Fig. 135) ;
but whenever it is high up, the en-
tire hand must be introduced into
the vagina, taking the precaution
to place the ends of the fingers be-
tAveen the head  and the os  uteri
so as  to be certain that the blade,
by  slipping along the palmar sur-
face of  the hand will get into the
uterine  cavity, and not pass  exter-          introduction of the first branch.
nally to the cervix,  perforate the
cul-de-sac of the vagina, and penetrate into the peritoneum.   The  convex
surface of the blades  glides along the palmar surface, and the convex  margin
along the cubital border of the hand;  in a Avord, this previous introduction
of the latter is intended to protect the vaginal  Avail  from the contact of the
instrument.
  6.  At what part of the pelvis should  the blade be  first introducedf — This
question has  been variously answered: thus, Baudelocque  directs it, in
nearly all  cases,  immediately on the point where it is to remain  after the
locking.   Levret  (and M. Velpeau  adopts  nearly  the same  vieAv)  recom-
mends that the tAvo  blades  be introduced at the posterior quarter of the
pelvis;  that, in the  diagonal positions, one of them be left in front of the
sacroiliac  symphysis, but that the  other be brought forward opposite to the
cotyloid  cavity which corresponds  Avith the anterior side of  the  head, by
making it traverse the Avhole  lateral half of the pelvis from behind forwards.
Lastly,  Madame  Lachapelle  has proposed a  mixed method, composed, in
part,  of both of the preceding:  namely,, both  branches are first introduced
in front of the sacro-sciatic ligament, and  then  the one which should  remain
posteriorly is pushed directly up to the sacro-iliac articulation ; but the other
 
968                  OBSTETRICAL  OPERATIONS.
is brought  forward at once opposite to the  cotyloid cavity in  the following
manner: "I insinuate the extremity of the blade just in front of the sacro-
sciatic ligament; then, as it passes in, I gradually depress the handle betAveen
the thighs, until it is inclined much  below the level of the anus;  by this
manoeuvre, the point of the blade  is  made to describe a spiral movement,
which is directed and completed by the fingers introduced into the vagina.
By this  movement, the blade is carried upAvards  and fonvards at the same
time,  so that  it is  made to pass around the head in an  oblique direction,
Avhich would  be represented by a line extending along the interior of the
pelvis from the sacro-sciatic ligament to the horizontal branch  of the pubis."
This  mode of procedure is  also adopted by M.  P. Dubois, and is the one
which appears to us the easiest of all.  It should be understood, hoAvever,
that it is only applicable Avhen the  head  is  already engaged in the excava-
tion.  The reader  will  see, hereafter, that above the superior strait the
branches are  applied on the sides of the pelvis without any particular refer-
ence to the position of the head.  Finally, some of the German accoucheurs
recommend the blades to be placed  on the sides of the pe'vis in all cases,
without regard to  the position of the head.  This precept is  folloAved as a
matter of  necessity when  the head is high up.  But Avhen engaged in the
excavation, it will  be found better in the  majority of cases to folloAv the rule
Avhich Ave have given.
  7.   The second blade is always introduced above and in front of the first; so
that,  in  some instances, the male branch  is found over the female one, as in
                                           Fig. 136;  i.e. between it  and
                                           the symphysis pubis.  It will
                                           then be necessary, in locking
                                           the blades,  to cross the han-
                                           dles, by  making  the  female
                                           one  pass  above  the  male.
                                           Attempts  have  been  made
                                           of latter  time to avoid  this
                                           crossing, and a particular kind
                                           of forceps has been devised by
                                           Tureaux, Tarsitani, and some
                                           others  for the purpose, which
                                           can be made to lock whatever
                                           may be the relative position of
                                           the handles.  This is doubtless
                                           an  advantage, but its impor-
                                           tance has certainly been exag-
                                           gerated.
                                             8. No  force should  ever be
                                           used in pushing  the blades uj>.
                                           — The  obstacles  met  with
                                           during their introduction are
                                           nearly ahvays created by folds
                                           of the scalp or vagina, in which
the point of the blade becomes entangled; or else the difficulty is OAving to
Introduction of the second branch. 
THE  FORCEPS.
969
the circumstance that the blade, being improperly directed, is not pushed
up in the line of the pelvic axis, and consequently strikes against the vaginal
Avails.  These are easily obviated by varying the direction of the instrument
a little, or  by carrying its handle tOAvards one or the other  thigh, and by
depressing or elevating it in a slight degree.  Force is ahvays useless and
may be injurious.  Thus, if the point of the male blade Avas arrested by a
fold of the scalp, the  instrument should  be partially withdraAvn, and its
handle be  carried toAvard the  right  thigh, Avhereby the extremity of  the
blade Avould  be someAvhat removed from  the  head, and could thus pass
beyond the obstacle; but if,  on the  contrary, it were arrested by one of the
transverse folds of the vagina, the handle should be carried toAvard the left
thigh, so as to make the point rest against and slip  over the head.
   The introduction of the second brasch is generally the most difficult, and
the difficulty is generally greatest when it is necessary to introduce  it  the
first.   When attempts, prudently made, prove fruitless, there should be no
hesitation in AvithdraAving both branches, and beginning again with the  one
which before Avas introduced last.  It Avere much  better to reneAv the opera-
tion tAvo or three times, than to strive pertinaciously against difficulties which
could never be  surmounted without endangering to a greater or less extent
the life of  the fcetus, or the integrity of the maternal organs.
   In Avithdrawing the branches, they should be  made to describe a curve
the  opposite of that Avhich  they folloAved during  their introduction;  the
handle of the male branch, for example,  should  be gradually raised  above
the pubis, and reclined obliquely upon the left groin.
   9. Mode of locking. — In  general, the locking is easily effected by bring-
ing the tAvo branches together after their  introduction  and adjusting  the
pivot in the mortise (Fig. 137),
Avhen an  assistant turns the
former;  but this  part of the
operation  demands  a perfect
parallelism betAveen the tAvo
portions of the  forceps Avhich,
unfortunately, does not ahvays
occur. For it frequently hap-
pens that the pivot does  not fit
into the mortise exactly, either
because one or both blades are
turned  outAvards,  or  because
one has penetrated deeper than
the other.  In the  former case,
we should  endeavor to correct
the deviation gently, by grasp-
ing the handles with the whole            The forceps applied and locked.
hand, and in the latter by with-
drawing or pushing up one of them.  But in none of these attempts should
much force ever be used ; for when considerable  difficulty is met  with, it is
probably OAving to an  improper  adjustment of the  instrument, and it is far
better to extract one or  even both blades than  to force their locking.
 
970
OBSTETRICAL  OPERATIONS.
  10. We must be satisfied that the head is properly secured, ai d that it alone
is included in the clams of the instrument.—To be convinced that no part of
the mother's organs is pinched between the head and the forceps, it is only
requisite to make  a moderate pressure on  the  handles, after  the locking,
when, if the patient does not complain of pain, the operation may be con-
tinued Avithout danger; if the contrary is the case, the forceps ought to be
unfastened, and the included part be removed by the finger.  A  feAV gentle
tractions made by the forceps, without compressing the head too much, will
serve to shoAV whether the latter is properly secured, and that the instrument
does not slip.
  11. The tractions ought to be made in the direction of  the pelvic axis. — If
the head is at the superior strait, Ave must first  drayv doAvnwards  and back-
Avards as much as possible;  then, as it descends into  the excavation, the
handles  are gradually elevated, so that, by the time it reaches the inferior
strait, they are found directed fonvards and someAvhat dowmvards; and the
tractions Avill then be made in this latter direction.  But Avhilst the head is
undergoing its  movement of extension, the instrument must be carried up in
front of  the symphysis pubis, and afterwards of the abdomen, so  that, after
the complete delivery of the head, the forceps shall  be lying almost horizon-
tally over the woman's belly.
  In performing the  tractions, the right hand is placed near the  clams and
above the instrument, the left hand in front of the articulation and beneath.
But as soon as  the disengagement is to be effected by raising the instrument
above the pubis, the position of the hands must be changed, and the left one
ahvays be placed in front of the pivot, but above, and the right one beloAV
the extremity of the branches.
  The tractions are to be  made  during a pain Avhenever possible, and  the
patient should  be encouraged to bring the abdominal muscles  into play, in
aid of the uterine  contractions and the efforts of the  accoucheur.  As soon
as the head has cleared the inferior  strait, and when it only has the resist-
ance from  the soft parts to overcome, the vulva being at  the same time freely
dilated, all tractive force should, as  a general rule, be abandoned, and the
rest be left to the powers of nature; for the mere presence of the head at the
external parts, by the tenesmus it gives rise to, will most certainly bring on
a sufficient degree of contraction to effect the delivery.
  Be satisfied,  then, Avith  facilitating the process of extension, by carrying
the  handles up in  front of the  pubis during  the mother's bearing-down
efforts;  the dilatation of  the vulva, being thus  sIoav and gradual, will  be
accomplished without  any danger of rupture, especially if you are  careful
to sustain the perineum, or, still  better, to have it supported by an assistant;
for, had  you  continued  the tractions, such a rupture could scarcely have
been avoided.   Madame Lachapelle even advises the instrument  to be with-
drawn altogether; but I think it is better to leave it in situ, for the double
interest  of the patient and the accoucheur: of the patient, because, in some
cases, a few tractions may yet be necessary; and of the physician, because,
if he remove the forceps from prudential motives, and with a view of saving
the parts, before the final delivery of the head, he might be regarded by the
woman  and her attendants as a bungler, who had failed in his operation. 
                            THE  FORCEPS.                        971

  He should, therefore, leave it  applied, and  allow the patient to expel it
and the head together.
  In cases attended Avith difficulty, Ave might doubtless draw on the handles
Avith a certain amount of force; but the example of some practitioners who,
taking a point of support by placing a foot against some solid body, hang,
as it Avere, on the handles of the forceps, and then  pull aAvay  with all their
strength, should never be followed.  It is only necessary to use  the arms,
and the operator should take such  a position that his  body would  ahvays
arrest any sudden slipping of the blades.  In fact, it is this precaution which
sometimes renders an application of the forceps so excessively fatiguing to
him.
  12. //;  the oblique or transverse positions, such a movement  of rotation is
to be imparted  to the  head as  shall bring the concave margin  of  the  blades
directly in front.—This rotation ought to be performed during the tractions.
just as the head is approaching or  clearing the inferior strait.   But  there
is no occasion for any violent exertions, for most  generally the head  turns
in its descent, carrying the instrument along with it in the  rotation.   Some-
times,  also, an  application of one or both blades is all that is necessary to
effect this change.
                          ARTICLE  III.
                             SPECIAL RULES.
  We have  already  stated that the forceps may  be  applied  in  the vertex
and  face presentations, and on the head Avhen left  behind  after the delivery
of the trunk.   Its application  is,  therefore, to be studied in these  three
varieties ; and  as the greater or less elevation of the head  greatly influences
both the course to be pursued and the degree of facility Avith Avhich the oper-
ation is  accomplished, Ave shall examine those cases  successively in Avhich
it has  reached  the inferior strait, in Avhich it is still engaged at the  superior
strait, and in Avhich it is entirely above the latter.

  §  1. Application of  the Forceps  in Vertex  Positions, avhen the
Head has reached  the Inferior Strait.
  The vertex,  having descended to the inferior strait, may be found in cor-
respondence with the various points of its circumference;  and, therefore, to
meet every possible case, Ave shall have to admit eight principal positions of
it: thus, the occiput may be in  relation Avith both extremities of the coccy-
pubal  diameter (the  occipito-anterior and  the occipito-posterior  positions);
with both extremities of each oblique diameter (the  left  anterior and  the
right posterior occipito-iliac, and the  right anterior  and the left posterior
occipito-iliac positions) ;  and  with  both extremities of the transverse  diam-
eter (the left and right transverse occipito-iliac positions).
  A.  Occipito-anterior Position. — In  this position, the occiput  is  placed
behind or under the loAver part of the symphysis pubis ; the sides of the head
corresponding  to those of the pelvis.   The  male blade will  here be intro-
duced first, because  it will  be  found  underneath in  the  locking.  Tavo or
three fingers of the  right hand having been passed into the vagina,  this
branch is seized by the left hand, either with the fingers, like  a Avriting-pen,
or, still better, with the Avhole hand (though in both cases close to the pivot), 
972                 OBSTETRICAL  OPERATIONS.
 and it is held inclined obliquely over the right groin; the point of the blade
 is then entered  at  the vulva in the direction  of its axis, and is slipped up
 along the palmar  surface of the fingers; as the blade  is passed into the
 vagina, the handle is gradually depressed betAveen the woman's thighs (of
 course, ahvays approaching towards the  median line) in such  a Avay as to
 direct the point of the blade in the direction of the axis of the excavation.
 The blade is thus directed at once upon the side of the head, and along that
 of the pelvis, Avhere it is ultimately to  be  placed.  While this manoeuvre is
 being effected, the convex border  of the blade ought to rest upon and  glide
 along the ring-finger of the right  hand, Avhich is in the vagina, Avhilst at the
 same time its concave surface should  bear exactly on the convexity of the
 head, and folloAv its outline.   The female  blade is  then  introduced in  the
                            same manner precisely.  Tavo or three fingers
          FiQ-138-            of the left hand are first passed in on the right
                            side  of the pelvis; the branch being held ob-
                            liquely by the right hand in front of the left
                            groin, with its point resting  on the palmar sur-
                            face of the left hand, is presented at the vulvar
                            orifice;  and  as its extremity is made to enter,
                            the handle is depressed, and brought tOAvards
                            the median  line by degrees, the blade being
                            thus passed up on the right side of the pelvis,
                            with the  same precautions  as in  the former
                            case.
                              When   both blades  have  penetrated to the
                            same depth;  they ought to be  parallel  with
                            each  other,  the  pivot  corresponding  to the
                            mortise exactly;  and the locking is then com-
                            pleted Avithout difficulty.
                              As the head is at the inferior strait, the first
                            tractions Avill have to be made in the direction
                            of the axis of this strait, that is to say, a  little
                            doAvnwards and forwards; then, as  soon as the
occiput.has passed under the sub-pubic ligament, and the head has  com-
menced its movement of extension, the instrument is to be gradually carried
upAvards in front of the symphysis and  abdomen..
   b.  Occipito-posterior Position. — The  blades  are applied and locked as in
the preceding case.  But  here, notAvithstanding the head is at the inferior
strait, Ave are not to draw in  the line of axis of this strait;  because, in these
occipito-posterior positions, the occiput has to  be delivered first at the ante-
rior perineal commissure.  (See Natural Labor.)  To effect this  object,  it is
necessary to carry the handles a  little upwards at  the  very  outset of the
tractions, so as to flex the head on the chest more completely ; being careful
to operate in such a Avay that the artificial aid may bear  particularly on the
larger extremity of the  head.   When  the occiput has gained the perineal
commissure, the traction  is  discontinued, or  rather, if there is any further
occasion for  it, Ave may dra\v moderately, at the same time depressing the
handles of the instrument towards the anus.
 The forceps applied on the child's
head in the occipito-anterior position,
lit the inferior strait. 
THE  FORCEPS.
973
  [The head should be extracted very slowly, because the highly distended peri-
neum, which bulges greatly before the occiput, would inevitably give w.iy under
an attempt at too rapid delivery.   The operation is far more troublesome than in a
case of occipito-anterior position, and as it requires the use of greater force, demands
also the exerciser of great care and prudence to avoid a laceration.]
  c  Left Anterior Occipito-iliac Position. — In this positron, one side of the
head  looks forward and to the right, the other  backAvard and  to the left;
and the blades are to be applied in a corresponding  manner on  the sides  of
the head.   The  posterior blade, 'which should  be entered first, will  at the
same time be on the left, and, therefore, the one that is ahvays  passed  on
the left side of the  pelvis, that is to say, the  male blade, Avill be introduced
first.  This  is held in the left hand just in front of the right groin ; and  its
point, placed  in front of the left sacro-sciatic ligament, is to be pushed
directly backAvards as far as the sacro-iliac articulation, whilst the operator
depresses the  handle and draws it towards  the median line.   In carrying
the handles doAvn between the mother's thighs, it is highly important to
keep the blade slightly everted.  Being once introduced^ the handle is given
to an assistant, Avho holds it near the internal surface of the left thigh.
  The female blade is to be placed behind the right cotyloid cavity,  where
the side of  the head  is found, by making it  describe the spiral movement
alluded to when speaking of the general rules of the operation.   The oper-
ator  accomplishes  this by taking  it in the right hand, in  the usual way,
and entering the point of the blade just in advance of the right  sacro-sciatic
ligament; then, pushing it in this direction  for about an inch, he  suddenly
changes the position of his  hand  so as to get hold of the instrument from
above,  Avhen,  by  strongly  depressing its
handle  along  the  internal  surface  of  the
left thigh, he  makes  the blade execute a
see-saAv  movement, by Avhich it is at once
carried  from  the  right sacro-sciatic liga-
ment up opposite to the cotyloid cavity of
the same side;  and  then the  locking is
effected.   (Fig.  139.)   During  the early
tractions  he should endeavor to rotate the
head so as to bring the occiput behind, and
then under  the symphysis pubis.   The rest
of the operation is completed as in the first
variety (a).   -
   D.  Right Posterior Occipito-iliac Position.
The   forceps are  applied here  exactly in
the same Avay as they Avere in the preced-
ing case ; the  blades being entered, the  one
behind  and to the left, the other in front
and  to the right (see Fig. 139) ; their con-
cave  margins looking toAvards the forehead.
As this latter part must be brought in front,
the object of the rotation will be to get it behind the symphysis  pubis, and
the occiput into the hollow of the sacrum ; and  the labor is then terminated
 just as in an original occipito-posterior position (b).
Application ot the forceps in the righl
    posterior occipito-iliac position. 
974                   OBSTETRICAL  OPERATIONS.
  [The effort required is sometimes so great, that some operators haA'e  thiughtit
woufd be better in very difficult cases, to rotate the forceps upon its axis, in order
to turn the  head in the cavity of the pelvis, as it sometimes turns spontaneously,
rolling the occiput, in fact, from behind forward, bringing it first to the side of the
pelvis and finally behind the pubis.  The plan has numerous opponents, who say-
that it turns the head  through more than a quarter of a circle, whilst the body  is
held fast bv the contracted uterus and thus exposes to the occurrence of fatal lesio.is
in the cervical region of the spinal column.
  These objections are more theoretical than real, and we have endeavored to refute
them in another work  (Accouchements, par Lenoir, See, et Tarnier).   At any rate,
clinical facts have proved that the occiput may be brought to the front and a living
child born in an occipito-posterior position.1

  1 A young woman, pregnant with her first child, having reached  her full term with-
out accident, was taken with her first pain on the 29th of October, at nine  p. m.  The
pains, though  feeble, were yet so frequent as to prevent her sleeping.  At  six o'clock
on the morning of the 30th, I found the neck completely effaced, and the thinned edges
circumscribing an orifice of about  the size of a dime.  The pains  occurred  every ten
minutes.  I  found the vertex presenting, but could  not make  out  the position.  The
pains continued all day, the 30th,  but quite as feeble and distant.   At four o'clock in
the evening they became stronger and more frequent, and sit eight o'clock the diameter
of the orifice was rather less than that of half a dollar.  The membranes being flattened
and applied closely to the head, enabled me to discover the biparietal (coronal) suture
running directly from before backwards, and on several different occasions I distinctly felt
the anterior fontanelle presenting directly forward and corresponding nearly with the
upper third of the posterior surface of the  pubis.   I had to deal with what had never
before occurred to me, a direct occipito-sacral position, engaged in the upper third of the
excavation.  I hoped in vain for its spontaneous conversion  into a posterior  diagonal
position, for, notwithstanding very frequent and powerful contractions, things  were
still in statu quo the next day, the 31st, at  six o'clock.   The orifice was at this time
dilated to the size of a dollar. At noon, the  dilatation was almost complete, and finally,
at two o'clock, the  head assumed a diagonal position.   I detected very  positively the
anterior fontanelle in front and to  the left,  and hoped that the movement of rotation
would continue.   I was  doomed to  be disappointed.  I then ruptured the membranes,
but this was followed by the escape of but a few spoonfuls of  fluid.  At four o'clock,
the anterior fontanelle had approached, I thought, somewhat nearer the left extremity
of the transverse diameter, and I encouraged the poor patient to believe that her labor
would soon be terminated ; but, unfortunately, instead of continuing to pass  backward,
the anterior fontanelle underwent a movement in the opposite direction,  and, notwith-
standing all my efforts to push it back, it again came forward, and  fixed itself opposite
the horizontal  ramus of the pubis, from which it did  not stir afterward.  At ten o'clock
in the evening, things being in the same condition, I determined to apply the forceps,
as much in the interest of the mother whose strength was exhausted, and who begged
me to deliver her, as in  that of the child.
  The head was then very near the inferior strait, and the forceps  were applied with-
out  difficulty upon its  sides.  I made traction, with the object of disengaging the
occiput in front of  the  perineum, but the contractions  were  feeble, and the woman
being exhausted with fatigue, was unable to assist the efforts of the uterus, and being
thus reduced to the mere  tractions with  the instrument, I could not make the  head
advance.  In spite of all my efforts, I was unable to overcome  the  great resistance of
the perineum which was very thick  and unyielding, so that my attempts were altogether
fruitless.  If I abandoned the operation, I had nothing to rely upon but the resources
of nature,  which here  Avere unfortunately,  powerless,  or else the performance  of
craniotomy   I had waited  long enough to test  the powers of the organism, besides
which, a more prolonged expectation would not be devoid of danger to both the mothe.v
and child.  Therefore, before deciding on craniotomy, I  determined to try whether  r 
THE  FORCEPS.
975
   Whoa, in a posterior occipito-iliac position, it is found very difficult to depress the
 occiput, it is allowable to bring it to the front.   To effect it, the forceps are to be
 rotated so as to bring the occiput  first to the side of the  pelvis in a transverse
 occipito-iliac position.  When this  happens, one of the  blades  is directly in front
 and the other  directly behind, provided, the  head was seized from one ear to the
 other.  The  instrument is then to be disarticulated, in order to reapply it as in a
 primitive transverse  occipito-iliac position.  In a future paragraph it Avill  be told
 how to proceed  to this application.   (See Application of the Forceps in Transverse
 Positions.)   Some operators, however, do not fear to complete the rotation without
 unlocking the  instrument, which  has then  an abnormal  direction,  the  smaller
 curvature being behind and the large convex one in front, the male branch to the
 right and the female  to the left, and all without any j»reat inconvenience, provided
 the  operator be adroit.  Nevertheless,  the direction described  is one to which
 Levret's forceps is not adapted.]

   E. Right Anterior Occipito-iliac Position.—In this case, the female blade is
 entered just in advance of the right sacro-iliac articulation.  Then the male
 blade is introduced  in front of the left sacro-sciatic ligament, and is made to
 describe the spiral movement before indicated, by Avhich it  becomes placed
 opposite to  the  left cotyloid  cavity.   The  movement  of rotation will be
 effected from right to.left, and the occiput be brought under  the pubic arch.
   F. Left Posterior  Occipito-iliac Position.— The  blades are introduced  in
 a similar order, and in the same  Avay, as in the preceding case.   The move-
 ment  of rotation is also effected in the same direction, but here it will bring
 the forehead instead of the occiput behind the symphysis.  The handles of
 the instrument are next  carried up a  little in front of the pubis, Avith a vieAV
 of freeing the occiput first at the anterior  perineal commissure.   After this
 is accomplished, the handle is  to be depressed tOAvards the anus, so as  to
 assist  the head in its movement of extension.

   [In  case it should be found difficult to disengage the occiput posteriorly, the head
 may be turned  so as to bring the occiput behind  the pubis ;  in short, to folloAv the
 same course as  indicated for the right posterior occipito-iliac  position (d).  It -will
 be understood that in this  case, the  head is to be turned from behind forward, and
 from left to right, in  accordance Avith the  same route  which it  usually follows  in
 natural delivery.]

   G. Left Transverse Occipito-iliac Position.—In this  variety, the  occiput
 corresponds to the left extremity of the transverse diameter  of the pelvis ;

 would not be possible to bring the occiput in  front.  I left off the tractions, and rotated
 the forceps on its axis, and carrying  the head  along in this  movement, I had soon
 directed the concavity  of the edges of the instrument toward the internal surface of
 the left thigh.  I then  wilhdrew the instrument and found that the longitudinal suture
 was directly transverse.  Introducing the female branch  behind and  to the left side, I
 used it as a lever, and  succeeded with  it in  bringing the occiput  almost directly behind
 the right acetabulum.   The  male branch was then placed behind the left acetabulum,
 and the forceps being locked after uncrossing the branches, I brought the occiput first
 behind, then beneath the symphysis pubis, and finished the extraction of  the head by
 the usual movement of extension
  The child was born in an evident state of congestion.   I allowed the cord to bleed
before  tying it, and it was  soon restored.   Two weeks afterward it was strong and
well.   The lying-in was unattended with accidents and the mother recovered quickly.
The whole duration of the labor was fifty hours. 
976                 OBSTETRICAL  OPERATIONS.
Fig. 140.
The forceps applied anJ locv tu in the left
   transverse occipito-iliac position.
one side of the head looks directly forward, and the other backAvard.   Here
also the posterior blade is to be introduced first:  noAV to distinguish Avhich
will be the posterior  one under such circumstances, we  must ascertain  to
                               what part of the  pelvis  the present poste-
                               rior side of the head will correspond after
                               the rotation shall have been completed.  As
                               this process of rotation, in  the transverse
                               positions, must always bring the occiput in
                               front, the left, or posterior side of the head,
                               -will then  look towards  the  mother's left
                               ilium, and consequently  the left or male
                               blade is entered first.  This blade is, there-
                               fore,  pushed  towards the left  sacro-iliac
                               articulation, and Avhen it has penetrated to
                               the proper depth, it is pressed into the hol-
                               low of the  sacrum  by bearing  on its  con-
                               cave margin with  the fingers already in the
                               vagina.   The  female blade is  next to  be
                               passed up by means of a spiral movement,
                               behind the right acetabulum ; and then the
                               hand in the  parts  must endeavor to work
                               it toAvards the median line, by pressing  on
                               its convex  margin, so as to get it just be-
                               hind  the  symphysis pubis.  From the ex-
tent of the  rotation to be effected, of course the  accoucheur  must be very
careful to operate sloAvly and gently.
  When the head is in a transverse position, it is occasionally still high up
in the excavation, even though it has, in a great measure, cleared the supe-
rior strait; and when this  occurs, it  is often exceedingly difficult to apply
one of the blades in front and the other behind; in  some cases even  Ave are
obliged to enter them  on the sides of the pelvis, that is, to seize the head by
the forehead  and occiput.   This is always an unfavorable circumstance;
although  it may possibly happen  that the mere application of the  instru-
ment Avill be sufficient to give the head an oblique or even a direct antero-
posterior  direction ; and Avhen this movement does not take place  at  the
time the blades are entered, it is often effected aftenvards by their locking,
or during the first tractions.   Again,  when  the forceps is thus applied, the
head  may occasionally clear the inferior strait in a transverse position ; but,
having reached the vulvar orifice, it then  turns betAveen  the blades, or, as I
have  several  times observed, carries  the instrument along Avith it  in  the
movement of rotation, in such a Avay that,  Avhen  the occiput is turned for-
wards, the concave  border  of the blades looks tOAvards one side.   In this
latter case, some practitioners recommend the instrument to be AvithdraAvn
as soon as the head has nothing but the resistance of the soft parts to over-
come, and, if necessary, to reapply them to the sides of the head.  I think it
Avould be better to remove the fonvard or sub-pubic blade only, for its pres-
ence  might retard the process of  extension, but  to  leave the perineal  one 
THE  FORCEPS.
977
applied, because, in case of necessity, it may act as a lever  in  facilitating
the extension.
  The difficulty experienced in  applying the forceps on the parietal pro-
tuberances in  the  transverse  positions  engaged in the excavation, often
becomes ' see hereafter; an  impossibility, Avhen the  head is arrested at the
superior strait or above it.  To render the biparietal application possible,
M.  Baumcrs, of Lyons, has  constructed a  neAV  forceps, Avhich I have had
occasion to try, and Avhich  appears  to  me  to overcome  the difficulty men-
tioned.   I am convinced that the biparietal application of the blades, AA'hich
is impossible with the ordinary forceps, is sometimes  easy Avith  that of M.
Bauiners, and  I think it right to recommend their application in the trans-
verse positions.  They differ from Levret's forceps in  being curved  on the
side instead of the edge, so that the general curvature  of one of the branches
is concave, and that of  the other  convex.  For further details respecting
this instrument and the  mode of applying  it, see the Gazette Medicate des
14 et 21 juillet, 1849.)
  This modification of M. Baumers is  altogether similar to that suggested
by Uytterhoeven.   This Belgian surgeon, it is  stated by M. Van Huevel,
constructed, forty years  ago, a forceps with the blades curved fonvards on
their sides, as the others are on the edges.   (See the  Atlas accompanying
the Belgian edition of this Avork, Fig. 11)4.)
  H.  Right  Transverse  Occipito-iliac Position.— In this position,  the ap-
plication of the forceps scarcely differs  from the  one just described, except-
ing that the female branch is introduced first, and the  movement of rotation
is to be made from  right  to left, and from behind fonvards.   When the
occiput gets behind the symphysis pubis, the labor is to be terminated as in
the preceding case.

  § 2. Application of  the Forceps in the Vertex Positions,  where
the Head  is  merely  engaged  at the Superior Strait.
  Whenever the head is engaged or locked  in the superior  strait, and the
vertex occupies the whole upper  part of the excavation, the rules for guid-
ing us in the application of the forceps are the same  as those already laid
doAvn for its use at the inferior strait.   We must remark, hoAvever,  that its
elevated position renders an introduction of the Avhole hand into the vagina
more necessary than ever;  that the points  of the fingers ought  to be care-
fully placed betAveen the head and the cervix uteri, so  as to direct the blade,
Avhich is slipped along the palmar surface of the  hand, directly into the
uterine  cavity; that, as it  is higher up  than usual,  the blades  are to be
pushed further in, in order to grasp it freely; and lastly, that, as the head
is not vet clear of the superior strait, the first tractions must be made in the
direction of the axis of that strait,  or in other words,  as far backAvards and
doAvnAvards as possible.
  But, although the theoretical precepts remain unchanged, it must not be
supposed that the difficulties are no greater here than in the former case;
for  the  elevation of the  part renders  the application of the forceps more
difficult and  less certain, as it is not an easy matter to apply the blades on
the sides of the head, in the oblique and more especially in  the transverse
      62 
978
OBSTETRICAL  OPERATIONS.
positions.  In a  word, the  higher up  it is, the more likely  ire Ave  to  en-
counter those difficulties and dangers about to be described ii applying the
instrument on a movable head above the brim of the pelvis.

  § 3. Application  of the  Forceps in the Vertex Positions, when
the Head is  movable above  the  Superior Strait.
  There are many circumstances that may require the intervention of art,
even Avhile the head is still above the superior strait; and as the nature of
■fiese causes of dystocia may have a bearing on  the operative procedure for
cerminating the labor, Ave must here take them into consideration.
  The intervention of our  art may be rendered necessary by an  accident
that endangers the life of the mother or child, such as hemorrhage, con-
vulsions, or a descent of the cord, &c, as also by a  contracted pelvis or an
excessive volume of the head.   In the latter  case, a resort to the forceps
is proper, provided the disproportion between the pelvic dimensions and the
size of the head  be  not very great;  since it  has elseAvhere  been shoAvn [see
Deformities of the Pelvis) that, whenever the smallest diameter of the pelvis
amounts to three inches, there  is  reason to expect that delivery can be
effected by means of the forceps.
  The question arises, Avhether version or an  application of the forceps is
to be resorted to in  those cases in Avhich the pelvis is properly formed, but
some  accident  has taken place  that requires a speedy termination  of the
labor?  Under such circumstances,  Ave do not hesitate to recommend pelvic
version; but as this is not the universally  received opinion,  we extract from
Madame Lachapelle the folloAving  reasons  on  which Ave ground  our pre-
ference :
  " An application of the instrument  upon a head Avhich is still above the
superior strait is both  a difficult and a  dangerous operation.  Difficult, 1st,
because its elevation renders the diagnosis of the position obscure, and often
leaves  us operating in the  dark; 2d, from its mobility it escapes  from the
forceps, and  not unfrequently it is merely held  by the points or margin of
the blades; so  that, as soon as  any resistance  is  met Avith from  the first
tractive efforts, it slips out just  like a cherry-stone when squeezed betAveen
the fingers; and, 3d, because  at  this height  it  is impossible to apply the
blades on  the sides of the  head, since the latter is usually found  either in
an oblique or in  a transverse position.   Noav,  to conform  to the rule gen-
erally  laid doAvn, Ave should apply one  blade in front and the other behind,
but this is obviously  impracticable, for the  curvature of  the  pelvic axis
prevents the forceps from passing far enough  in, unless the blades are intro-
duced  along the sides of the  pelvis.1  Dangerous, because the hold on the

  1 When an attempt is made to  apply them over the parietal regions, the perineum
presses the instrument forward, and gives it such a degree of obliquity with regard to
the superior strait, that there is not room enough between the fenestrae for the recep-
tion of  the smallest-sized head.  The  latter, being  placed above the abdominal strait,
has its long  diameter situated very nearly in the line of the axis of  that strait;  but
as the long axis of  the  head ought to correspond with that of the blades, it therefore
follows that the forceps  must be introduced in the direction of  the axis of  the upper
strait;  and, consequently, that the articular part of the instrument is to be depressed
beyond the  point  f the  coccyx   But the  perineal resistance will evidently preven/ 
THE 'FORCEPS.
979
head, being very imperfect, in  consequence of  the  difficulties  just enu-
merated, the instrument may slip;  and, should such  slipping take  place
Avhiie we are  making strong tractions on the handles, the edges of the for-
ceps, acting like a cutting instrument, might seriously Avound the  cervix."
  We. therefore, prefer version in the case under consideration.   HoAvever,
there is  one instance Avhich might demand the use of the forceps; that Is,
Avhere the uterus is so contracted  on the child's body after the discharge  of
the waters, as to render an introduction of the hand or an evolution of the
fcetus absolutely impossible ;  but  fortunately, in such a case, the head would
be so firmly held at the strait, during the strong contractions of the organ,
as to be nearly immovable.
  On the Avhole, then, the  application of the forceps above the superior
strait should be  limited  to  those cases of  pelvic deformity  in Avhich the
shortest diameter of  the pelvis does not exceed three to three and a quarter
inches, and to those in Avhich the uterus is firmly contracted.
  Mode of Application. — Unless the position is  directly antero-posterior,
which  is extremely rare, no attempt  should  be  made to apply the blades
upon the parietal protuberances, but they should be passed along the sides
of the pelvis.   It is,  however, very unusual for this precept to be followed
in practice, and for the blades to  be really placed upon the two extremities
of the transverse diameter;  Avhen the head is  diagonal, the blades are natu-
rally directed toAvard the  two extremities of one of the  oblique diameters.
Now in the directly transverse positions,  this is  Avhat generally  happens,
even Avhen the surgeon Avishes to place  them  at the sides of the pelvis;  for
at this elevation, and especially in the sacro-pubic  contractions, which are,
the most common, the head is almost always  in a transverse position; noAV,
according to the remark of Ramsbotham  and of  Simpson,  and notAvith-
standing the formal precept ahvays  to apply the blades  to the sides of the
pelvis, it is found after delivery that  the head has not been seized from the
forehead to the occiput.   The marks of the blades are almost always to  be
discovered  upon one of the  occipital protuberances and the  parietal pro-
jection opposite.  It  is natural, in fact, if the head is transverse, for its long
diameter to correspond  with the transverse diameter of  the pelvis.   Noav,
as the latter is  narroAved from before backward, the blades can be applied
readily, only  bv directing one of them  behind the acetabulum, and the
other in front of the sacro-iliac  symphysis, which  are the only points not
occupied bv the head.  This, therefore, is the direction  Avhich  should   be
given them in all cases.
  As soon as the forceps are applied, it Avould in most cases be advisable  to
tie the handles together before draAving upon them.  At  first, the tractions
should be  made as  far  back as possible, and the instrument ought to  be
gradually brought forward as the head descends into the  excavation.  The
head, seized by  one  coronal  boss and the opposite  occipital protuberance,

this, where one blade is  entered behind the  pubis and the other in front of the sacrum.
Therefore, we are obliged to introduce the blades along the sides of the pelvis; that
is. to seize the  head by the forehead and occiput in the transverse positions, and  by
the coronal and occipital protuberances in the oblique positions.   M. Baumers1 instru-
ment might in some cases overcome, these difficulties. 
980
OBSTETRICAL  OPERATIONS.
 will soon reach the inferior strait.  In  thus traversing  the Avh >le excava-
 tion, the  head may possibly turn within the blades and become  converted
 into an  antero-posterior position ; but it may also happen that this sponta-
 neous version does not take place at all.   If, therefore,  the obstacle exists
 at the superior strait alone, and the  uterine forces appear adequate to the
 prompt  termination of the  labor, we may  AvithdraAV  the  instrument and
 trust the rest  to nature.  But in other cases I think it Avould be proper to
 endeavor to transfer the blades to the sides of the head, or even  to reapply
 them in accordance Avith the  precepts before given for their application at
 the inferior  strait.  It is  evident that,  Avith the assistance  of  Baumers'
 forceps, the latter inconvenience would be avoided.

   § 4. Application of the Forceps  in the Face Positions.
   When the face presents, an application of the forceps may become neces-
 sary, either Avhen the head has descended to the inferior strait,  when it is
 engaged at the superior one, or Avhen it is  still  movable  above the brim of
 the pelvis.
   1.  When the Head is at  the  Inferior Strait.— If both  the head and the
 pelvis retain their usual size, the face  can  only  reach the perineal floor by
 descending Avith the chin directly fonvards, or nearly so.  (See Mechanism
 of Face Positions.)   As the application of the forceps in these three different
 cases does not differ in the least from that described in  the corresponding
 vertex positions, we deem it useless to pass over the same ground.
   But the face, without having reached  the perineal strait, may, neverthe-
less, be low down in the  excavation; and  the process of rotation, whereby
 the chin should be  brought under the  pubic arch in all cases, may not have
 commenced at all, or it may either be partially accomplished or  fully com-
 pleted.   We might, therefore, have to apply the forceps in a mento-anterior
 or pubic, in a left or a  right anterior mento-iliac, or in a left or a right
 transverse mento-iliac position.
   Since it  is absolutely necessary, in the face positions, for the chin to come
 under the pubic arch, the instrument  is  ahvays to be applied Avith its con-
 cave edges looking  tOAvards  the chin, taking care to introduce the posterior
 blade first.
   By Avay of example, let us suppose that the face is situated in a left ante-
 rior  mento-iliac position, and is  Ioav clown in the excavation.  Here, in
 conformity Avith the directions before given, the male blade will  be  placed
posteriorly and to  the left, near  the  left  sacro-iliac articulation, and the
female blade just behind the right anterior arch of the pelvis; Avhen locked,
the concave edges of the blades will  look forwards and to  the left.  The
rotation is then effected from behind fonvards, and from left  to right, so as
to bring the chin behind the symphysis; and when this is accomplished, we
draAV directly forwards, and a little downwards, in order to free this part
from the pubic arch; and then, after having secured its delivery, the han-
dles are gradually carried up, at the same  time draAving moderately,  with a
view of promoting  the flexion and disengagement of the head.
  2.  When the Head is at the Superior Strait.— The  face may be found iD
every possible relation with  the different  parts of this  strait.  Should the 
THE  FORCEPS.
981
chin correspond to any portion of its anterior half, the forceps .nay be applied
without any  particular difficulty ; but  if the face is  in a mento-posterior

               Flo. 141.                               Eio. 142.
   Application of the forceps in the left anterior          Application of the forceps in the mento
            mento-iliac position.                          posterior position.

 position, 'the pelvic or cephalic  version, Avhenever possible, ought to be
 chosen in preference.   For Avhen the forceps  is once  applied, the  object
 would  evidently be to bring the chin  behind the symphysis pubis;  but as
 the body is probably held motionless by the contraction of the Avomb, it Avill
 not participate in the rotation of the head produced by  the instrument, and
 hence luxation Avould occur at the  joint between the first and second cervical
 vertebrae, Avhich  does not admit of movement  beyond a quarter of a circle.
   When the face is situated in a mento-posterior position, and has descended
 so far into the excavation that it is altogether  impossible to return it above
 the superior strait with a vieAV of performing the cephalic or the  pelvic
 version, the use of the forceps becomes a matter of necessity.   Under such
 circumstances, we should therefore apply them  for the purpose of relieving
 the mother from her threatened danger; not, as Ave observed in the preceding
 editions, to bring the chin in front, but merely Avith the  intention of flexing
 the head, and converting the face position into one of the vertex. To accom-
 plish  this,  the blades are to be placed on the sides of the head,  and in oper-
 ating, the handles should be  depressed as  far backwards as possible, so as
 to act chiefly on the vertex,  until  the  occiput  is brought down under the
pubic arch ; if the chin Avere directly posterior, such a movement of rotation
might be given to the head,  prior  to any tractive effort,  as Avould carry the
former into the great sciatic  notch  on one side or the other.   This appeared
to me the  most  feasible operation some  years  ago.   I  observed,  however.
that, according to M Mascarel, (Thesis,  page  84,) M. P. Dubois  has pro
 
982
OBSTETRICAL  OPERATIONS.
 posed another;  or  rather  he inquires Avhether  it Avould  not  be possible tc
 convert a mento-posterior into a mento-anterior position.  It may be objected,
 he continues, that, if the head is forced to undergo too great a rotation, and
 the body does not turn simultaneously, the  child's neck Avould  be tAvisted;
 but as the only thing to be done, if this will not ansAver,  is to perforate the
 cranium, and consequently to sacrifice the  infant, be  considers the former
 measure preferable; more  especially as  the chin might  escape under  the
 ischio-pubic ramus, Avithout the necessity of getting  it exactly beneath  the
' pubic arch.  I know that  this method has sometimes succeeded, and  M.
 Blot informed me  quite recently, that he  had delivered three times,  by
 bringing the chin in front.
   It may be that the  shape of the  instrument is, in this case, one of the
 principal causes of the difficulty met with, and that the use of a straight
 forceps would  render the manoeuvre much easier.  This advice, given I  be-
 lieve by M. P. Dubois, deserves to be taken into consideration.
   In 1850, M. Danyau read a paper before the Academy, in AA'hich he gave
 preference to  this  operation; he recommended, hoAvever, that, unless the
 straight forceps are  used, the curvature of the edges should be turned toAvard
 the chin, as Avas practised by Campion.  He claims to have succeeded sev-
 eral times, and even to have delivered children alive.
   Still more recently, M. Danyau  and myself succeeded in bringing the
 chin in front by the use of the forceps, the  child remaining alive.   In this
 case, it is true that the face  had begun to  rotate,  so that when the instru-
 ment Avas  applied  it Avas quite near the  right extremity of the transverse
 diameter.   Facts of this nature have so accumulated, of late years  espe-
 cially, that they can no longer be regarded  as exceptional;  and if the chin
 corresponds  exactly with the sacro-iliac  symphysis, especially if it  has  al-
 ready undergone a slight movement fonvard, there is reasonable ground to
 hope that the  spontaneous  rotation thus begun will second that impressed
 by the forceps upon the chin, and the extraction be  accomplished Avith the
 chin to the pubis, the body, in consequence of the contractions of the Avomb,
 having partaken of the motion communicated by  the  instrument to the
 head.
   It must, hoAvever, be remembered that, in direct mento-posterior positions,
 this excessive  rotation is likely to  kill  the child;  and such a  case I have
 already quoted.  Besides this,  it must especially be borne in  mind  that,
 hoAvever skilful the  operator, it has often proved impossible.   Messrs. Du-
 bois, Danyau,  Cazeaux, and many others have failed;  and Smellie himself,
 who long since advised bringing the chin fonvard, was often unable  to suc-
 ceed.  On consulting  the voluminous record of observations published  by
 Smellie, I have found  but four cases in Avhich the face was deeply engaged
 in  the  pelvic  cavity in a  mento-posterior position.  In all these cases,  he
 first tried to push  up  the  head, failing  in  which he  applied  the  forceps.
 Noav in these four cases, he only once succeeded in  bringing the chin for-
 ward ; in one  other, he was only able to flex the head Avith the instrument
 and disengage the vertex and occiput, the first beneath  the  pubis; in the
 remaining two cases, he was obliged to use the crotchet.   The latter course
 was also pursued in a case furnished him bv one of  bis old  mini Is.   Thiw 
THE  FORCEPS.
983
of five cases, did but one permit of rotation forward; it being impossible  in
all the others.
  Are we prepared to say that after rotation fonvard has failed, craniotomy
alone remains?   I think not, but believe  it right first to endeavor to flex
the  head by means of the forceps.   By so doing I extracted  a living child.
Smellie also succeeded, after vainly trying  to bring the chin  forward ; and
similar cases are to be found in the medical journals.   It ought, therefore,
to be attempted before having recourse to craniotomy.
  In  estimating the value of the A'arious modes of  procedure Avhich have
been  mentioned  for effecting delivery in these difficult cases, Ave  must not
be too exclusive ; for experience shows that  the plan Avhich succeeds in one
case fails  in another, without our being able fully to account for the differ-
ence ; often, indeed, after having tried them all fruitlessly, it is necessary to
have  recourse to craniotomy.
  Especially do I  think it necessary to a proper estimate of the utility of
each, that great regard should be had, at the time of  operating, to the exact
relation of the chin Avith the  posterior plane, to the  energy of the contrac-
tions, and to the tendency Avhich the head  may exhibit to perform its rota-
tory movement.   An almost direct  mento-posterior position, immobility of
the head, and continuance in that position  after a long  labor, as also the
Aveakening of the  pains so often  consequent upon  great prolongation of
labor, are conditions evidently opposed to artificial rotation.
  In short, apply the forceps and attempt the  rotation,  making  the efforts
coincide with the contractions of the womb  ; if unsuccessful, try to flex the
head; should this fail, perform craniotomy.
  3.  When the face is still  above the superior strait, an  application of the
forceps is only to be attempted Avhen the  pelvic version is altogether impos-
sible.  In  fact, it  is Avell known that the face  is  then  usually found in a
transverse position.  Besides, as previously stated,  when the head is so high
up, the blades are  necessarily applied  along the sides of the  pelvis; conse-
quently, one of  them would come  into contact with the vertex, the other
with the neck, and the pressure  made on this latter  part Avould most assur-
edly compromise the life of the child.  We were, therefore, right in saying
that  the  forceps ought only to be used as an  extreme  measure, and  that
before using it, unless Baumers' forceps are tried,  an  attempt should  be
made to convert the face position into one of the vertex  by the cephalic
version, and then  apply the forceps on the head in this rectified position.
                                                 •
  §  5.  When the  Head  remains behind  after the  Body is ex-
pelled.
  When the head is retained in the mother's parts, after a natural delivery
by the  breech, or after the  pelvic version,  an application of the forceps is
rarely indispensable, for the hand  alone is usually  sufficient to effect  the
delivery; more  particularly in those cases  where an extension of the head
is the sole cause of difficulty.  But when the manual operation has failed,
or the base of the cranium is arrested by a contraction of the pelvis, the
forceps may certainly be very useful, Madame  Lachapelle to the eontiarv
notwithstanding. 
981
OBSTETRICAL  OPERATIONS.
    Whenever an application of the instrument is decided upon, the rules for
 operating are nearly the same as in the vertex  positions;  here, also, the
 blades are placed as nearly as possible on the sides of the head, having their
 concave  edges always directed  toAvards the part  that is to come under the
 pubic  arch, &c.  We may further add, that it should be entered  along  the-
 sternal plane of the child, as also, that the body is to be supported and car-
 ried towards that  side Avhere the occiput is situated, i. e. directly forward
 and upward in the occipito-pubic positions, forward  and to the left  in  the
 left anterior occipito-iliac positions, &c, &c.
   The blades  having been introduced in  the  usual  manner, Ave are next,
 as a general rule, to attempt the disengagement of  the head  by a  move-
 ment of flexion, having the nape of  the neck as  its  centre; which is situ-
 ated at times under the  symphysis  pubis, and  at others at  the perineal
 commissure.
   In one case only Avould the accoucheur be Avarranted  in entering the for-
 ceps along the dorsal plane of the child,  and freeing  the head by a process
                                of rotation.   We mean, where  the  face is
                                above, the occiput being behind;  but  this
                                manoeuvre, Avhich was recommended  by
                                Madame Lachapelle, does not  always suc-
                                ceed  ; for other practitioners are not  so for-
                                tunate as that skilful midwife in turning
                                the face  into  the hollow of the  sacrum.
                                We rather believe, Avith M.  Velpeau, that,
                                relying on the result  of  the  cases reported
                                by Eckard and Michaelis, it might be pos-
                                sible,  by means of Avell-directed  tractions,
                                to free the occiput at the anterior perineal
                                commissure, after which the  delivery of the
                                head  Avould be completed by its extension.
                                  But a much more  difficult case may be
                                met with in consequence of an arrest of the
                                head  above  the  superior  strait; whether
                                arising from  an unusual extension, incapa-
                                ble of being  remedied by Madame Lacha-
 AppHcation of the forceps where the head is   pelle's manoeuvre, or from a  contraction of
  retained after the delivery of the body.     ,,     n  .       .     -tit    ,. .
                                the pelvis,  too inconsiderable of itself  to
 require the use of the forceps.   Both  Smellie and Baudelocque, who were
 as skilful as fortunate, have succeeded in  its application under such circum-
 stances; but, notwithstanding  the great  authority of  their names, cases of
 this kind  may well be dreaded when  such a man as  Dewees ahvays  failed
 in the  operation!  In fact, what a series of difficulties are here  met  Avith!
 Thus, not  speak of  the obstacle to the operation  caused by  the  trunk fill-
 ing  up the vulvar  orifice, Ave  must  remark:  1.  That, when the head is
 lodged  transversely with regard  to the  pelvis, as frequently happens,  the
 forward inclination  of the upper strait makes it impossible to apply the
 blades on the sides of the head ;  2. That the vertical  diameter of the head
•will necessarily be placed in the direction of the axis of the blades, and that
 
THE  FORCEPS.
985
 >.he latter will consequently be  applied  upon the  tAvo extremities of a long
 diameter, — a circumstance tending  strongly  to  defeat the  operation;  3.
 That on account of the elevation and position of the head, it is often imper-
 fectly grasped by the instrument, which is liable, upon the first tractions, to
 slip and Avound the parts of the  mother.  It is, hoAvever, the extreme resource,
 and  must be attempted Avhenever tractions, as strong as are compatible with
 the life of the child, have proved unavailing.
   The rules for  its accomplishment are very simple; namely, to carry the
 trunk tOAvards the part  corresponding with the occiput;  to depress the chin
 as much as possible, Avith a vieAV of diminishing the extension of the head;
 to enter the blades on the side  of the pelvis; and, lastly, to operate, as far
 as practicable, in the direction  of the pelvic  axes.
   Should the  base of the cranium present  after the accidental or designed
 separation of the head from the  body, it would be proper, provided the pelvis
 Avere well formed, to apply the forceps, after having taken the precaution of
 placing the head in a proper position ; that is, with the  smallest diameters
 corresponding Avith the plane of the pelvis, and the occipito-mental diameter
 Avith  the  direction of its axis.   Should  the deformity be too great, the em-
 bryotomy forceps Avill be the only resource.   (See Craniotomy.)

   § 6. General Considerations of the Employment of the Forceps.
   Although an  exceedingly useful instrument Avhen employed by  skilful
 hands in proper cases, the forceps, by being badly directed or improperly
 applied  in  those in Avhich it is not  indicated, may give rise to  the most
 serious  disorders.  It is particularly important, therefore, in closing this
 article,  to point out the cases in Avhich it may be advantageously employed.
 Besides, this short revieAV will serve to illustrate the precepts just given, and
 render its mode of action more  intelligible.
   The forceps has been recommended : 1st. In cases of irregular or inclined
 vertex and face positions, which are neither corrected spontaneously nor can
 be by the unaided hand.  2d. Where a disproportion exists betAveen the pelvic
 dimensions  and  the size of the head, Avhether dependent on an excessive
 volume of the latter or  a contraction of the  former.  3d. Where any acci-
 dent, serious enough to compromise the life of the mother or child, occurs
 during  the  labor, Avhich is not  remediable  by version.  4th. Lastly, Avhere
 the head has   descended to the  pelvic floor, and is there  arrested either by
 the resistance  of the soft parts or by the shortness of the cord.
   1.  Inclined  Vertex or  Face Positions. — As heretofore stated, we consider
 an application of the forceps preferable to the use of the vectis (or lever) in
 these cases,  after  the inefficiency of the natural poAvers has been fully deter-
 mined  by a delay of  seven or eight hours.   The  retraction of  the  uterus
 would  render   version too difficult.   In  fact, Ave believe  that  a prompt
delivery is equally demanded for the benefit of the mother and the child,
and that  the  forceps  alone can accomplish  this result.  Moreover, as the
inclined  lateral  or parietal  positions are  nearly ahvays  transverse, it  is
unnecessary to add, after what has been elseyvhere said, that the blades are
to be entered on the sides of the pelvis ; and that, as the head descends into
the excavation, it will probably undergo rotation, Avhereby it Avill be con- 
986
OBSTETRICAL  operations.
\Terted into an antero-posterior position.1  By proceeding in thi.- manner, we
will avoid, according to Duges, the difficulties of a direct anttro-posteriol
introduction  as  regards the pelvis, and  the  dangers  to the  foetus  from a
biparietal  application;  for it must be obvious that, if the inclination Avere
considerable,  one of the blades Avould bruise the upper part of the neck.
   2.  Contractions of the Pelvis. — The ultimate limit to Avhich Ave restricted
the use of  the forceps, was three inches;  because any reduction,we could
hope to obtain in the diameters of the head beyond  that, Avould not,  as a
general thing, be great enough to permit  it to pass through  the  contracted
diameter of the  pelvis.   In truth, the enlarged experience of Baudelocque
has proved that,  Avhen the forceps is applied in the direction of the biparietal
diameter, the  greatest reduction attainable, Avithout compromising the child's
life, is not  more  than half an inch.  Noav, this diameter, on a Avell-formed
head, averages from three and a half to three and three-quarter inches,  and
even supposing that Ave can reduce it  half an inch, there will still  be  left
three inches at the least.
   Certain  practitioners, having  observed that the head became  gradually
moulded to the shape and dimensions of the pelvic cavity, by the efforts of
the Avomb  alone, in some cases in Avhich  the  pelvis Avas contracted to  less
than three inches, have  therefore imagined that the resources of art could
accomplish Avhat nature  alone  sometimes effects; that  by the forceps a
similar reduction in the diameters of the head might be obtained  ; and  con-
sequently,  that the instrument could be usefully applied Avhen the  contracted
diameters are even less than three inches.   But they have instituted a com-
parison betAveen  tAvo  forces  that are wholly dissimilar.   Indeed there can
be no dcyabt that the expulsory efforts of the womb have succeeded  in forc-
ing the head through the pelvis where the smallest diameter did not exceed
two and three-quarter inches ; but this result Avas only effected after a tedious
labor of thirty,  or forty, or even  sixty  hours; and  where the sIoav  and
gradual  compression,  to Avhich the head was  then subjected,  enabled  the
brain to accommodate itself thereto  by degrees.  On the contrary, the reduc-
tion obtained  by the forceps is  produced by a force  that does not extend
beyond half an hour or an hour at the most.   Noav, everybody knows  that
a tumor, Avhose development extends  over a period of several  years, may
exist Avithin the cranial cavity Avithout giving rise to any serious disturbance,
Avhilst a little drop of blood, suddenly  effused, brings on paralysis at once.
Consequently, the pressure made by the  forceps may  kill the child by its

  1 This phenomenon'occurred in a lady, in  Rue St. Paul, to whom I was called by Dr.
Ducros, about seven o'clock in the evening.   The membranes had been ruptured since
eight a. m. :  the head was  situated in a transverse occipito-iliac position,  and was in-
clined on its anterior parietal region ; it had not made the least progress  since morn-
ing, and was so inconsiderably engaged at the superior  strait, that I was forced to
introduce nearly the whole  hand rbr the purpose of ascertaining the position: the
waters had escaped, and I attempted in  vain to effect a reduction; but an application
of the forceps,  made in the manner above indicated, was attended  by the  happiest
results.
  Tlie head  descended, and rotated within the blades, and in less that, five minutes the
child was born living.
  Toe Lying-in exhibited nothing unu*uai. 
                            THE  FORCEPS.                        987

mdden action, notAvithstanding the reduction is  absolutely le&j than Avhat
nature herself sometimes produces after several hours of suffering.
  But when the pelvic diameters exceed three inches, the forceps may prove
very useful; though I am induced to believe that the character of its action
has been misunderstood, by supposing that it is to serve both  as an instru-
ment of traction and as one calculated to reduce the dimensions of the head
by its pressure.  Let it be understood that the forceps  merely acts  here as
an instrument of traction.
  In fact, the contraction usually exists at the superior strait, Avhere it  is
particularly apt to affect  the sacro-pubic diameter; and as the head ahvays
has  a tendency to present its long  diameters to those of the  pelvis, Avhen
retained above, it  is generally found  in  a transverse or an oblique position
(more frequently the former).  Its biparietal diameter will, therefore, cor-
respond  to the sihallest one of the  strait, and of course the  blades of the
forceps should be  applied  in  the direction of this diameter; but Ave  have
shoAvn that such an application is not possible in  any case, and this impos-
sibility is still more evident Avhen contraction exists.   For, as Dr. Collins
observes, if the sacro-pubic diameter amounts to  but three inches, it would
be impossible to apply an  instrument, the interval betAveen whose  blades,
when closed,  is from three and a half to three and three-quarter inches.
  The forceps Avill therefore have to  be applied laterally; but it is evident
that the pressure exerted by it will  bear upon the occipito-frontal diameter.
Noav, although the experiments of Baudelocque may have  proved that the
head, Avhen flattened in one direction, is not very sensibly enlarged in another,
it cannot be supposed that a reduction effected in the occipito-frontal diam-
eter would at  the same time diminish the biparietal one, Avhich  is  perpen-
dicular to it.  How, then, does  the forceps  act?  Simply by its tractive
poAver, Avhich, conjoined with  the uterine contractions, induces the head  to
engage in  the excavation; Avhen, of course, as  the parietal protuberances
correspond with the anterior posterior diameter, the biparietal  one  becomes
compressed between the pubis  and sacrum ; the pelvis itself acting here as
the compressory agent, and not  the  forceps,  which latter merely facilitates
the process by  its tractions.  The pressure exerted by the instrument would
certainly be  more  hurtful  than  useful, by preventing Avhatever elongation
the  occipito-frontal diameter  is capable of receiving  during the  forcible
reduction of  the biparietal one.   This vieAV of the action of the forceps has
at least the advantage of demonstrating the uselessness, if not the danger, of
the  poAverful  efforts  sometimes resorted  to by certain accoucheurs for the
purpose of compressing the head, and reducing  its.size; for Avhen the head
is Avell grasped by the instrument, all that is requisite is to tighten the latter
enough to prevent it from slipping during the operation. If the forceps can
ever be used  as a means of reduction, it is only Avhen the head  is arrested by
a shortening  of the bis-ischiatic diameter.
  The limits just  assigned  to  the application of  the forceps, are the conse-
quence of  experiments upon  the dead  body, and of the  most frequently
observed cases; but we shall have  occasion  to prove  hereafter that they
cannot be  regarded  as absolute.  When  the  smallest diameter of the con-
tracted pelvis is less than three inche&. we are still almost obliged tc try the 
988                 OBSTETRICAL  OPERATIONS.

forceps before having  recourse to craniotomy or symphyseotomy (sets Sym-
physeotomy), and it has several times been the means of extracting a living
child through a diameter of but two and three-quarter inches, for example.
   But are the  forceps the only resource left  before having recourse to a
bloody operation in cases of  contracted  pelvis ?  We long thought that it
was, and, notAvithstanding the impression made upon our mind by the perusal
of the observations  of Madame  Lachapelle, we shared on this important
practical point the opinion of the majority of French accoucheurs, and pro-
scribed  pelvic version in cases of contracted pelvis, except in the obliaue
oval variety, in  which it was admitted by all to have undoubted advantages.
   The recent publication of Drs. Simpson and  Radfort led us to a fresh ex-
amination of the question.
   " On  reading cases of contraction of the pelvis," says Dr. Simpson, " I Avas
struck Avith the  fact, that the labor in certain malformed females Avas much
easier and more fortunate Avhen  the child had  presented by the feet than
Avhen the head Avas the first to offer.   In several cases even, which Avould
have required craniotomy, the presentation of the feet or  pelvic version en-
abled me to  effect the delivery in a succeeding pregnancy.  Five observa-
tions of this kind are recorded by Smellie."
   " According to my tables," says  Madame Lachapelle, "• of fifteen children
delivered  by the forceps, on account of contracted pelvis, seven lived, and
eight perished ;  Avhilst of twenty-five delivered by the feet,  fifteen survived."
The proportion of success is, therefore,  three-fifths  for version, and rather
less  than  one-half for the forceps.  " These fortunate results of version,"
adds the illustrious midwife, " are  doubtless due to the greater facility Avith
which Ave  are able, Avhilst draAving upon the pelvic extremity, so to direct
the head of the foetus as to place  its transverse diameter in correspondence
Avith the shortened  antero-posterior one.   When, on the contrary, the head
presents first, it  is, in fact, generally situated transversely; but it may pos-
sibly occupy  much more unfavorable positions, and those, too, of a kind
Avhich the forceps is incapable of altering."
   Supposing  the head to be situated transversely above the shortened sacro-
pubic diameter, would it traverse the passage Avith any more ease if present-
ing the top of the head,  than Avhen,  after the extraction or spontaneous ex-
pulsion of the body, the base of the cranium is presented  to the shortened
diameter ?  Here,  theory seems  to be quite  in  accordance Avith the above-
mentioned facts.  The head, regarded  as a Avhole, represents  a cone, Avhose
base is the biparietal diameter, amounting to from three and a half to three
and three quarter inches, and the top of the head by the bimastoid diameter,
amounting to but from three  to  three and a quarter  inches.  This  latter
diameter is irreducible, Avhilst the former is susceptible, under  the influence
of pressure applied for a longer or shorter time, of  being shortened to  the
extent of three-eighths, or even five-eighths of an  inch.   Noav, vvhen  the
top of the head presents first, the base  of the cone Avhich  it represents is
brought in relation Avith a shorter diameter than its own, and all the efforts
of the womb,  as Avell as the tractions of the forceps,  can have but the single
result of flattening the  vault of  the cranium  against the opening of  the
pelvis, and consequently of increasing, instead of diminishing, the biparietal 
THE  FORCEPS.
989
diameter.  If, on the contrary, Ave suppose the cone repiesented by the head
to engage by its point, that is to say, by its bimastoid diameter, the tractions
upon the body of the child might have the following effects : namely, if the
shortened pelvic diameter presents at least from tAvo  and three quarters  to
three and a  quarter inches, it will present no serious obstacle to the engage-
ment of the bimastoid diameter, and from that time, the compression upon
the sides of the parietal protuberances,  produced by the resisting symphysis
pubis  and sacro-vertebral angle, tends  to force them nearer together, that
is to say, to  shorten the biparietal  diameter, and the  head draAvn doAvn by
the accoucheur will engage in the contracted part of the pelvis like a Avedge,
the base of Avhich is compressible.  In  short, the resistance of the bones of
the pelvis in the presentation of the top of the head, tends to lessen the oc-
cipito-frontal  or occipito-mental  diameter, whilst in  foot presentations, it
tends to diminish the transverse diameter, that  is to say, the only one Avhich
it is important should be reduced.  (Simpson.)
  A greatly prolonged  labor ought, doubtless, be  regarded as one of the -
most dangerous circumstances affecting  the Avelfare  of both mother and
child, for the lives of both are hazarded in proportion to the lengthening out
of the expulsive stage;  noAV, according to Dr.  Simpson, version affords the
immense advantage of enabling us to terminate  the labor more quickly.
What, indeed, is the course generally pursued Avhen it is proposed to apply
the forceps  in these cases of contraction?  It is  evidently, to  Avait before
acting, in order to determine the incapacity of the uterine efforts, and it is
not until after five, six, or eight  hours  of expectation, that the instrument
is used.  In the  meanAvhile, the  head  is compressed  poAverfully,  and the
maternal organs are  so  seriously contused  as  to  expose them  to  gan-
grene, or, at least, to those inflammations of the uterus  or of the cellular
tissue of the pelvis, so  dangerous during the  lying-in.  On  the  contrary,
Avhen turning is intended, the most favorable moment can be chosen in many
cases, which is immediately after the membranes are ruptured and the neck
completely dilated.   The term of expectation would  be still longer in pres-
ence of a pelvis so  contracted as to require embryotomy ; for, unless the
foetus  is  found to  be  dead, the  operation is deferred until  it  shall  have
perished, or at least until the labor shall have lasted so long as to render its
viability exceedingly doubtful.
  If regard  be had only to the interests of the  mother, version, as affording
opportunity  to act immediately after the membranes are ruptured, should
therefore be  preferred ;  but is the case  the same as respects the fcetus ?  If
we compare  the results of podalic version Avith those of embryotomy, the
reply is ready, for  the facts mentioned by Madame Lachapelle, and some
authors, afford us  at least the hope of  sometimes saving the child by turn-
ing, whilst its death is  the inevitable  consequence of any other operation.
But do not the forceps,  within the rational limits Avhich Ave have fixed for
their employment, afford greater chances to  the fcetus than the extraction
by the feet?    Madame  Lachapelle and Drs. Radfort and  Simpson do not
hesitate to declare for the turning.  NotAvithstanding the facts collected by
the illustrious midwife,  and whilst admitting with the English accoucheurs,
that the  compression is less dangerous to the foetus when exerted on the 
990                  OBSTETRICAL  OPERATIONS.
sides of the head than when its tendency is  to  shorten the occipito-frontal
diameter, Ave confess that we cannot share their preference Avhen the top of
the  head presents in a favorable  position.   The  arrest of the base of the
cranium above the  contraction, the possible extension of  the  head, the
stretching of the cervical  region to Avhich the tractions made on the body
necessarily expose it, the possible compression of the umbilical cord during
the time occupied in the extraction of the child, are, indeed, very unfavor-
able circumstances  for the latter, and, unfortunately, greatly to be feared
during version.  But yvhen, with a shortened diameter of three and a quarter
inches, there coincides  an unfavorable presentation, as those  of the face or
of the trunk, and Avhen,  before the  application of the forceps,  it is  first
necessary to  perform the  cephalic version;  or Avhen,  the  top of the head
presenting, it is so situated that its longitudinal diameter corresponds to the
contracted one,  we are  of their opinion, and  prefer version to the use of the
instrument.
  When the antero-posterior diameter of the  pelvis amounts to but from
two and three-quarters to three and a quarter inches, and the child, being
still alive, is placed in the conditions just mentioned, we also think  that
version should  be preferred.
  If, after several fruitless attempts made Avith the  forceps upon a favorably
situated head, the heart is heard to beat distinctly and regularly,  we should,
if the  pelvis has  at least two and three-quarter inches, attempt the pelvic
version before resorting to craniotomy.
  We Avould add, Avith Madame Lachapelle, that version is  also preferable
to the use of the instrument, Avhen the inferior strait is contracted  trans-
versely, and  the pubic  arch is  narroAV  and  angular.   When, in  fact, the
head is the first to be delivered,  the occiput appears first beneath the pubis,
and its disengagement under these circumstances is very difficult, and some-
times even impossible.   When, on  the  contrary, the extraction takes place
by the feet, the occiput places itself behind the pubis, the forehead is the
first to appear in front  of the perineum, and only  the  back of the neck  en-
gages in the arch  of  the pubis.

  [Our colleague, M. Joulin, expresses a much more positive opinion.   He insists
that turning ought to  be rejected and the forceps preferred Avhenever they can be
applied, except in cases of obliquely deformed pelvis.  In his paper ( On tlie Forceps
and Version in Contractions of the Pelvis)  are recorded  experiments of undoubted
value, made upon the  dead body ; yet it Avas a great mistake that, in an account in
other respects very well  prepared,  M. Joulin should have  supposed the previous
editions of this work (Cazeaux, 1858) to contain  inconsistencies  in reference to the
subject under consideration.   To know that the charge is unfounded,  it will only
be necessary to consult the full text in order to ascertain its true meaning.  To it
we refer the reader who would judge for himself.  The apparent  contradiction is
really but an expression of reserve in the judgment given.]

  To recapitulate: Avhen the pelvis has at least tAvo and three-quarter inches
in its sacro-pubic diameter, the forceps should be used if the top of the head
presents in a transverse position.   The pelvic version should be  preferred:
1, in direct antero-posterior positions ; 2, in inclined or irregular positions of
the top of the head ; 3, in  face and trunk presentations; 4, in contraction? 
THE  FORCEPS.
991
of the inferior  strait attended with narroAving of the sub-pubic arch.  It
Avere useless to recall  the  important distinction Avhich we have  established
for the oblique oval pelves, in Avhich version is the rule.
   3. Accidents.— It  is  only necessary to recall  the conditions in which
version is practicable, to show the part the forceps  may play in those acci-
dents that require a speedy termination of the labor.   We need not  mention
the dilatation or dilatability of the os uteri, for this is indispensable to both
operations.   Should  a completion  of  the delivery be deemed  imperative,
when the head has cleared the cervix,  or  is Ioav down in the excavation, Ave
would apply the forceps; but, on the contrary, if it be but little or not at all
engaged at the superior strait, version  would *be preferable, unless the pelvis
Avas very narroAV, or the Avomb Avas so firmly contracted as to render an
introduction of  the hand unusually painful, or even impossible.
   4.  The Resistance of the Perineal Muscles is  one of the most  common
reasons for resorting to the instrument; for nine out of every ten applications
of the forceps are made for the purpose of extracting the  head, Avhich has
been detained at the pelvic floor for four, five, six, or seven hours; indeed,
if the measures recommended on  page 078 have proved ineffectual, this is
our  only resource.  But,  even here, it is possible that  obstetricians  have
been in error Avith regard  to its modus operandi, since every one, avIio, like
myself, has frequently had occasion to apply  it, must have been  struck Avith
the fact  of  Iioav little effort is required, under such circumstances,  to effect
the delivery of  the  head.   For, Avhere this part  has been retained at the
same point for seven or  eight hours, notwithstanding the most energetic con-
tractions of the organ, and all the uterine forces have been expended on an
apparently insurmountable obstacle,  the accoucheur, in  resorting to his
instrument, may anticipate the necessity of using  some considerable force;
and yet, as soon as  a feAV slight  tractions are made, this great resistance
seems to give Avay at once, the uterine  contractions that Avere  so long  inef-
fectual are  henceforth adequate, and the  patient soon expels the head  and
forceps together.  Far different Avould  be  the result, if the arrest of the  head
were altogether  dependent on an  over-resistant perineum ; for  the exertion
requisite in those cases, where this part has been rendered less extensible by
abnormal bands or cicatrices, is  Avell knoAvn.  Doubtless, this resistance
from the pelvic  floor is the first source, but it is  far from  being the Avhole
cause of the difficulty.
   In my opinion, the folloAving is the true state of the case: Avhen the head,
urged on by the uterine contractions, reaches the  floor of the pelvis, it is
already in a state of  flexion, Avhich must certainly  increase as  the pains be-
come stronger, and the perineum more resistant;  for, being placed  betAveen
two opposite forces, it will necessarily be flexed on the chest to the  greatest
possible extent.   Noav, it  is this excessive flexion that constitutes the  most
serious difficulty, for, in  this  position,  the spinal column abuts  directly on
the occiput, and  every expulsive effort transmitted  by it has a tendency to
depress the  latter, and to  flex the  head;  but here  its extensiou can alone
effect a delivery.  The question recurs, hoAv then  does the  forceps operate?
I  answer, in a very simple  manner: by the first tractions it extends the head,
changing this part to a more favorable position relatively to the spine,  and 
992
OBSTETRICAL  OPERATIONS.
thus restores the efficacy of the  uterine contractions, which latter are quite
sufficient for the subsequent completion of the delivery.
  Hence, the reader will understand that, although the perineal resistance
is, Avithout any doubt, the original cause of the arrest of the head, yet, in a
vast majority of cases, it merely acts by producing an exaggerated flexion;
and  that, as soon as this is created, if alone constitutes the whole difficulty;
a proof of which is  satisfactorily  afforded by the ease and rapidity of the
termination of the labor, after  the first  moderate  tractions made by the
instrument have effected a partial extension.
  5. Lastly, it has been shoAvn hoAv a shortening of the cord may become a
cause of dystocia.  Where this happens, the forceps is a hazardous resource,
that ought to be avoided ;  but the real source of the delay is generally un-
knoAvn, and, even if  it Avere not, I knoAV of nothing better to be done, if the
head is low down in  the excavation.
  The period of labor  for applying the  forceps varies Avith the cause that
demands its use.  When any accident  Avhatever renders it advisable to pro-
duce a speedy delivery, and the forceps be deemed appropriate, the time for
operating will be judged of by the danger of the accident itself; for Ave are
evidently to interfere as soon as there is reason to fear that the life of either
the mother or child is involved.   When the head is arrested above the supe-
rior  strait by a contracted  pelvis, we might Avait in ordinary cases, as else-
where stated, for six, seven, or even eight hours after  the membranes are
ruptured and the os  uteri is fully dilated; but a longer delay would expose
both mother and  child to the most  serious hazard.   Again, Avhen the arrest
of the  head is dependent on the  resistance of  the  soft parts, the pressure
thereby created on the vaginal walls and sometimes even upon the parietes
of the womb, might  eventually determine a gangrene  of  those parts, and
render the  patient liable to the vesical and recto-vaginal fistulas, which often
result in consequence.   Besides  Avhich, the foetus, being subjected for a long
time to compression, may suffer from  it, and  from the disorder thereby
created in  the omphalo-placental  circulation; and the uterus, having ex-
hausted its energy against resistances which it cannot overcome, falls into a
state of inertia that continues after the delivery, and becomes then a source
of hemorrhage; and, lastly, the inflammation of  the Avomb or vaginal walls
that occasionally takes  place,  may extend to the peritoneum after, or  even
during the labor, and  speedily prove  fatal.   All these dangers are easily
obviated by the proper application of the forceps; and though, on the one
hand, the  abuse of the  instrument, by employing it too early, as some prac-
titioners are in the  habit of doing, is to  be avoided, yet, on  the other, Ave
must not virtually interdict its use by trusting too long to the poAvers of
nature.   We must again allude to Avhat avus  previously stated in regard to
the importance of observing the stage of the labor at Avhich  the  delay occurs:
thus the time that has elapsed prior to the rupture of  the  membranes, can
have but little  influence on the mother's condition,  and none on that of the
child, so that, even Avhere the labor has lasted from thirty to thirty-six hours,
there is often nothing to be done;  though if the head Avere Ioav doAvn in the
excavation, and it had made no progress for seven or eight hours, the forceps
ought to be applied.   But this rule, which is applicable to most cases, admits 
THE  FORCEPS.
998
 ,»f some exceptions; and  it would  seem useless to add that the itate of the
 patient's health, the strength or feebleness of the uterine  contractions, the
 slowness and  intermission,  or the  regularity of the foetal  pulsations, &c,
 must influence the time of its application.   The accoucheur would be justly
 liable to censure for not acting soon enough, and equally so for recurring too
 early to the use of instruments.
   Statistics, and General  View of the Operation. — We find the same  diffi-
 culty in forming  an exact idea of the frequency of the cases requiring the
 application of the  forceps, as Ave  did of the cases demanding version, for
 they vary much in different  countries, and even in the practice  of accou-
 cheurs of the same locality.   Thus, on consulting the statistics collected by
 Churchill, we  find for England, 120 forceps cases in 42,196  labors, or about
 1 in 351; whilst  in  France, the  instrument  has been used 277 times in
 44,776 labors, or about 1 in 162 ; and in Germany, 1702  times in 261,224
 labors, or about 1 in 153.
   It is still more difficult, correctly to estimate the danger of the operation
 to the mother and child, for  the statistics generally represent only the num-
 ber of  mothers and children who  perished, without  stating the  cause re-
 quiring the intervention  of  art, and, consequently, leaving us uninformed
 as to the probable  danger of the operation in any given  case.  Thus, the
 risks to which the mother and child are subjected when the use of the for-
 ceps is demanded only by the resistance of the soft parts, is not comparable
 to that which  threatens them Avhen the head is arrested by a contraction of
 the pelvis.  The length of time which elapses between the  discharge of the
 Avaters  and the intervention  of art, necessarily influences greatly the result
 of the  operation: now, with  the exception of Dr. Collins,  whose statistics,
 though  unfortunately too limited,  prove that the  mortality is greater in
 proportion to  the lateness of the  operation, very feAV authors have noted
 this particular point.1
   There  can be no doubt that the use of the  forceps increases the dangers
 of the  delivery.2   Besides its being ahvays  prejudicial to interfere Avith the
 operations of nature Avhen they are going on  regularly, the application  of
 the forceps, though apparently of the simplest character, may prove  dan-
 gerous to the mother, and especially to the foetus.  The too  rapid depletion
 of the  uterus  exposes the woman to hemorrhage from inertia.  The dilata-
 tion of the soft parts takes  place with far  less regularity Avhen the head is
 extracted by the forceps,  and the perineum is, therefore, much more liable
 to laceration, hoAvever carefully  the tractions are  performed.  Finally, I
 shall not  speak of the lesions of the  cervix and of the perforation of the
 vagina, since  it is ahvays possible to avoid  them by conforming  to the
 precepts already  given.

  1 -Dr.  Collins gives the following as regards the mothers.  When the labor was ter-
minated  in 24 hours, but one  wmnan died  out of 13; between the 28d and 30th hour,
there was one death  for 6 cases;  between the 37th and 48th, one death in 4; and be-
yond 48, one death in 2 cases.
  8 In natural labors, the mortality was, for the mothers, 1 in 346, and for the chil-
dren, 1 in 31; in deliveries by the forceps, it was, for  the mothers, 1 in 22, and for
the ch ldrei.  1 in 43.
      63 
994
OBSTETRICAL  OPERATION'S.
  Therefore, the  instrument should be  had recourse to c ply av ien the in-
sufficiency of the powers of nature  shall  have been well ascertained, and
we are convinced that a longer expectation Avould be injurious to the mother
or to the child.
  The posterior position of  the head, when the vertex presents, also adds to
the difficulties  and danger of the operation.  Especially when the occiput
is directly behind, or  behind and to the left, is the operation more laborious.
I have mentioned a case of direct posterior position in which I was obliged
to bring  the occiput forward (page 974, note).   In two other cases of left
posterior  diagonal position, the  head was delivered only by the strongest
exertions.  The occiput in  these cases pressed so strongly upon the sciatic
plexus, that  both the patients suffered, for a long time after, great pain in
the course of the sciatic nerve, and one was unable to walk for more than
a year.
  On the other hand, the compression of the child's head by the instrument
may be prejudicial to its health  or even to its life, and Ave have to point out
as possible occurrences, cerebral effusions, fractures, and depressions of the
bones of  the skull, exophthalmia, contusion, laceration, and separation of
the scalp, compression  of the umbilical  cord betAveen  the head  and the
blade of  the forceps, and, lastly, paralysis of the facial  nerve, on which we
shall make some  remarks.
  Quite  recently, M. Landousy has called attention to  the facial paralysis
of new-born children, that often follows an application of the  forceps ; and
M. P. Dubois has also alluded to the same fact in his lectures.  This palsy,
which  affects only one side of the face, is caused by the pressure of the
blade on the seventh  pair of nerves.   OAving to the nearly total absence of
the mastoid  process, and the defective development of the auditory canal,
?uch a compression of the facial nerve just as it escapes from the stylo-mas-
toid foramen may occur very easily.  The affection is easily recognized imme-
diately after birth, by the folloAving circumstances : the commissure of the
lips  is drawn out of  place ; the nostril is neither so dilated nor so movable
as its  fellow of the opposite side ;  the eyelids are open, Avhile those on the
sound  side are closed; the Avhole side of the face is distorted, and  this de-
formity, heightened by the infant's cries, gives it a very peculiar expression.
As  soon  as the crying is over,  the  deformity is so slight as scarcely to be
noticed, if the  eye on the  sound side happens to be open ; but when the
child cries again, the want of symmetry in  the features  is once more ob-
servable.   This difference in  the phenomena of the  disease, dependent on
the condition of repose or agitation of the face, is much better marked than
it is in  the  facial hemiplegia  of  adults.   The  difference  is particularly
striking just before it  cries, for its face then exhibits alternations of rest and
excrement such  as those just described.  In the course of a week or ten
days these symptoms  nearly all  disappear, and the equilibrium between the
two sides is  gradually restored.  When the compression of the nerve has
been moderate, the hemiplegia  does not last so long, and occasionally dis-
appears in a few hours ; but  in other instances it may  persist for a month
or two.  Hitherto, this  affection has never terminated in death, having
always passed o^ even where  no active medication has been employed. 
THE  VECTIS.                          995
  The only precautions necessary in such cases, are k prote t the eye from
the light;  and, when  sucking is interfered with by the paralysis, as it occa-
sionally is, to find a nurse having  a well-formed nipple.
                           CHAPTER,  Y.

                             OF THE VECTIS.

   The vectis (oj lever), Avhich  Burns  proposed calling the tractor, Avas
 formerly much used, though, at the present day, it is scarcely ever resorted
 to, since, in  nearly all the cases in which it has been  recommended, the
 forceps may be  advantageously substituted.   It was employed to effect the
 correction of the head in cases of inclined vertex presentations, to depress
 the occiput  in face positions, to  force the  head to descend, and to free it
 from the genital organs.  It Avas probably devised  at about the same time
 as  the  forceps, and if Roonhuysen Avas not  really the inventor, he was, at
 any rate, one of the first to use it, and through his example it soon acquired
 a great reputation.  But the vectis h*as  undergone  numerous modifications
 since it became public.  The one now in  use  resembles a  branch of the
 forceps; the blade is provided with a fenestra, and is curved  on one side so
 as  to adapt itself to the convexity of the child's head; being terminated
 below by a long  flat stem, which becomes narroAver and rounded, so as to
 fit in a  wooden handle, which latter is either continued out in  the same line,
 or else is slightly bent in the opposite direction from the blade.
   We agree with Dr. Coppee, that if  the lever is to  be used at the  superior
 strait, it ought to have a very slight curvature, for if it were otherwise con-
 structed, the difficulties Avhich Avould be  met Avith in its  application might
 be  charged to the method when, in fact, they were  due to the form  of the
 instrument.

  [The lever is to be introduced in the  same way nearly  as a blade of the forceps.
 The bladder ought first to be emptied, a precaution even more necessary than when
 the forceps is used.  The woman ought  to lie across  the bed, and very horizon-
 tally, the latter position being  regarded  by the advocates of the vectis as  highly
 important.
  The instrument  being warmed and greased, the hand  or a few fingers are to be
 passed into the vagina, in order to guide  the blade to the head of the child.  The
 operator takes the handle of the instrument in the other hand and passes the blade
 into the vulva.  The blade may be placed  at once in front, just where it is intended
 to apply it, though we think that it would be better  to observe the same plan  as
 with a blade of the forceps, that is, first to direct it backward until it reaches the
 sacro-sciatic ligament, and then give to it a spiral motion Avhich brings it more or
 less toward the front according to circumstances.  AVhen properly applied, the vectis
 will always be found at last behind the most anterior segment of  the pelvis and
in  relation with the body of the pubis, for it ought always to act  upon the head
from before backward.
  It is of the first importance to be sure of the presentation  and position, inasmuch
as the instrument ought never to be applied except to the bony parts of the head, as
the  occiput, temple, or mastoid apophysis, the occiput or mastoid region being the
parts vhich offer the greatest advantage. 
996                   OBSTETRICAL  OPERATIONS.

  The choice of the side of the pelvis upon which the vectis shall  be appl ed AviU
depend more especially  upon the position of the occiput and the movements which
                                the accoucheur wishes to impress upon the head,
                                in accordance with the mechanism  of natural
                                labor.   In  anterior and transverse occipito-iliac
                                positions, for example,  the  blade ought always
                                to be passed to  that side of the pelvis where the
                                occiput is  situated, so that it may be applied to
                                it, draw it  down, and turn  it to the  side of the
                                pubis.  We shall have occasion  to revert to this
                                subject hereafter.
                                   The vectis ought not to be passed in too far, as
                                it might come in contact with the face or sides
                                of the neck and  occasion serious mischief.  About
                                three inches would be far enough to bring it to
                                the part upon which it is to act.
                                   When the  instrument  is properly placed, the
                                handle is to be raised, and the arch of the pubis
                                serving as a fulcrum, it acts as a lever of the
                                first kind.  The head  is then depressed by the
                                power at the  handle, and by drawing donvnward
                                at the same time that this action of leverage is
                                performed, is finally delivered.
                                   To prevent injury to the  urethra, the lever
                                should be  wrapped with a piece of linen or gum-
                                elastic and placed  a little to one side of the  me-
 Mode of using the lever to pull down the   dian line . but when applied in the way we have
      occiput, or to flex the head.        -,i     ■-,   i  -,   i-            •,'   i  •
                                just described,  it  slips very  easily,  producing
 more or less contusion  of the parts overlying the  ischio-pubic ramus.  To prevent
 all these inconveniences, the instrument ought to be held firmly at its middle by
 the left hand, so as to prevent slipping, at the same time that it is  pressed strongly
 backward to strengthen, as it were, the fulcrum and lessen the pressure against the
 arch of the pubis.
   The use of the vectis has been alternately  depreciated and immoderately praised.
 It was strongly condemned  by Baudelocque, and  is at this  moment so little known
 in France that our present classic  authors devote  barely a few lines to an account
 of it.  This indifference to  an instrument which  has numerous partisans  in  Bel-
 gium and Holland seems to me unreasonable ;  and Ave also find that some  French
 authors  think better of it :  Desormeaux, for example, who tells us that he used it
 successfully in  two cases in which it would have been difficult  to apply the for-
 ceps.
   The subject is an important one, and I propose, in treating.of it, to avail myself
 of the theoretical views and clinical facts which  abound in Boddaert's excellent
 paper.   I myself witnessed a case-which convinced me that the vectis may some-
 times be used with the greatest advantage, and sometimes even successfully when
 the forceps has  failed.
   In 1863, Professor Fabri (of Bologne), who wrote  an  important paper upon the
 vectis, being at Paris, I made some experiments with him upon the dead body.
 A. contraction of the pelvis having  been imitated by fixing a  plate of  sheet-iron
 upon the promontory of the sacrum, and a fcetus  placed as  though it presented by
 the vertex, I applied the forceps, but was unable, with all my strength, to bring it
 into the  cavity  of the  pelvis.  Dr. Fabri then used his lever,  and immediately
 brought it into  the excavation.
    The exp^'iment was npeated.  I applied the  forceps again, but with no better
Fia. 144.
 
THE  VECTIS.
997
success ;  taking then the lever, I have to assert that I accomplished my object with
wonderful ease.  It will be admitted that a result of this kind merits attention.
  If comparison be made between the lever and the forceps, it will be found that
they act  differently.   The  forceps is an instrument for traction, and, in this point
of view, is far superior to the vectis.   That the head may be extracted by the latter
cannot be doubted, for the  facts are there to prove it; still, its power in this respect
I regard  as far inferior to  that of the forceps.  The lever acts, on  the contrary, by
compressing the  head from before backward, and when compression in this direc-
tion is desirable,  it would seem to have the advantage of the forceps.
  Is not  the exclusive use  of one  or the other calculated to deprive  us of a pmverful
instrument?  The vectis is not intended to supplant the forceps, but  may be used
in certain cases which it is important to determine,  inasmuch as the surest Avay of
exciting  doubt of its utility would be to employ it  without discretion.   We shall,
therefore, study the action of the vectis in,  I, presentation of the vertex; 2, in pre-
sentation of the face; 3, in presentation of the breech, when, the body having been
expelled, the head remains in the genital parts.
   Of the Vectis in Vertex Presentations. — We shall  consider its use successively at
the inferior strait, in the cavity of the pelvis, and at the superior strait, because the
results to be obtained by it vary with each of these  three conditions.
  When the  head, being  at the  inferior strait, is  arrested  by inadequacy of the
expulsive efforts, or by too strong resistance of the perineum, the forceps has the
very great advantage of acting as a powerful  extractive agent in consequence of its
enabling the operator to folloAv with it the  central axis of the genital passage.  In
this respect the forceps is  free from all reproach,  and is far preferable to the lever
which would  have the bad effect of crowding the head toward the coccyx and re-
moving it from the centre  of the vulva.  Besides this, it is liable to occasion lacera-
tion of the  perineum, which is stated by all operators to be of frequent occurrence
under these circumstances.  There is nothing, then, to recommend the use of the
lever at  the inferior strait. We  have but one reservation to make in favor of those
rare cases of  transverse contraction of this strait in consequence of the approxima-
tion of the  ischio-pubic rami or  of the tuberosities  of the ischia, the use of the for-
ceps being  rendered  difficult under  these circumstances by the narrowness of the
pubic arch, whilst the tractions direct the head too  far forward.  The lever,  on the
contrary, has the advantage of being easily applied  in consequence of its small size,
and at the  same time by pressing the  head backward,  directs  it towards the part
of  the pelvis Avhich  has  not undergone contraction.   Herbiniaux and Boddaert
mention cases which seem to prove  that, though  under these circumstances the
lever may be useful, it is the only case in which it has the advantage of the forceps
at the inferior strait.
   When the  head is in  the cavity of the pelvis, the forceps will still be almost
always   preferable for the  same reasons.   Nothing,  in fact, can be more rational or
easy than with it to turn the head to the  proper  direction, and then extract it in
the direction of  the pelvic axis.  We have no doubt that the  lever would be less
efficient, and, especially in occipito-posterior positions, even hurtful, because when
 passed  behind the pubis  it might come in contact with the face  and  particularly
 with the eyes, and cause great mischief.   Boddaert, however, used the  vectis  suc-
cessfully in the pelvic cavity, but recommends it chiefly when the  head is extended
and the  anterior fontanelle is near the centre of the pelvis.   According to him, the
forceps applied upon a head in this position would hold it so  and cause it to engage
with its  unfaAwable diameters, whilst the lever applied upon the  occiput brings it
doAvn and causes the chin to  approach the breast.  In  exceptional cases this  pro-
cedure  may be useful,  but Ave think that in by far  the  greater number the forceps
 ihould be preferred when  the head is in the cavity  of the pelvis.
   At the superior strait, on the other hand, the vectis  Avould seem to have an un 
998
OBSTETRICAL  OPERATIONS.
doubted advantage oyer the forceps.   That we may judge of this with a full knowl
edge of the  reason why, it would be well, in the first place, to remember how the
head presents at the superior strait, and how the lever and forceps are capable of
acting upon it.
  The head  presents at the superior strait: 1, in an oblique or transverse direction ;
2, it is imperfectly flexed as  yet, and the occipito-frontal  diameter coincides with
the. opening of the abdominal strait; 3, the direction which  it has  to follow, in
order to descend into the pelvic cavity, is parallel  to  the  axis of the strait, and
consequently oblique from above downward, and from before backward.  We would
add, that all these conditions are exaggerated in contractions of the pelvis, which
are one of the most common causes of dystocia, and, consequently, of surgical inter-
vention.
  If the forceps be applied under these circumstances, it is impossible to act other-
wise than in direct contravention to all the indications.  Thus: 1, the blades have
to be applied to the sides of the pelvis, inasmuch as at that elevation  it is difficult
to place them obliquely; consequently the head is seized from the forehead  to the
occiput, in the direction of its longest diameter, which would make the extraction
difficult; 2,  the pressure of the branches together, in order to secure a firm hold,
fixes the head and hinders the movement of  flexion ; 3, it is impossible to draw in
the proper direction, and the head, instead of being brought down  according to the
axis of the strait, is always directed  too much in front.  We would  add, that  all
these disadvantages are increased when the pelvis is contracted, and that it is often
difficult or impossible to apply the second branch; besides this, the  lateral compres-
sion of the head lengthens it from before backwards, which  is precisely the direc-
tion of the antero-posterior diameter, the most contracted part of the pelvis.
  The lever has the advantage over the forceps of  being smaller,  consisting, as  it
does,  of but one  blade.  Besides this, its mode of action  is entirely different;  it
presses only upon the occiput, which  it tends to bring down, and,  consequently, to
increase the flexion.   When applied  behind the pubis, it also compresses  the head
from before  backward, which is the direction of the obstruction to be passed, Avhilst
it elongates  it in the direction of the transverse diameter, which is not shortened.
  These views seem  to us  both important and  true.  They are also confirmed by
clinicaf observations,  of which Boddaert's paper alone contains enough to  be con-
vincing, showing as they do,  that labors rendered difficult from  contracted pelvis
have been successfully terminated by the vectis after the  forceps had failed.  "It
is, therefore, only through  a blind obstinacy that almost  all the  partisans of the
forceps continue to use that instrument and reject the lever,  which might be used
so much more effectually.  An accoucheur  might be excused for this  exclusive
preference of the forceps if the affair were one of no consequence; but as it often
happens that wh<m it is used  first, the woman cannot be  delivered with it, and that
both she and the  child are  in  the greatest danger  of death, it becomes impossible
to adduce plausible excuses for the conduct of those who will persist in the immo-
lation of so many victims."   (Boddaert.)
  The advantages of the lever are most evident when applied at the superior strait,
and in cases of contracted  pelvis; and we have seen how it fulfils all the indica-
tions.   Its powerful action cannot be questioned, for in some cases it  is found that
the head  plunges suddenly into the cavity of the pelvis with a peculiar crackling
6ound, indicative of the depression of  the cranium  upon the sacro-vertebral angle.
  In applying it at the superior strait, the general rules should be observed,  placing
the blade  upon the occiput in anterior occipito-iliac positions, and upon the mastoid
region in transverse positions.  In these cases the manipulation of the instrument
is  very simple.   The difficulty increases in posterior occipito-iliac positions, for
there is then some danger of wounding the face when the lever is  applied in front.
Here  it is necessary to act carefully, acquiring an exact  knowledge of the relations 
THE  VECTIS.
999
of the head to the various points of the pelvis, and thm  place the blade upon the
frontal region, Avhich is next to be pressed backward in order to bring the occiput
in front.   Let us take, for example, a right posterior occipito-iliac position; here
the lever should be applied upon the left temple, in order to press the forehead
backward  and to the left,  whilst the  occiput  turns  from behind  forward,  and
approaches the pubis.
   When  the head is once brought down into the excavation, it can, doubtless, be
extracted by means of the lever; but, as we have already said, the forceps answer
better, and  in a  case of the kind we would not hesitate to  use both instruments
successively.
   Though we are disposed to believe that the vectis is capable of being very useful,
Bonie difficulty in its  application must  be looked  for.  In  the  first  place, we would
mention the mobility of the head above the superior strait, which makes the instru-
ment liable to slip when the  handle is raised, or the  head to recede when  pressed
upon by the blade.  Whoever uses the vectis in  a contracted pelvis  will recollect,
also, that it is impossible to deliver below certain limits, and that attempts  to do so
at all hazards with the  instrument must not be persisted in.   Too forcible or  too
long-continued manipulations expose the woman  to ruptures, vesico-vaginal  fistulas,
and endanger her life; the risk, in short, being almost  the same  for both lever and
forceps.
   The Lever in Face Presentations. — Ought the forceps  or lever to be used  in  face
presentations?   We would reply that each  case requires a  separate answer, and
that the principles which have guided us in the use of  these instruments in vertex
presentations, are also applicable to those of the face.
   When the face is arrested at the superior strait, and  especially when its progress
is impeded  by contraction of the pelvis, the lever may be preferred  as in  a vertex
presentation, because it directs the head more in accordance with the axis of  the
strait, and reduces its volume from  before backward, which is the direction of  the
shortest diameter of the pelvis.   The forceps are liable to the same objection as in
vertex presentations, to which may be added the fact,  that, as the head  is situated
transversely, the placing of the forceps upon the sides of the  pelvis would  grasp it
in an unfavorable position, and  that, as one of the blades Avould be applied upon
the front of the neck, the pressure there might be dangerous.
   If the lever be preferred, the same rules should govern  its application as in vertex
presentations ;  therefore it ought to be applied above the face, with particular care
to avoid compressing it; it must also be passed higher  up, in order to place it upon
the sides of the cranium or upon the occiput; finally, the head, through its  agency,
should be caused to  undergo the same movements Avhich it experiences in  natural
delivery.
   When the face is  in the cavity of  the pelvis or at the inferior  strait, the lever
has no advantage over the forceps ;  it would even be dangerous when the  chin is
toward the front, because, if applied under the pubis, it would come in contact Avith
the chin or with  the  neck of the  child.  It might, indeed,  be  used in posterior
mento-iliac positions, with the view of turning the head in the pelvis and bringing
the chin in front;  but except in this particular case, the forceps should be preferred.
   Application of the Lever upon the Head after  the Body has been Delivered.— In
breech cases, or during turning, it often happens that  the child  perishes in conse-
quence of arrest of the head at the superior  strait  or in the cavity of the pelvis.
Generally,  well  directed efforts Avith the hand are sufficient to overcome the diffi-
culty ; but no time is to be lost, and, if  unsuccessful, the use of the lever or of  the
forceps is to be thought of.  AVe state  at once, that the  forceps has the disadvantage
of having two blades, Avhich are applied with difficulty on account of the presence
of the trunk ;  the advantage  of the lever is,  that it has but one blade.
   Under these circumstances, Dr. Coppee declares himself in favor of the lever.  " I 
1000                 OBSTETRICAL  OPERATIONS.
have learned," he says, "its merits through its practical application.  It has been
my fate to see children perish  because the  hand was unable to extract  the  head
soon enough to save them.  Reflecting on these cases, and remembering the good
results which I had derived from the use of the lever in the various positions of the
vertex and of the face, I conceived the idea of using it also after the body had been
delivered, provided there should be any difficulty in the disengagement of the head.
I was successful beyond my expectation.  Every one will  admit that rapid action
is necessary  in these cases.   If the pelvis is well formed, try the manual process
advised by authors; but if not immediately successful, have recourse to the lever
without further loss of time.  In cases where it is necessary to drag for a long time
with the hand, the least effort with the lever suffices to extract the head ; and in
difficult cases, on  account of contracted pelvis, the  use of the  instrument is  most
effectual."   (Coppee.)
  This method will doubtless be welcomed by the partisans of version in cases of
contracted pelvis,
  The operation  is  conducted according to  the general rules :  the woman  lying
across the bed, the body of the child is depressed towards the perineum, and in the
meantime the vectis is  slipped behind the pubis.
  The conduct to be pursued is nearly the same, whether  the head be at the supe-
rior strait or in the cavity of the pelvis.  If the occiput be directed transA^ersely or
in front, the instrument  should be applied either  upon  it or  upon the mastoid
region.  But when the forehead looks toward the anterior  arch of the pelvis, there
is danger of  wounding the face, and the temple is  then the part to be acted on ;
remembering that the  further the instrument is inserted,  the less will the face be
exposed to injury.   The head, under these circumstances, has a position the reverse
of that which it has  in  vertex  presentations ;  so that, when the lever  passes
rather deeply, it goes  beyond the face  and applies itself either upon the forehead
or upon the sinciput.  Here, again, is the natural labor to be imitated and the fore-
head  sometimes  to  be pressed  backward, so as to roll it into the hollow of the
sacrum, and sometimes to be brought directly down under the arch of the pubis.
The state of  flexion or  extension of the head will indicate which course it is best to
pursue.
  When the  head has reached the inferior strait, and, most especially, when  it is
arrested merely by the resistance of the perineum or vulva, the hand ought  to be
sufficient to complete its extraction; but if not, the forceps should be preferred to
the lever.]
                           CHAPTER VI.

                  INDUCTION OP PREMATURE LABOR.

  The title of premature artificial delivery is applied  to a labor  that is
designedly  brought  on prior to the ordinary term of pregnancy, but not
before the foetus is viable.
  No obstetrical operation has ever been more warmly or more profoundly
criticised than this.  In fact, it  has been supported  or  condemned by the
leading accoucheurs of all countries, and as a consequence of this disagree-
ment among the masters of our arth no part of obstetrical  science has  ever
been studied with greater care.   To trace out the first dawning of the induc-
tion of premature labor, we  should have to go back through the gropings 
INDUCTION  OF  PREMATURE LABOR.
1001
that  characterize all human works, to the manoeuvres of Aspasia, to the
forced dilatations of the os uteri recommended by Louis  Bourgeois and J.
Guillemeau, or to the more gradual procedure of Puzos.  But, in all of these
methods, the principle differs Avholly from the operation under consideration;
for, " in a premature delivery,  nature accomplishes nearly everything, art
merely contributing a slight though certain impulse;  Avhilst in the forced
labors, art acts almost alone, for all that nature yields must be draAvn from
her by continuous efforts."  (Ritgen.)
  Under this important distinction, we believe there can  no longer be any
loubt that  the induction  of premature labor had  its origin  in England.
According to a few Avriters, Mary Donally, a midAvife of that country, first
performed it in 17.18 ; but most of the English authors look upon this as a
gratuitous assertion.  The judicious  Denman  states "that, about the year
1756, there was a consultation of the most eminent men at  that time in
London, to consider the moral rectitude of, and advantages which might be
expected  from, this practice, which met  Avith their general  approbation.
The first case in which  it was deemed  necessary and proper, fell under the
care of the  late  Dr.  Macaulay, and it terminated successfully."  His ex-
ample was soon followed by numerous  imitators.1
  From Great Britain, this operation  shortly  passed to Germany, where it
Avas proposed by A. Mai, of Heidelberg, in 1799, but Wenzel first put it in
practice in 1804.   Owing to his success, and the  publication of Reisinger's
remarkable  work, it has  since been supported  by  numerous  and zealous
partisans.  It has been performed a number of times in Holland  by Salo-
mon,  Welenbergh, and SchoAV ;  Lovati has been equally fortunate in Italy;
and the periodical Avorks of Denmark, of America, SAvitzerland,  and Poland,
have  severally reported interesting cases of delivery  before term.
  In  France, the reception of this  operation into practice is quite modern;
indeed, for a long time  prior to its admission as a valuable resource, it Avas
rejected as a crime.  Roussel  de Vauzesme proposed it as early  as  1779,
though it  then  received but little attention.  It Avas  imperfectly understood
for a  very long period, and Ave may doubtless  attribute the blind and pas-
sionate opposition of Baudelocque and his pupils to their Avant of a clear and
definite idea of Avhat might be expected from its employment.   Fodere,
however,  persisted  in recommending  premature  delivery,  on several oc-
casions, notAvithstanding  the  anathemas  of.  this celebrated  school.   In
1830, M. Burchardt, in a  remarkable  thesis on  this subject,  sustained  its
propriety  at  Strasbourg, and, finally, in 1831, Professor  Stoltz performed
the operation for  the first time in France, and with the most perfect success.
Since then,  all doubts  have gradually vanished,  and most of the French
accoucheurs have at length adopted a practice, which has  noAV,  for nearly a
century, rendered such important services  to humanity.

  1 The first idea of the induction of premature labor is found in Raphael Moxius (Liv.
II., chap. 16, p. 495); he recommends the provocation of labor with the object of saving
the mother, at two different periods of pregnancy.  In the first months, before the foetus
becomes animated, and in the last two months, because  then " foetus etiam si per vim
ab utero extrudutur, vivere tanien potest, aut saltern non defraudatur vita animas, auia
vivus  lascitur et baptizari potest." 
1002                 OBSTETRICAL  OPERATIONS.
  [In 1832, two years subsequent to Burkhardt's  thesis, Dezeimeris, in .m article
published  in  the  Dictionary in  thirty volumes, defends  in his turn the induction
of premature  labor in cases of deformity of the pelvis;  making reservations, how-
ever, in respect to other indications for the operation.  M. P. Dubois, in his thesis
for the Concours, (1834,) also recommends  the same practice in certain cases of
contracted pelvis, and in 1840 he presented to the Academy of Medicine the account
of a mother upon whom he had carried his views into  effect with entire success.
Since that time, his numerous pupils at the Hospital of the Clinique have witnessed
many similar  operations.  In 1847,  Professor Dubois also published a work upon
the propriety of inciting labor in certain cases of disease during pregnancy.  Since
that time, many papers have  appeared on this subject, and numerous theses been
defended before the Faculties of Paris, Strasbourg, and Montpellier.  We would
mention, as amongst the most meritorious of the latter, those of M. W. Lacour and
Lazare See, which contain documents both numerous and important.  At present,
everybody is well  satisfied  that  premature  artificial delivery is  one of the finest
operations of obstetrical art, and that its use will become increasingly frequent.]

  Being once rid of the question of its morality, which for  so long a period
deterred some practitioners, who did not hesitate about the  Caesarean opera-
tion or symphyseotomy,1 we have only to resolve,.at the present day, the two
following questions :  In Avhat cases is premature labor to be induced ?  And
which is the best method of effecting it ?

                            ARTICLE I.
              CASES REQUIRING A PREMATURE DELIVERY.
  A.  When summing up the indications presented by the pelvic deformities.
it Avas stated that premature labor might be brought on Avhere the smallest
diameter of the  pelvis did not exceed  three  and three-quarter inches, and
Avhere it Avas not less than two and a half  inches ; but Ave must noAV explain
this proposition  more fully.
  It should be remembered that  this operation is always resorted to for the
double purpose of saving the child's life, and of preserving  the mother from
a danger which very  frequently  threatens her own  existence.   In other
words, it is not to be attempted until  the pregnancy is so far advanced that
the viability of  the foetus is fully established, and only in those cases where
the contraction of the pelvis is such that delivery at term is Avholly impossible
Avithout performing either a bloody operation  on the patient, or mutilating
her child.
  The French law, Avhich has been constructed Avith a vieAV of meeting all
possible anomalies, has decided that the end of the sixth month is the period
at Avhich  a foetus might be considered viable; but, laying  aside some  rare
exceptions, Avhich ought not to be brought in  question, every practitioner
well  knows that the foetus seldom  lives if born before the end of the seventh
month.  Consequently Ave should not think  of determining its premature
expulsion  before the full term of seven  months.   Although this  point  is

  1 It is really wonderful  that the consequences of  this operation  have  been so  long
dreaded;  since, in two hundred and fifty cases collected by M. Lacour, in the  com-
mencement  of 1844, more than one-half of the children survived, and scarcely one
woman in sixteen died.  Let any one compare these results with those furnisb'-.l eithei
by Symphyseotomy or by the Caesarean operation 
INDUCTION  OF  PREMATURE  LABOR.           1003
easily decided, so far as the interests of the neAV being are  concerned, yet
with regard to the mother such is not the case;  for the mere assertion  that
this operation is  to be performed whenever it is knoAvn  that a natural de-
livery at term will be impossible, is altogether too vague and uncertain for
a question of such importance; and therefore the  tAvo folloAving points are
to be established with the  greatest possible precision ;  namely, 1st, the degree
of contraction beyond Avhich the provoked delivery is no longer practicable;
and, 2d, Avithin Avhat limits its employment is justifiable.
  As the operation  is only admissible after the seventh month of gestation,
we must of course ascertain what is  the length  of the various diameters of
the head at that period ; because the  extent of the biparietal diameter, which
in most instances corresponds to the contracted one of the pelvis (the antero-
posterior), Avill evidently show to Avhat ultimate degree of pelvic contraction
delivery is still  possible.   Now, it appears  from the researches  of Dubois,
of Stoltz,  and Madame Lachapelle, that the  biparietal diameter at the end
of the seventh month averages from tAvo and a half to two and three-quarter
inches; in addition to which, Ave may hope for a further  reduction of one-
fourth of  an inch, on account of the compressibility of the head.  There-
fore, the smallest pelvic diameter must be two and  three-quarter inches at
the least.   This, then, is  the extreme limit beyond which  the  induction of
premature delivery is no  longer to be thought of as affording any chance of
success.
  [A few cases of deliveries having been effected through a contraction of two and
a quarter inches (see page 040), rare and fortunate as they are, Avould seem, how-
ever, to prove that the limit mentioned above may be extended to two and a quarter
inches.   I  am aware that  exceptional facts do not justify the  relinquishment of
general rules, yet I think that pelves contracted to two and a quarter inches, call
for the induction of premature labor; if, Avhen this is done, it be still impossible to
deliver the fcetus alive, embryotomy is  the last resort, and will be more easily per-
formed on  account of  the imperfect development of the child.
  Below two and a quarter inches, premature labor ought not to be thought of, un
less as preliminary to the easier accomplishment of embryotomy.  It noAV remains
to decide upon the limit above which it were useless to bring on premature labor,
as also the time Avhen, if done, it Avere  best to accomplish it.  The solution of this
double question depends  upon  the gradual development of the fcetus after the
seventh month of intra-uterine life.  The dimensions of the fcetal head  may be
estimated approximately as follows: At seven months, the great  transverse  or bi-
parietal diameter measures two  and three quarter inches; at seven months  and a
half, three inches; at eight  months,  three and  three-sixteenth inches; at  eight
months and a half, three and three-eighths inches ;  at nine months, three inches and
nine-sixteenths.   Beside this, a certain amount of diminution may be counted on
varying in  different cases from three-sixteenths to six-sixteenths of an inch.  Assum-
ing one case as an example, it is proper, therefore, taking the above reduction into
account, to bring on labor at eight months  and a half when the pelvis has a diam-
eter  of but three  inches and three-sixteenths  of an inch,  and to  fix three and
three-eighths inches as the  limit above which it were useless to induce  it.
  Unfortunately,  these dimensions have but a mean value, for  they vary in  every
case with the size of the child, and the extent to which the head xvi 11 yield, nor are
there any clinical means of ascertaining the differences beforehand.
  Many accoucheurs hold that,  in a first pregnancy, premature labor ought not to
be thought of when the pelvis has a diameter of more than three and three-eigrlths 
1004                 OBSTETRICAL  OPERATIONS.

of an inch.  Indeed, the fact that the Avoman is pregnant for the first time has beer
regarded as a formal contraindication of the operation.  We shall state our own
opinion the more freely on this subject, as we cannot understand why there should
be any doubt about it.   Premature artificial delivery is an innocent operation;
how great, therefore, would  be the regret if, after  having waited until term, it
became  necessary to perform embryotomy upon  a child which might have been
saved  by the former operation!  In the interest, therefore, of the child itself, were
it not  better that it should encounter the incomrenience of a premature birth than
the danger of a difficult delivery by the forceps?  We would, therefore, in a case
of first pregnancy, recommend premature delivery whenever we felt uncertain  as
to the result of labor at term, at the risk of being accused of having accomplished
it unnecessarily ; with much  less  hesitation, therefore, would we  advise  it Avhen
the pelvis is so contracted that  labor at term would probably  be  very difficult or
even impossible.
  Previous labors afford fuller information as to what may be expected.   If labor
at term  has been impossible or very difficult, premature delivery is indicated, how-
ever slight the contraction of the  pelvis  may be.  But supposing  the labors of a
woman who has already  borne children, have been  easy, notwithstanding a con-
traction of three and three-sixteenths of  an inch,  ought anything to be done?
Almost  all accoucheurs reply that it would be  better  to  wait, inasmuch as  the
probabilities are in favor of all the subsequent deliveries being accomplished in
the same manner.  I should feel less certain on this  point, because there may
r«,sult, as I have seen, a labor so difficult as to require the  performance of embry-
otomy.  Consequently, I Avould  willingly advise the  induction of premature labor
in a case like the one supposed.
  The longer the fcetus remains Avithin the uterus, the more probable is it that it
will survive.  This proposition, acceded to by all, becomes a law to  the accoucheur,
requiring him to postpone premature labor as long as possible.   It is plain that it
ought not to be had recourse to, unless the  interest  of the mother or of the child
should require it, and it would be immoral to operate recklessly, without a serious
motive.   Still, there should be  no hesitation through mere timidity, inasmuch as
there  is no real ground for it. One does not grieve long over a spontaneous prema-
ture delivery, and we know that,  by care, many of the  children  may  be raised.
Whether premature labor be spontaneous or artificially induced, the material con-
ditions are the same ; why, therefore, should there be any great hesitation in cases
where it is proper to effect it artificially ?]

   Perhaps it would be proper here to.give our opinion with regard  to certain
circumstances  that have been stated  by some accoucheurs as contraindica-
tions  to the induction of labor; Ave allude to tAvin pregnancies and malpre-
sentations.   Could it be certainly ascertained that the patient was pregnant
with twins, the time for performing  the operation  might be considerably
postponed or everything even be left to nature  if the pelvis were  not very
much contracted.   The reason  for this  is, that tAvins are  generally smaller
than  single children and their organization  rarely complete enough to enable
them to live Avhen born before term.
   With regard to a malpresentation of the foetus, Avere Ave to pay any atten-
tion to  it, Ave should often  lose the advantages of the operation, since this is
an obstacle of very frequent occurrence.  And as a  delay of a few days only
may compromise the success of the  attempt, it Avould be better to change
the presentation by external manipulations, as performed  by  Stoltz.  When
thi^ measure proves unsuccessful in modifying  the  presentation, Ave should 
                INDUCTION  OF  PREMATURE  LABOR.           1005

still endeavor to excite the uterine  contraction, so as to perform  version as
soon as the os uteri shall be sufficiently dilatable.
  The mere detection  of a vertex presentation is not a sufficient  reason for
feeling secure as respects an unfavorable position.  In one of the  six opera-
tions which I have had occasion to perform, although the contraction affected
the antero-posterior diameter, the head presented in  an occipito-pubic posi-
tion after the membranes Avere ruptured: and as this circumstance required
the application of the forceps and considerable traction, the child was born
dead.
  B. The cases in Avhich there is  a contraction of the  pelvis do not constitute
the only ones in which  premature  labor  has been recommended.  For
the many serious diseases to which  females are subject  during  the  latter
months of gestation  are  evidently connected  Avith   that condition;  and
depletion of the  Avomb  is the best  and often the only means of removing
them.   This is also advised by some writers in certain  affections  that en-
danger the patient's life ; among  others, M. Ferniot has endeavored to prove,
in a recent thesis, that under such circumstances the  premature  labor is
quite as  justifiable as  in  the pelvic contraction.   Forced  delivery was
long since recommended in c^ses of profuse flooding, particularly  in those
dependent on the insertion of the placenta over the os uteri;  and the artifi-
cial  rupture of the membranes, resorted to in  our  day, is merely another
method of bringing on the uterine contractions. Further, many skilful physi-
cians have  not hesitated to bring on labor Avhen an  attack of convulsions
has resisted  the ordinary remedies, or  Avhich, after being checked, returned
every feAV days Avith  a constantly increasing severity, (see pages 813 and
820.)  And Avhy should not the same  course be pursued, Avhen any serious
disease, that existed before pregnancy, is so highly aggravated by this con-
dition  as to threaten   an early termination  in  death, if  its course be  not
speedily arrested  by emptying theAvomb?  In  1827, M. Costa  submitted
the question to the Academie de Medecine, Avhether or not it is proper to
bring on labor Avhenever the pregnancy is complicated by any disease that
seriously  threatens the  mother's life, supposing the  foetus is viable.   We
think the Academie erred  in  treating this  proposition as inexpedient; for
although Costa's question was too general,, and, doubtless, ought  to have
been better  matured  before making a final decision, yet restricted within
certain  limits, determined by observation, it already  has received and will
still receive  numerous  applications in practice.  For instance, an aggravated
disease of the heart, general serous infiltration of the tissues, accompanied
by effusions into the great cavities, a threatened suffocation, and the existence
of a large aneurismal tumor, Avhich is liable to be ruptured from the obstruc-
tion to the general circulation caused by the developed uterus, are certainly
quite as dangerous as  flooding or an  attack of convulsions; and a  premature
delivery appears to me advisable, after  all the therapeutical resources usually
resorted to in such cases have been  tried without benefit.  It is important,
however, that a determination of this kind should be  come to very carefully,
and, as  often as possible, after consulting with enlightened practitioners.
  In describing the disorders to which the pregnant  condition exposes the
female,  it was stated, that whenever they became so  serious as to threaten 
 1006                OBSTETRICAL OPERATIONS.

 the life of the patient, we thought that the induction of premature labor was
 thereby sufficiently justified.   Thus, A'omiting which resists  all therapeutic
 measures, extreme dropsy of the amnion, ascites connected Avith  amniotic
 dropsy and  threatening the patient Avith suffocation, and the recurrence of
 convulsions  at short intervals and Avith increasing severity, are all of them,
 Ave have said, sufficient reasons for performing the operation.
   But these are not the only cases in Avhich the operation has been proposed,
 and we have yet some other indications to settle.
   1. Abdominal Tumors. — In treating of the various  tumors that so often
 complicate  pregnancy and  parturition,  Dr. Ashwell  suggests  premature
 delivery  as  the most  certain method of preventing  those  serious  conse-
 quences, to Avhich the patient is then exposed during the labor, or lying-in.
 But this opinion, in our estimation, is only admissible in the folloAA'ing cases :
   1st.  When any voluminous tumor whatever exists in the belly and incom-
 modes the enlargement of the Avomb ; or is itself exposed to such a compres-
 sion as almost necessarily to lead to consecutive inflammation.
   2d. When a tumor developed in  the excavation  is so fixed and adherent
 to the pelvic Avails that it can neither be pushed above the superior strait
 nor drawn doAvn beyond the vulva; provided its bulk is sufficient to prevent
 the expulsion of a foetus at term.
   2.  Smallness of the Abdominal Cavity.—The capacity of the  abdominal
 cavity in some individuals of very  Ioav stature, is so small  as to be insuffi-
 cient for the normal  development of the uterus, which after attaining a cer-
 tain bulk might render the regular performance of the great functions im-
 possible.   Thus, M.  Depaul  mentions a case of  asphyxia occurring  in a
 rachitic female aa-Iio was affected with a deformity7 of this kind.   Hence, it
 is evident that under similar circumstances, premature delivery might and
 ought  to be thought of.  Still, it  is  rarely necessary to have recourse  to
 the operation, for the  elasticity of  the soft walls of the  abdomen of these
 individuals permits the development of the uterus  to take place outside, as
 it were, of the abdominal inclosure; and if the Avails should prove too resist-
 ing, it is infinitely probable that in consequence of its violent compression,
 the uterus Avould enter spontaneously into action.
  3.  Nervous Disorders.—The nervous disorders  Avhich come on during
 gestation may  sometimes become  so serious as  to suggest the  question,
 Avhether it be not advisable to terminate the  pregnancy Avhich gave rise to
 them.  M. Dubois Avas consulted in the case of a young lady in the third
 month of gestation, who had'  been  affected  for six weeks with symptoms
 resembling chorea.  The spasms Avere first limited to the voluntary muscles,
but finally invaded those of organic life, so that deglutition and  speaking
had become  difficult.  All the antispasmodics had  been  employed Avithout
success.  M. Dubois replied, that he approved of the means that  had been
used,  but  that, whenever  the convulsions invaded important organs, he
anticipated the necessity of inducing premature labor.
  We have  in  charge a young lady avIio, Avhen in her ordinary health,  has,
very ^arely,  some short paroxysms  of asthma, and  then  almost  ahvays in
consequence of an emotion or physical pain, but Avhich become much more
 frequent and distressing Avhen pregnant.  Having reached the fourth month 
                INDUCTION  OF  PREMATURE  LABOR.           1007

of a fifth pregnancy, she has just had a slight attack of varicella, preceded
by  six  days of intense  fever.  During  these  six days, the  suffocative
paroxysms became so  serious,  that  MM. Andral and Dubois, who were
called in consultation, delivered the most unfavorable prognosis.  All these
symptoms vanished  upon  the  appearance of a dozen very small pustules,
only tAvo of Avhich presented the umbilical depression.   The idea of prema-
ture delivery might certainly present itself, should such accidents reappear
and continue at a later period of the gestation;  but it should not  be for-
gotten that, as M. Laborie  remarks,  too much haste should  not be made,
inasmuch as these nervous phenomena often cease instantaneously; and the
operation should be carried into effect only Avhen the condition of the patient
demands it imperiously.
   4. Intercurrent Acute Diseases. — Most of the acute affections which occur
during pregnancy, seem to be affected unfavorably by abortion and sponta-
neous delivery.   We have  already stated that in cholera, in which the in-
duction of premature labor and abortion have  been  recommended as a
therapeutic measure, there  Avas nothing to prove conclusively that the ex-
pulsion of  the foetus was attended with  any favorable result.  We  think
therefore that, as yet, it were wisest to abstain.
   5. Death of  the  Foztus  in  preceding  Pregnancies.—There are  certain
women avIio, after reaching the eighth or ninth month of  gestation Avithout
the slightest disorder,  suddenly find the active  motions of the fcetus  to
diminish, and  the child  dies.   This unfortunate event occurs Avith some
again and again, for several consecutive pregnancies, so that certain females
have  been knoAvn to be delivered thus prematurely, and always of a dead
child, five and six times in succession.   Denman, and several others, thought
that by bringing on labor before the period at Avhich the fcetus had perished
in  the preceding pregnancies, there  Avould be a chance of obtaining  living
children.   In tAvo cases  mentioned  by the English author, the operation
proved successful.  The  indication  should not,  therefore, be entirely re-
jected.  HoAvever, it is Avell to observe Avith  M. P. Dubois, that, notAvith-
standing the  fatal termination  in preceding  pregnancies, there is always
cause  to hope for a happier issue as  respects the one in charge, so that it is
impossible to establish a general rule in reference to the matter. It  is one
of the cases in Avhich the responsibility of the physician is deeply implicated.
(See page 558.)
   6. Finally, the induction of premature labor has also been recommended
in cases in Avhich the fcetus is dead, and in pregnancies which overrun the
usual time.   At present, and  especially in France, the supposed disorders
attributed by Mai and Fodere  to the death of the foetus in  the Avomb, are
no  longer  believed in.  Expectation is adopted, because it  is well knoAvn
that the mother  incurs no danger,  and that nature will  rid herself of the
dead foetus without requiring '.he intervention of art.   Nor are the dangers
of the delayed pregnancies less illusory.
                           ARTICLE  II.
        OPERATIONS  FOR THE  INDUCTION OF  PREMATURE LABOR.
   The methods proposed  for effecting the premature expulsion of the child
are quite numerous; they  are all based upon the contractile poAver of the 
1008
OBSTETRICAL  OPERATIONS.
womb, which they are intended  to  call into activity until the ovum is ex-
pelled.   We shall divide them into three classes, to the first of Avhich  belong
all those which, by primarily influencing the general organization, have the
secondary effect of exciting the uterine contractions;  to the second, those
depending upon the  excitement of  some  organ, the  breast for example,
which by reflex action stimulate the uterus to contraction;  and to the third,
all those that operate directly and  mechanically upon the womb, for  the
purpose of arousing its action.
   The operation of the means appertaining to the first division is too un-
certain  to  be  relied upon in a  case Avhere it is necessary to act promptly
and surely ; and although tepid bathing, A^enesection, &c, have occasionally
been  folloAved by a premature delivery, yet  no one would  ever think of
employing them with this vieAV.   Even the  partisans  of ergot  are  feAV in
number; for though its influence in rendering the sIoav and  feeble contrac-
tions of the organ more energetic is undoubted, there is  no positive evidence
that it is capable of arousing them when none have previously existed.

  [The second class includes the means of stimulating the womb by reflex action.
To effect it, the  close  sympathy known to exist between it and the breasts is made
use of, the stimulus applied  to the one being reflected upon  the other.   The obser-
vation of this fact led Frerichs to suggest the application of sinapisms and flying
blisters upon  the breasts  in order to excite  uterine contraction.   Scanzoni after-
ward took up the idea and recommended the application of gum-elastic cups to the
breasts, reporting at  the same  time several instances of success, though  he also
witnessed some cases of fainting produced by them. Chiari, Kilian,  and Stohl  have
not met Avith  much success by this method, so  that, upon  the Avhole, it must be
reckoned as too uncertain to  be relied on.
  Therefore the agents of the third class only,  Avhich act directly  upon the ovum
or the womb, are capable of bringing on with  certainty, the contractions of the
latter.  We shall divide them into five categories, determined by the part to which
they are applied, viz:  a. External  stimulation of  the body of  the  uterus;  B.
Stimulus applied to the circumference of the os tincae ; c.  Dilatation of the  neck
of the womb ;  d. Stimulants  inserted between the walls of the uterus and the ovum ;
e. Rupture of the membranes.]

      a. External Stimulation of'the Body of  the Uterus.
   Dry Frictions over the Abdomen. — The repeated frictions over the anterior
part of  the belly, and the fundus of the womb, originally recommended by
Professor D'Outrepont, to which  Ritgen added direct  excitation of  the os
uteri by one  or more fingers introduced into the vagina, are uoav generally
rejected.  In truth,  the irritation thereby produced is too feeble  and  transi-
tory to bring on a genuine labor.

   [Electricity. — Electricity was proposed and tried by both Kilian and Schreiber
without  much  effect.   One pole of a galvanic battery was  put in connection Avith
the fundus of the womb and the other with its A^aginal portion.   An electro-mag-
netic apparatus may also be made use of; that of  the Lebreton brothers was tried
by M. P. Dubois,  though without success.  Great hopes, indeed,  had been based
upon electricity as an agent for producing the effect in question,  but experience
soon showed that they would have to be relinquished. 
INDUCTION  OF  PREMATURE  LABOR.
1009
        B.  Stimulus applied  to the Circumference of the Os  fi ;c.t.
  The means of accomplishing this,  comprise the various modes of applying the
uvmpon, and douches either of water  or of carbonic acid gas.
  Hater's Process. — Hiiter inserted into the vagina, so as to be in contact with the
neck of the womb, a bladder filled either with wrater or decoction of ergot, hoping that
the latter  medicament  might  transude by  exosmosis  and assist  the mechanical
action of the  bladder.   Prof. Bush substituted  a dog's  bladder for that of a oalf,
and advised it to be withdrawn every six hours, in order to wash out the vagina
by means of injections.   This  process is deficient in irritating power, so that in
most of  the cases in which it was used, it Avas necessary to have recourse to more
energetic measures.]
   Seine I lev's  Method. — Quite recently, Dr. Schoeller, of Berlin, has suggested
a measure Avhich is new as to its proposed object, though one of long stand-
ing in  obstetrical  science.  Every practitioner  is  aAvare of the principal
objection to the use of the tampon, so highly extolled by Leroux, of Dijon,
as a remedy for uterine hemorrhage ; noAV M. Schoeller has conceiA-ed the idea
of employing the irritation it produces as a means for the induction of pre-
mature delivery; for it is Avell knoAvn that its application is most generally
folloAved by uterine contractions.   He first made use of it in 1839, and Avas
entirely7 successful; since that time he has performed five similar operations,
and the child Avas born living  in four  of  them.  The mode of operating,
according to Stoltz's translation, is as folloAvs (Gaz-. Med. de Strasbourg, Jan.,
1843):
   Before  commencing, the  bladder and rectum are to be  emptied; then
several  little rolls of charpie, steeped in oil, or smeared with cerate, are suc-
cessively pushed toAvards  the upper part of  the vagina, the  first of  them
having  a  piece of tape attached, to  facilitate  its subsequent  extraction.
Prepared sponge might be used for the same purpose, but  it would  then be
requisite to retain it in situ by another common sponge.  It is not necessary
to fill the Avhole vagina; in fact, this would be  attended with some incon-
venience, for the excretion of the urine and fecal matters  would be thereby
impeded.   It is advisable to introduce  the tampon  in the evening, Avhen the
patient  is recumbent, because she will be more likely to remain quiet during
the early  periods of its operation.
   The effects of this measure are shortly manifested by pains in the abdo-
men and loins, and  by a feeling of tension  in  the womb itself;  repeated
frictions are then made over the fundus uteri, Avith  a vieAV of aiding  its oper-
ation.   As the tampon soon becomes  saturated with the  mucus from the
vagina, and exhales a disagreeable odor, it ought to be reneAved at least once
in the course of the day, or even tAvice, if the sensibility of the parts permits ;
but, before introducing the second one, the  vagina is  washed  out by an
injection.   As soon as the tampon has roused the uterine contractility, and
the orifice dilates, it may be  withdrawn ;  though, should the labor be linger-
ing, and the contractions become slow and feeble, it must be reapplied, and
ten grains of the secale cornutum  be administered by the mouth every half
hour.   The pains may also be restored  by dilating the orifice yvith the index
finger, carefully avoiding a  rupture of the membranes, until the dilatation
is nearly completed. 
mio
OBSTETRICAL  OPERATIONS.
  [Schceller's tampon, unfortunately, is both  uncertain and painful in its applica-
tion.  Hoffman's statistics show that out of 20 cases it succeeded  in 12 only, when
used alone.   Once it was necessary to dilate  the cervix besides, and  in 7 cases it
had no effect Avhatever.
  Braun's Process. — Braun (of Vienna) proposes substituting Schceller's charpie
tampon, and Hliter's bladder  of animal membrane, by a reservoir of vulcanized
gum-elastic  from two to four inches in diameter, and provided with  a  stopcock.
His instrument has received the name of Colpeurynter, and is used  very easily,
being managed like Gariel's air pessary.  It  is first emptied and inserted into the
vagina, and  afterward dilated by the injection of warm water.  The gum-elastic
bulb does not deteriorate like the bladders of animals ; besides which, Braun claims
for it the advantage of distending the upper part of the vagina only, without com-
pressing the lower portion.
  Professor Stoltz says that the colpeurynter has been used only five times in cases
of contracted pelvis, and twelve times in cases of disease during pregnancy.  It
proved ineffectual in the first set of cases, but succeeded better in the second, prob-
ably because thare was already present a tendency to labor.]

   Uterine, Douches. — Lastly, there is a still more recent process, possessing
undoubted  advantages over all  the others, namely, that Avhich  consists  in
directing a stream of warm Avater upon  the neck of the uterus.   The honor
of introducing it  into obstetrical  practice is due to Professor Kiwisch.  His
apparatus  Avas a simple tin box, provided Avith a long tube furnished Avith a
stopcock.  The extremity of the  tube is introduced by the vagina to the
neck of the uterus.  The temperature of the water should be about 76°  or
78° of Fahrenheit, and the jet should be large and powerful.   The  injec-
tions should last from 10 to 15 minutes Avithout interruption.
  Instead of Kiwisch's apparatus, M. P. Dubois uses Dr. Eguisier's instru-
ment foi irrigation and steady injection.  The latter containing six quarts
of fluid, is  sufficient for a douche  of  a quarter  of  an hour in duration, and
there is  no occasion to reneAv the water  as in Kiwisch's contrivance.  Be-
sides, there is no necessity for  its  being very elevated like the other, which
renders it much more convenient to  manipulate.  I  made use of Eguisier's
pump in the three cases in which I  employed  the uterine douches.   Unfor-
tunately, it is quite  expensive, and not  readily procured out of  the  city.
Therefore,  it is well to remember  that any vessel capable of containing eight
or ten quarts of  water, placed at an elevation of  seven or eight  feet, and
provided Avith a flexible tube of  sufficient length, will serve the same pur-
pose.  The tube  is furnished Avith  a stopcock about a foot  from its free
extremity.   To this extremity is  adapted a gum-elastic canula with a single
orifice the  sixteenth of an inch in diameter.*"   The poAver of the jet may  be
increased or diminished at will by varying the calibre of the canula.
  The woman's seat is brought to the edge of the bed, Avhich is previously
covered  with oil-cloth, so that the  Avater may fall into the  vessel placed
betAveen  the legs without wetting the clothes or the bed.  The forefinger  of
the  left  hand is  introduced to  the cervix for the purpose of guiding the
canula Avhich the accoucheur holds in the right hand.
  In ordinary cases three or four injections a day  are sufficient, though, if
the case  Avere urgent,  they should be repeated  more frequently.
  The numb*/ r of douches required  varies greatly.   Sometimes the contrac- 
                INDUCTION  OF  PREMATURE  LABOR.            1011

tions appear upon  the third or fourth application; in one of my own cases,
the first pains Avere  perceived after  the second douche, though generally a
much greater number are required.  In the ten observations of KiAvisch, he
was obliged to repeat them  four times at the least, and eighteen times at the
most;  the mean for  the ten cases being ten douches.
  The mean  length of time between the commencement of the operation
and the moment of delivery, was about three days and a half.  In one case,
but tAventy-four hours  elapsed, whilst  in tAvo others it Avas delayed seven
days.

   [To  increase the  efficiency of the uterine douches, it is only necessary to direct
the extremity of the canula upon the os tineas, so that the water may be projected
directly into the neck of the  uterus.   M.  Blot on several occasions even inserted
the canula into  the neck, so  that the jet reached  and detached the  membranes.
This is a modification  of Kiwisch's method, well calculated to bring on labor within
a very short time.
  There can be  no doubt as to the efficiency of the douches, and they are, conse-
quently, very much used.  The apparatus is made very readily, and women submit
willingly to an operation of so simple a character as  to be readily understood by
them, and Avhich gives them no pain.
  Of eighty-one  cases quoted  by Stoltz, in which  the douche was used in order to
bring on labor, it, alone, was  successful in sixty-eight; but in thirteen cases it was
necessary to use more active  measures  in addition.   The method, therefore, some-
times fails, which is not, however, the most serious objection that  can be made to it.
Though I have often had occasion to use it both at the Maternity  Hospital at Paris
and at the hospital of the Clinic,  I  do not  share the enthusiasm to which it has
given rise. It is almost always slow in  its action, and so exhausts the patience of
both the woman and  the  operator, besides compromising the successful issue  in
some cases by the delay which it occasions.  But this is not the worst,  for notAvith-
standing afl that has been said of its  innocency, the douche is dangerous,  and may
prove rapidly fatal.   In a paper read  at  the Academy of  Medicine I related  the
case of a woman, the  posterior cul-de-sac  of whose vagina Avas lacerated by it; an
event which experiments upon the dead body assure  me is of  very possible occur-
rence Avhen a powerful apparatus is used.  I also reported several cases of sudden
death whilst the  douche was being administered under the charge of such men as
MM. Depaul, Salmon  (of Chartres), and Simpson, whose skill  is beyond question-
ing.   Prof. Depaul,  in relating his own case to the Surgical Society, thought he
could account for the  event by the introduction of  a few bubbles of air  into  the
uterine sinuses, and I think his explanation a good one, for in every instance  the
symptoms observed were those produced by the entrance of air into veins.   It will
readily be admitted that such accidents as these ought to make  accoucheurs more
careful in the use of uterine douches than they have been.
  Douches of Carbonic Acid Gas.—Scanzoni (of  Wiirtzburg) recommends the  use
of a jet of carbonic acid gas, directed upon  the neck of the womb by an appropriate
apparatus.  Though employed by its  author, the method is not likely to come into
common use.]

              c Dilatation  of the Neck  of  the  Womb.

  Dilatation by Prepared Sponge. — Some accoucheurs have endeavored to
bring on contraction of the Avomb by keeping a foreign body within its neck,
which shall act both as an irritant  and a mechanical dilator.  Kluge may be
rcgardol  as the inventor of the process by dilatation, and his method is the 
1012
OBSTETRICAL  OPERATIONS.
one still generally preferred.   It consists, as is Avell known, in  thb  imer;rm
af a cone of prepared sponge in the cervix, and keeping it there by means
of a tampon, until the pains are  fully developed.   The mode of operating
is as folloAvs:
  After having obtained the  patient's  consent, and, Avhenever possible, the
advice of some professional brethren, the  accoucheur has  the Avoman pre-
pared, by directing her to use Avarm emollient and  narcotic injections into
the vagina, for a feAV days  previous  to  the operation;  before  commencing,
the bladder and rectum are to be  emptied, and a fresh examination is to be
made for the purpose of ascertaining the degree of the pelvic contraction, as
Avell as the child's position.
  The female being placed in  nearly the same position as if the forceps Avere
to be applied, the operator first draws the  cervix towards  the  median line,
whenever it is found deviated; or  he might endeavor to get the neck within
the uterine extremity of a speculum (Dubois).  But this is not always prac-
ticable, especially if the part be directed a little fonvard; in general, the fin-
ger answers every purpose as a conductor; then a conical plug of prepared
sponge, about two inches long, and half an inch in diameter at its base, and
having a piece of tape  ten inches long attached to it, is held by its large
extremity, in a pair of  long curved forceps, and is  carried up towards  the
uterine orifice where it is gradually made to enter.   After holding it there
for five or six minutes, the forceps and speculum (if used) are Avithdrawn,
and the vagina is next filledmp with a large  sponge, or bits of  charpie, so
as to keep the first sponge  in its place; the Avhole  is to be retained by a
proper bandage, and the patient replaced in bed.  The mode  in Avhich  the
                                             foreign body acts here is ob-
                  Fl°145-                      vious; the prepared sponge
                                             becoming saturated Avith the
                                             fluids from the neighboring
                                             parts, SAvells up, and irritates
                                             the cervix by its  bulk; this
                                             determines a dilatation of the
                                             latter, and the irritation thus
                                             caused, by reacting on  the
                                             fibres  of the   uterus,  often
                                             brings  on  the contractions
                                             in five or six hours.  Should
                                             it happen that the  pains are
                                             not  fully established, or the
                                             dilatation of the os uteri  is
                                             not completed in the course
                                             of  twenty-four  hours,  the
                                             operation ought  to be per-
                                             formed again, taking  care
        Kluge's method of dilating the os uteri.           this   time   to  introduce  a
                                             larger piece of sponge (the
first having been extracted  by the tape); this  second operation  is  nearly
ahvays successful.   If,  however, the labor-pains be still too sIoav rnd feeble,
 
INDUCTION  OF  PREMATURE  LABOR.           1013
local  irritants, such as frictions over the  abdomen, and titillations  of the
cervix, or, still better, the general stimulants, ergot particularly, might be
resorted  to.
  The necessity  of plugging  the vagina, and keeping the tampon applied
foi tAvo or three days, and sometimes even longer, occasions  great suffering
to ihe Avoman.  From having witnessed this  suffering, I had  an instrument
constructed, in 1845,  by means of Avhich the  prepared sponge is kept in its
place within the  cervix.   It  is composed: 1. Of a hypogastric belt, to the
middle and front part of which is secured a metallic stem eight inches long,
and curved  at its free extremity, Avhich carries  a canula one  and a  half
inches in length; 2. Of a  stem of Avhalebone, six or seven  inches  long, and
about a quarter of an inch in diameter, bearing  at its extremity a forceps
with claAvs capable of being closed  at will, by means of a  sliding ring, like
those of  a porte-crayon.   The  prepared sponge is first fixed in  the forceps
and then introduced as usual  Avithin the cervix : the whalebone stem is  next
introduced into the canula and held fast by the pressure of a screw.
  In  this Avay, the use of the  tampon, Avhich  is ahvays painful, is avoided ;
the sponge cannot be  displaced and  escape  from the cervix, as often happens
in Kluge's process, nor are the  functions of the bladder and rectum in any
degree interfered with.  The  patient is not  condemned to the absolute re-
pose usually directed, but can move in bed Avithout inconvenience.  I there-
fore  regard  it as a  plan which does  away  Avith  most of the  inconveniences
justly complained of in the performance of the operation.
  [A  great recommendation of the prepared sponge is, that it acts very gently and
is devoid  of danger either to mother or child ;  on this account it was  preferred by
all accoucheurs before  Kiwisch's  method was known.  Unfortunately, the opera-
tion, apparently so simple, is really quite difficult; for the cervix is often so high
up that it is found to be no easy matter to fix it with  the fingers and  insert the
sponge.  Kluge himself, in  one case, after several fruitless attempts, was obliged
to relinquish  his own process.
  Another inconvenience of the sponge is,  that it sometimes acts very slowly, and
occasionally is not sufficiently irritating to excite the uterus to contraction.
  Prof. Hoffman gives an analysis of 70 cases,  furnishing the following results: 56
times the sponge alone was sufficient to bring on  labor, and it was  rarely necessary
to use  it twice ; 7 times it was used in  connection with other processes; 7 times it
failed, but still dilated the neck  sufficiently to allow the membranes to be ruptured.
The duration of the labors was noted, in the same number of cases, as follows : 24
hours in 9 cases;  48  hours in 14 cases;  3 days in 10 cases ; from 3 to 8 days  in 12
cases ; from 9 to 13 days in 3 cases.
  The event in every instance was favorable, both as regards mother and child.
  The use of prepared sponge, therefore, compares favorably with  uterine douches,
and  has, besides,  the immense advantage of not exposing the  patient to  sudden
death.
  Busch's Dilator. —Busch devised a  three-branched dilator which, when closed,
is of about the size of a pair of dressing-forceps, and whose slender  extremity passes
easily into the uterine orifice. When used, it  is   inserted into the neck to the dis-
tance of five-eighths of  an inch only, and then opened further and further at inter-
vals,  until'it shall have excited contraction of the womb or occasioned considerable
local pain.   Busch's  instrument has far less merit than the  sponge;  its action is
intermittent,  and its valves, as they spread, act only on the points with which thei
are directly in contatv  necessarily giving rise to  painful stretching. 
1014
OBSTETRICAL  OPERATIONS.
  The results obtained by this instrument are  neither numerous nc. encouraging,
Hayn, it is true, professes to have excited the pains of labor in eleven hours ;  but
Busch himself never accomplished the  same object in less time than three days,
and in two cases not until after eight days of strong  and  painful  effort.  There
are, therefore, serious objections to the process, and it ought never to be used unless
for the purpose of facilitating the  introduction of a cone of prepared  sponge.
  Krause's and Meade's dilators are very similar to Busch's instrument, and  are
liable to the same objections.
  The Spheno-Sijihon. — The dilator  invented by Schnackenberg  is entirely differ-
ent from the preceding.  It is called the spheno-siphon,  and  is composed of  a
syringe, to which is adapted a tube  two inches in length, and provided with  two
lateral fenestra.  The latter is covered with a distensible  bag  of prepared skin,
which, when  most widely dilated,  has a diameter of from an inch and three-quar-
ters to two inches.  The operator passes the canula gently into the cavity of  the
neck,  and Avhen in situ depresses the piston, which  is held by a  screw.   This ends
the operation for the first day, and the instrument  is attached to a body bandage.
The next day the piston is pressed down  still further, forcing more  fluid into  and
dilating the bag.  The same process is repeated on the third day.
  The spheno-siphon, like the prepared sponge for which it is a substitute, is in-
tended to dilate the cervix mechanically and  excite the uterus to contraction.   It
is  a complicated instrument, necessarily inconvenient  to the patient,  and seems
thus far not to have been put much into service.  It is figured in Busch's Atlas.
  Barnes' Dilator. — Dr. Barnes introduced, in  the year 1862, a  new dilator, com-
posed of  a gum-elastic  bag,  in shape resembling  a violin, and ending  in a long
tube.   The instrument is of three  sizes, the smallest being  from three-quarters of
an inch to an inch and a quarter in width:  The inventor begins  by exciting con-
tractions through the use of  the uterine  douche, Braun's colpeurynter, or the pre-
pared sponge, and when the neck is sufficiently dilated, inserts  his  bag  by means
of a probe whose end passes into a little pouch made for the purpose.  The central
part of the dilator is intended to be co-extensive with the entire length of the  cer-
vix, its upper extremity/extending beyond the internal orifice, whilst the lower  one
projects into the vagina.  The peculiar shape of the instrument is intended to guard
against its slipping ; for when distended,  its middle portion is cylindric,  whilst the
ends  spread out like a mushroom.   When in situ, water is forced into it by means
of a syringe, and its distention dilates the neck considerably.  A larger instrument
is then substituted, and the process continued until the dilatation is sufficient to
allow version to be performed.
  Dr. Barnes'  method  is complicated, and his instrument comes into  play only
when labor has begun through the use of other means.  Therefore, as his object is
merely to hasten it, he entitled his paper, "A New Method, of Accomplishing Prema-
ture Delivery at a Specified Time."  But  let us  hear the author himself:  "All  the
known methods of exciting premature labor are very uncertain as respects the time
required for producing the desired result.  The slowness of the  process is liable to
serious objections, for whilst the accoucheur is kept waiting for hours and days for
the labor to be completed, the woman herself is Avorried by the delay  and  tormented
by fear.   Thus her  moral and physical  forces are severely  tried,  and,  after  all,
whsn  the delivery is about to take place, the  doctor may be  away.   Thus mother
and child are exposed to needless risk.
  " Nor is the  doctor's  position an enviable one : when he  began the operation for
inducing  labor, he involved himself in professional responsibility and personal  soli-
citude.   He is obliged to be at the disposal of the patient until she is delivered,  and
can, therefore, assume no other engagements.   This impossibility of being at liberty,
and that for an uncertain period, is a serious inconvenience, not only to  himself,
but to his other patients.  Now the patient, as well as the physician, may 13 relieved 
INDUCTION  OF  PREMATURE  LABOR.            1015
 of all these uncertainties  and inconveniences  by the  operation which I propose,
 and which has proved successful on various  occasions.  Labor may be brought on
 at will, and terminated at any hour he chooses, with as  much certainty as any other
 surgical operation.  By adopting the new method, he may attend to  engagements
 at any distance from  home, and then finish the  case  at once, just as he Avould cut
 for the stone.  The operation is under the entire  control of the performer, who is
 n<: longer the slave of circumstances, and not obliged to await anxiously the efforts
 of nature.   In short,  he is  master of the position,  and determines beforehand what,
 under the requirements of  the case,  shall  be the period at Avhich the  patient shall
 find herself free from the dangers  Of childbirth, and  can  confidently inform  her
 when  her anxiety shall be over."   (Barnes.)
   In more than one respect we are obliged  to differ from Dr. Barnes, though  his
 instrument  seems calculated to be of real service.   We used it successfully in a case
 of induced  abortion  in which  the  labor  was too tedious.   It  certainly, in this
 instance, very much hastened the moment of delivery.

    d.  Irritants  placed between the Walls  of the Uterus and the  Ovum.
   Detachment of the  Membranes.— This operation is accredited to Hamilton, who,
 in the year  1800, proposed  passing the finger forcibly through the neck and internal
 orifice of the womb, and  detaching  the membranes as far as practicable.  He had
 observed that when the ovum becomes separated for a considerable extent  from  the
 wall of the  uterus, its expulsion necessarily ensues very soon.  His process, how-
 ever, was so rough, violent, and often impossible, especially in first  pregnancies,
 that it was soon abandoned.
   Mampe, and subsequently Pfenninger,  Billeter, and Campbell, thinking that  an
 instrument  capable of being  inserted more easily than the finger, might be  substi-
 tuted for it, proposed the use of a gum-elastic bougie, with its  extremity rounded
 in order to avoid  rupturing the membranes. The operation would seem  to be of
 easy performance and free  from danger to  either mother or child.
   Other  accoucheurs have made use of sounds of  horn or metal, for the purpose of
 detaching the membranes.
   In 1848, Professor  Lehmann (of Amsterdam)  recommended that  a  bougie  of
 medium  size be passed into the uterus to the distance of  eight  or ten inches, and
 immediately withdrawn ; the operation to be repeated  until  labor is fairly begun.
 His idea is,  that the double object of detaching the membranes and stimulating the
 uterus to contraction is thus obtained.  In 1852 he published  eight successful cases,
 in one of which the  bougie was twice inserted, and three times in another.  The
 duration of the labor Avas  from one  to five days, and  the delivery accomplished
 fa\Torably to both mothers and children.   This plan was favorably received in Eng-
 land, and is still frequently used there.  Its simplicity and easy execution give it
 a claim to consideration, though it is far from being  as certainly and promptly
 effectual  as in the cases reported by Lehmann.]

   Cohen's Method.— Ought we  to  attribute any greater value to the uterine
 injection, recently proposed by Dr. Cohen,  of Hamburg, for the artificial
 induction of premature labor?   Experience can alone  determine  the ques-
 tion.   His  process is, however, so  simple, and, according to the author, is
 attended Avith such prompt effects, and is so  devoid of danger, that Ave  think
 it  right to notice it.  He says, " I perform the injection as folloAvs:  I use a
small syringe, usually of  pewter, containing from  tAvo to  tAvo and  a half
ounces of tar-Avater, and  Avhose canula, from eight  to nine inches in length,
and about the eighth of an  inch in diameter, has a curvature similar to that
of a female catheter. I lay the Avoman flat on her back  Avith the hip raised, 
L016
OBSTETRICAL  OPERATIONS.
ihen, inserting two fingers up to the posterior lip of the os tincae, I use them
as a guide to the  canula, which  I pass between  the anterior Avail of the
uterus and the ovum to the distance of tAvo  inches within the uterus.   It is
then only that  I commence  the injection.   I  force it  gently and  slowly,
taking  care to raise the syringe  a little to avoid applying  the opening
against the  wall  of the uterus, and changing the direction of the instrument
whenever any obstacle presents to the  passage of the fluid.   The  syringe
is withdraAvn very gradually;  ten  minutes  afterward, the woman may rise
and walk, and if at the expiration of six hours there is no appearance of
labor,  the  injection  is  renewed.".....As M. Cohen  has  succeeded
once, and the process is so harmless, it is very desirable that he should try
again.

  [Krause's Operation.— This Professor recommends that a flexible bougie be passed
into the uterus to  the distance of from eight to ten inches, and  left  there until the
desired effect is obtained.  It was done successfully at Grbningen, and it is desir-
able that its merits be proved  and compared with those of the intra-uterine dilator.
  Intra-uterine Dilator.— Lastly, I have  myself proposed the use of a new instru-
ment, which I call the intra-uterine dilator.  The principle of its construction is as
follows: the insertion through the cervix to some distance above the internal orifice
of a gum-elastic tube of the size of a goose-quill, which is so constructed that its
end swells out into a  bulb of the size of an  English walnut, when an injection is
forced  into it.  The  apparatus  is to be left in situ until expelled  by the uterine
contractions.
  The first case in which it Avas employed was published in the Gazette des Hopi-
taux, January 9, 1862.  I then used a metallic tube of medium  size, terminated by
one of gum-elastic about an inch and a half long.   A stopcock, placed  near the
trumpet-shaped end  of the instrument, and a  syringe, completed  the apparatus,
which is represented in M. Charriere's catalogue, published on the occasion of the
London Exhibition.
  The operation of the instrument is  readily understood.  The dilator is  passed
into the neck of the womb until its dilatable portion, that is to say, the part covered
with gum-elastic, has got beyond the internal orifice into the cavity of the organ.
Then warm Avater is forced  into the tube, the gum swells out into a ball, the stop-
cock  is closed, and the apparatus keeps its place without a.bandage, being pre-
vented  from slipping  out by the dilated extremity of the instrument.
  The direction assumed by this dilator, when in situ, is nearly that of the uterus,
the metallic stem emerging from the vagina at the  posterior  commissure of the
vulva, and projecting behind the thighs.  This sort of caudal  appendage was so in-
convenient that the women could neither lie on  the  back nor be seated without the
risk of suddenly displacing  the  instrument.  This  great defect was remedied by
cutting off the metallic tube about two inches below the gum.  To the end of this
segment is adapted, on the one hand, a movable handle, Avhich can be withdrawn
when the instrument  is applied, and, on the other,  a flexible tube which  traverses
the vagina and is fitted externally with a stopcock to which the injecting syringe
is adjusted.  With this alteration, the women may assume any position, lie down
or walk about, without inconvenience or danger. This last instrument is the one
which I exhibited before the Academy  of Medicine  in November, 1862, and  is
figured in the report of the  Gazette des Hopitaux of  the same month.
  I now use  an instrument which is more complete and simple, although at first
sight it would seem to be quite complicated.  It is  composed of two fundamental
oarts:  a gum-elastic tube and a conductor.
  1.  A gum-elastic tube, of the size of a goose-quill,  about a foot long and  closed 
INDUCTION  OF  PREMATURE  LABOR.
1017
Fio. 146.
Fig. 147.
Fig. 148.
 Rt one  end (Fig. 146, b).  This tube is thick and resisting in the  greater  part of
 its length (Fig. 146,  b), but its walls grow thinner toward its end for the space of
 from an inch and a quarter  to an inch  and a half.   (Fig. 146, b).   When an injec-
 tion is  forced into it,  the unequal thickness of the walls causes the thin part to be-
 come d.lated.  (Fig.  148.)
   To the end of the tube (Fig.  146), a
 cord about eighteen  inches long is at-
 tached,  strong and small; the best for
 the  purpose that  I know of being what
 the  women  call "soutache," of white
 silk.  This thread being very liable to
 slip, in order to  prevent it,  I drop  into
 the  end of the tube  two  shot soldered
 together, and am  careful  to  tie the
 thread exactly in the  groove between
 them.  When this is done,  the  thread
 ahvays holds.  The  other  end  of the
 tube is fitted with  a socket provided
 with a  stopcock (Fig. 148,  c), for the re-
 ception of the injecting syringe.
   2. A metallic conductor with  a blunt
 extremity  grooved  through  its   entire
 length, and curved like a hysterometer.
 (Fig. 146, a.)  A tolerable idea  may be
 formed of it by imagining a  male cathe-
 ter cut in half, lengthwise, and the  con-
 vex  portion removed.   This conductor is
 pierced with three  holes for  the passage
 of the thread.  The two first  are near its
 end, and  about three-eighths of  an inch apart.   The third is near the handle to
 which the conductor  is attached.
   To adapt the tube to its conductor, the free end of the thread is  passed through
 the eye nearest the end of  the conductor, from the grooved toward the convex side.
 It reenters the groove through the eye next below (Fig.  146), and then passes along
 it through  its entire  length, coming out again through the eye near the  handle.
 When the string is drawn tight, the upper end of the tube fits into the end of the
 conductor, and is held there  by fixing the string  by means of a string provided for
 that purpose.  (Fig.  146, a.)  The body of the tube is  next placed in the groove,
 and  made fast by a few turns of  the remaining portion of the string.  Lastly, the
 end  of the string is secured  by passing it beneath  the  spring  already mentioned.
 (Fig. 147.)   The  entire apparatus,  when mounted, is not longer  than a common
 catheter.   (Fig. 147.)
   The instrument is used as follows: When-the  tube has  been provided with its
 string, an experimental injection is  made into it, in order to ascertain Avhether a
 crack or other opening exists in  it.   This having  been accomplished, the  tube is
 held vertically, Avith the stopcock uppermost and open.   A few bubbles of air are
 first  discharged, followed by  water, which is allowed to flow away.   When the tube
 has resumed its usual  size, it collapses ; that is to say, the air  has been expelled,
 and  the stopcock is closed,  to prevent any more from entering.  This  precaution is
 taken, lest any air should be  forced into the  uterus, in  case  the gum-elastic bulb
 should happen to burst.
  The  tube thus  prepared is next  adjusted to  the conductor in  the way above
described.   To lubricate it, glycerine should be used, because  fatty matters alter
the gum very quickly, and cause the apparatus to rupture.
Intra-uterine dilator. 
1018
OBSTETRICAL  OPERATIONS.
   The woman being placed across the bed, Avith the hips raised and projecting over
 the edge of the mattress, the legs being held apart by two assistants, the operator
 passes two fingers of the left hand into the A'agina, and places the end of the fore-
 finger upon the os tincae.  The dilator, held in the right hand, is  passed into the
 vagina;  its extremity is guided into the cervix,  and by depressing the  handle, it
 usually passes without difficulty into the uterus,  going between the ovum and the
 anterior wall  of the Avomb.  It ought to go an inch and a quarter  at least beyond
 the internal orifice ; a small  projection upon  the conductor, four inches from its
 end, serves as a guide.
   The instrument is held in position Avhilst the turns of the string  which hold the
 tube to the conductor are unwound.  An assistant fills a syringe with warm water,
 expelling the air, and  inserts its tube into the  socket which  hangs outside  of  the
 vagina.  The  injection should be made very slowly, though it requires considerable
 force, especially at the outset.   A little more than an ounce and a half of liquid is
 sufficient to swell the gum-elastic bulb to the proper size. When the injection  is com-
 pleted, the stopcock is closed, the string is detached from the spring Avhich holds it,
 and the conductor is easily7 withdrawn by gentle traction.   The tube being held by
 the bulb at its extremity, remains  with the string hanging beside it.
   It only remains to take measures for preventing the  stopcock from opening, and
 to attach it to  a simple or body bandage.   I prefer, however, merely to tie the tube
 securely at the vaginal orifice, and  remove the stopcock  altogether.  The women
 being  then  free from  any  impediment to motion, are free  to move  about their
 chamber  and  engage  in their  usual occupations.  It is even  preferable that they
 should keep up, for then the gum-elastic bulb presses  directly upon the internal
 orifice, and labor commences earlier.
   The pains sometimes come on whilst the instrument  is being applied, though, on
 an average,  they do not begin until  three or four  hours after operating.  At first,
 they are feeble, but become gradually stronger  and nearer together, as in natural
 labor.  The cervix becomes effaced and opens out, until at last the instrument falls
 into the  vagina.   This  expulsion generally takes place in  ten  or  twelve  hours,
 though sometimes much sooner or rather later.  Statistics of all the operations I  ex-
 pect to give hereafter.
   By the time the dilator is expelled, the neck of the uterus has become effaced, is
 widely open, and the membranes  are  projecting through it.   In the majority of
 cases, the labor continues, but sometimes it ceases.  I  have often remarked that it
 was only necessary  to make the women walk about, and to  leave the instrument in
 the vagina, where it doubtless  acts, like Braun's colpeurynter, to make certain the
 continuance of the contractions.  When, notwithstanding all these precautions, the
 labor stops, it becomes necessary to introduce the dilator again, giving it, this time,
 a larger size.
   Once only, in a case of M. Depaul's, was this plan ineffectual;  whenever the in-
 strument was expelled from the uterus  into the vagina, the labor ceased.  M. De-
 paul was  obliged to rupture the membranes, and even then his patient was not
 delivered  until a long while after.  I  am satisfied that in  this case success Avould
 have quickly followed the use of Barnes' instrument immediately after the dilator
 was expelled.   I  even think  that it would oftentimes be very useful to associate
 these two instruments, on  account of the  impulse which  they Avould give  to the
 progress of the labor, and that their conjoined  use is destined  to be a real step in
advance in the induction of premature  delivery.
   I attribute the efficiency of the dilator  to a special property  of the uterus, in
 virtue of which it tends to contract,  in  order to expel a foreign body within  it.  It
 also acts by detaching the membranes,  though here less decisively, since it  seems
to be shown by some of my cases that the labor stops when the instrument is Avith-
drawn too socn, although detachment of the membranes had resulted from its ap-
 plication 
INDUCTION  OF  PREMATURE  LABOR.
1019
  Having by this time had quite a large experience, I ain justified by the facts in
saying that there is no difficulty in the operation, as will be attested by Drs. Dan-
yau, Depaul, Pajot, and Blot, all  of whom have frequently performed it success-
fully.  It is, besides, entirely innocent as regards  both  mother and child, and is
far more  certain  and  rapid  than any other process.  A no less great adA^antage is
its extreme simplicity as compared with the difficulties met with in the use of the
prepared sponge  and  uterine douches.  It is also completed at one time, and in ex-
ceptional cases only has it to be repeated; when the instrument is once  applied,
there is nothing to  be done but  to await the delivery.
  It would have  been thought, d priori, that this process would be liable to rupture
the membranes, but it will suffice  to say that  in tAventy cases it did  not happen.
A more valid objection is the  possible rupture of the gum-elastic  bulb.  This oc-
curred four times in  the first ten recorded cases ; but since  then, having used an
improved dilator, I have known it to occur but once.  The result was an  involun-
tary injection into the uterus, as in Cohen's process, giving rise neither to pain nor
accident  of any sort; the operation being merely interrupted  for the time required
to adjust  to the conductor another tube, which it is always well to have on hand in
case of accident.
  The only serious  fault to be found Avith the intra-uterine dilator is, that in some
rare cases it would  be impossible to introduce it into the uterus.  Should the head
be very low down, or the neck much deviated, insurmountable difficulties might be
met with.  Whilst acknowledging the objection, I  would only observe that it ap-
plies  equally to the  various processes of detachment of the membranes, Cohen's
intra-uterine injections, and to  all the methods of puncturing  the membranes.]

                   e. Puncture of the Membranes.
   Usual Method. — Puncture of the membranes is certainly the surest of all
the processes and  the one most likely to be  the  first to suggest itself.  It was
performed by Macaulay Avhen, for the first time, he acted on  the  advice
given in 1756 ,by the most celebrated physicians in London.   Most accou-
cheurs Avho have performed this operation since his day have likeAvise punc-
tured the  ovum;  the  various  modifications  suggested  at  different  times
merely refer to  the  shape, the length, or the curve of the instrument used,
and  scarcely merit a notice.  For it must be evident that any canula Avhat-
ever that is sufficiently curved  to correspond with the line of the pelvic axis,
and  is long enough to reach the  os uteri Avithout  difficulty (that is, about
eight to  eight and  a half inches), and  furnished with a trocar, having-  its
point concealed yvithin, or only projecting a few lines beyond the end of the
canula, will  be all that is  requisite.   The only precautions to be observed
consist in guiding the instrument  along  in such a way  as not to injure the
mother's parts,  and so as not to AA'ound the foetus by  the  point of the trocar.
  As elseAvhere stated, this is the most certain  plan, because a discharge of
the waters  necessarily occasions a retraction of the uterine Avails, and sooner
or later a manifestation of the pains ; Ave may further add, that it is quite as
easily accomplished, and  is   less painful to the mother than those about to
be described; but Ave must   acknoAvledge that the child's existence is much
more endangered, because a  partial or even a total  escape of  the amniotic
liquid is  not always folloAved  at once by the occurrence of the first pains.
  Sometimes forty or even sixty hours elapse before  the  uterus, irritated by
the prolonged contact of the fcetal inequalities, begins to  contract; and even
when the labor  has actually  commenced, the dilatation  of  tbe os uteri pro- 
1020
OBSTETRICAL  OPERATIONS
gresses very sloAvly, for at the seventh or eighth month the fibres in the neck
have not as yet undergone those  modifications Avhich, at the ordinary term
of gestation, render the dilatation easy; and thus a further period of tAventy-
four or thirty-six hours often passes away before  the os uteri is sufficiently
dilated.  Noav, during all  this time, the fcetus, being no longer protected by
the amniotic liquid, is subjected to the direct pressure of the contracted
uterine walls; the umbilical cord might very easily be involved, and from
its compression, an interruption of the circulatory relations, Avhich are indis-
pensable to the support of the child's life,  Avould inevitably result; besides
which, the placenta itself might be partially detached in consequence of the
retraction of the Avomb.
  Many  accoucheurs, influenced by these palpable dangers, had altogether
rejected the perforation of the membranes, Avhen a modification was proposed
by Meissner, of Leipsic, Avhich fortunately prevents the accidents just indi-
cated, and therefore  merits a further investigation into  the  propriety of
puncturing the ovum.   Various plans were suggested for moderating, as it
were, the discharge of the  amniotic liquid, and of only permitting the escape
of a sufficient quantity of it to secure the induction of the  pains; but no
one had  hitherto succeeded in accomplishing what Meissner has so happily
effected.   His process is as follows:
  Meissner's process. — Instead of puncturing the bag of waters at its lowest
part, he  perforates it high up close to the fundus of the womb, by  using an
instrument consisting of  a canula and two stylets.  The  canula, which  is
made of  silver, is nearly thirteen inches long, and about two lines  in diam-
eter ; and it is curved so as to correspond to a segment of a circle Avhich has
a radius  of eight inches.   A ring is attached to it, near the lower extremity
on the convex side, by Avhich the instrument  is managed, and which serves
to indicate the direction of the curvature after the  introduction.   The tAvo
stylets (one being terminated  above by an olive-shaped button,  and the
other  by a trocar) are adapted to the canula;  their lower end is  flattened
out so as to keep them from slipping in too far; the olive-shaped extremity
of the first stylet ought not to project more than two or three lines beyond
the canula; but the trocar point  of the second should advance at least half
an inch.   The first stylet is intended to facilitate the introduction of the
canula, and the second to make the puncture.
  M. Meissner performs the operation in the folio Aving manner: The patient
is placed in an erect posture, and the operator, stooping down on one knee
before her, first ascertains the exact position of the cervix ; if this is high
up, and  at the same time  is directed so  far  backAvards  as  scarcely to b.
reached,  the patient will have to  sit down on the edge of a chair, or else lie
on a settee.  The  accoucheur then introduces the  canula armed  with the
blunt stylet, along the palmar surface of the index finger into the cavity of
the cervix, and presses it on until  it has passed the internal orifice ; of course,
always having the convexity of the instrument directed towards the IioIIoav
of the sacrum.   When the point of the  canula has once got beyond the
internal  orifice, it is easily  slipped up  between  the  membranes  and the
uterine Avails, to the extent of eight or ten  inches above the os uteri.  After
having ascertained that  the point of the  instrument  does not rest on any 
INDUCTION  OF  PREMATURE  LABOR.           1021
portion of the fcetus, the accoucheur withdraws the olive-shaped stylet, and
substitutes the trocar, Avith which he then  punctures the membranes.  The
trocar is  next withdraAvn, a small  quantity of liquid  is  allowed to escape
through the canula, and then the latter itself is removed.   After the opera-
tion is  over,  the Avoman may be permitted  to  sit doAvn or Avalk  about at
pleasure.   The Avaters gradually escape, thus lubricating and preparing the
passages,  and the pains  make their  appearance in the  course of tAventy-four
or forty-eight hours;  and, in most cases, the dilatation is soon effected, the
contractions are strong, and the labor is completed in thirty-six or forty-eight
hours.  When the labor does not advance regularly, and the resistance from
the contracted pelvis is very considerable, M. Meissner resorts to the meas-
ures usually employed under similar circumstances at  term.
   He has tried this mode  of  operating fourteen times, and he  avers that
both mother and child Avere saved in every instance; such a result, as com-
pared Avith those obtained  by other plans, certainly demands attention, and
must encourage  other  practitioners to attempt it.   Let us  hope  that  the
principals of  large lying-in hospitals will shortly confirm, by fresh success,
the favorable accounts given by Meissner.
   The introduction of Meissner's canula is liable to occasion a partial separa-
tion of  the placenta, and consequently endangers the  lesion of some of its
vessels.   This, indeed, happened in a case observed by Kivisch, of Wiirz-
burg:  the canula would ascend no higher than  five  inches, and after  the
puncture,  nothing  escaped  but a  little  blood   and  serum.  Not having
obtained a discharge of Avater, it Avas decided tAvo hours afterwards to punc-
ture the ovum in the usual way.  .  . .  Why not have directed the  canula
toAvard another  point?
   [M. Villeneuve (of Marseilles) substituted for Meissner's double mandril, a single
one endino- in a hook for seizing and rupturing the membranes.  Whilst this in-
strument has all the advantages of the trocar, it is not liable to wound the child.
  Whatever instrument is used to accomplish it, perforation of the membranes  at a
point high up has afforded  good results,  inasmuch  as out of  twenty-four cases
recorded up to this date,  all the patients survived, and twenty-two children were
born alive.
  Meissner's method is little used, probably because of a  fear of penetrating so
deeply into the womb and of wounding its walls or the foetus, or of separating the
placenta.  It will  always  be  an exceptional operation.
                               Appreciation.
  The means by which labor may be brought on prematurely are, as has been seen,
very numerous "and  have  all been used with various degrees of success due not
merely to the nature of the process adopted, but also to the great  difference in the
degree of excitability of the uterus in pregnant women.  Sometimes the slightest
cause will bring on contraction of the womb, in which  case any process will suc-
ceed admirably ; at other times it will remain completely inert under the most
active stimulation, and then the very best methods become apparent failures.
  The best operation is that which is the most uniformly and rapidly successful, at
the same time  that it affords the greatest security to both mother and child.  Apart
fromspecial indications, which the clinical history of a case may supply, there are
three operations to which  we should accord the preference : 1, detachment  of the
membranes; 2, dilatation  of the cervix; 3, stimulation of the circumference of the
os tincae. 
1022
OBSTETRICAL  OPERATIONS.
    1.— We would  practise detachment of the membranes whenever  the  internal
 orifice can be entered.
    2.— We would  perform dilatation of the cervix, when it is impossible to pass the
 instruments through the internal orifice.
    3.— Stimtdation of the circumference of the os tincaz would be  our last resort,
 when the  two preceding methods are found to be impracticable.
    We have next to compare the processes included in these three methods; but not
 wishing to repeat here Avhat has already been  said in describing each operation,
 we Avould  call attention more especially to the intra-uterine dilator, Krause's per-
 manent sound, the prepared sponge, and uterine douches.
   To have  succeeded in bringing on labor prematurely does not limit the accoucheur's
 responsibility:  he has yet to devote  much attention to the child whose imperfect
 development demands especial care, which is necessary in proportion to the earli-
 ness of the period at which the pregnancy shall  have been  interrupted.   Children
 born at term are brought up  under ordinary conditions, but those born before term
 require unusual precautions, upon whose proper execution success must depend.
 With them they often live, but Avithout them they are almost sure to perish.
   All children born prematurely require the most careful protection from cold, so
• that, beside  the usual clothing, the whole body, the head and  limbs especially,
 should be  enveloped in  a layer of corded cotton.  Bottles of hot water ought also
 to  be placed in  the cradle as a permanent source of artificial heat.   The tempera-
 ture  of the chamber in  which they  are  kept should be maintained at about  64
 degrees (Fahrenheit).   If, notwithstanding all  these precautions, the circulation
 languishes in the  integuments, and  the subcutaneous  cellular tissue becomes in-
 filtrated, stimulating baths, the best  of which are  made of wine,  should be used.
 From time to time the children ought to be exposed naked before a warm fire, and
 the occasion taken to rub gently the entire surface of the body with the hand.
   Their proper nourishment  is not less important.   It is indispensable for them to
 be suckled, either  by the mother or a  wet-nurse.  When strong enough to take the
 breast, it is only necessary to nurse them often, but when too weak or  lethargic for
 this, they should be made to swallow the milk previously expressed from the breast
 into a  dessert-spoon.  This ought to be done twelve or  fifteen times a day, two  or
 three spoonsful at a time being as much as they  will require for the first feAV days.
 The quantity will afterAvards be increased gradually, until the  child  is strong
 enough to  take the breast.  To the  combination  of all these attentions very many
 children born before term owe their lives; their omission almost always results  in
 death.]
                         CHAPTER  VII.
                        PRODUCTION OF ABORTION
  Premature artificial delivery requires, as just seen, certain dimensions in
the diameters of the pelvis; but when  the contraction is so great that the
smallest diameter is  less  than two inches  and a half, a question of the
highest interest presents itself, namely, that of the production  of abortion.
  When a Avoman, three to four months pregnant, has so contracted a pelvis
as to preclude all hope of a  possible  expulsion or  extraction of a viable
foetus, may  Ave think of inducing abortion?   This  question, put  to  Dr.
Hunter, in  1768, by  W. Cooper, was  shortly aftenvard decided  in  the
affirmative by most English practitioners.   The propriety of the  operation
was also acknoAvledged in  France, by Fodere (1813), Marc (1821), Velpeau 
PRODUCTION  OF ABORTION.
1023
(1829), and by ourselves (in 1840), in  the  first  edition of this  work.   In
1843, M.  P. Dubois published an article  in the Gazette Medicate,—an
article Avhich foreshadoAved  his  opinion, although it did  not  positively
express  it.  About the same time, M.  Simonard, of Brussels, published a
dissertation, in Avhich, after showing the morality of the operation, he points
out the indications.  Finally, MM. Stoltz,  Jacquemier, and  Chailly, have
adopted the vieAVS of the English accoucheurs.
  Too many imposing  authorities  have pronounced in favor of producing
abortion to make it necessary for us to stop in order to discuss  the moral,
religious, and medico-legal questions which this operation has raised.1  Like
premature delivery, it  is noAV received as  an obstetrical  operation, and it
only remains for us to determine the indications, and the most expeditious
and least dangerous means of accomplishing the object.
  1. The  extreme contractions of the pelvis, those Avhich afford the woman
at the term of her gestation only the sad  choice between  embryotomy and
the Caesarean operation, and for a still stronger  reason,  those  Avhich, by
affording less than tAvo  inches to tAvo inches and a half, allow of the extrac-
tion of a dead or living foetus only by incision of the abdomen, constitute the
most positive indication for producing  abortion.   If, indeed, as Ave shall en-
deavor to prove in the folloAving chapters, the sacrifice of the child  is fully jus-
tifiable Avhen the choice only lies betAveen hysterotomy and  embryotomy, this
sacrifice Avould be still  more rational at a period of gestation in which the
operations necessary to the production  of abortion are much  less dangerous
than those which the mutilation and extraction  of a foetus  at term Avould
require.   For our OAvn  part,  therefore, Ave think that the accoucheur is Avar-
ranted in producing abortion, Avhenever a Avoman, Avho is five orsix months
pregnant  at the most,  shall have  less  than  tAvo and  a  half inches in the
smallest diameter of the pelvis.
   2.  Contractions of the pelvis are not the only cases in  which  it has been
proposed  to produce abortion.  A  host of  accidents connected  Avith the
pregnant condition, and a multitude of coexisting morbid  phenomena, all
becoming very dangerous to the mother in  consequence of this coincidence,
have appeared to some physicians to be quite as rigorous  indications as the
pelvic contractions.  We cannot  partake  of this view, at least as respects
the majority of cases.   The precepts laid down by us in treating of prema-
ture delivery, require to be greatly  modified when abortion  is concerned.  In
a grave case, indeed, but one in Avhich the issue is only probably favorable,
Ave may conclude to induce labor after the  seventh month: the danger to
which the  mother is probably exposed certainly legitimizes an operation
which affords considerable  chance of  saving the child's  life. The same is
by no means the aase  as respects  the  production of abortion; here it is no
longer sufficient  that the mother's  life is probably compromised, it should be
almost certain that death is imminent.   Under this head,  hemorrhages that
have resisted all kinds  of treatment, irreducible  displacements of the womb,
extreme dropsy  of the amnion, tumors of  the soft parts which  cannot be
displaced, punctured, incised, or extirpated,  seem to  me  to be the only ad-
  1 For further details, see M. Cazeaux's report  to the Academy of Medicine, and the
discussion which followed it.  (Bulletin de VAcadimie et V Union Medicate, 1852.) 
1021
OBSTETRICAL  OPERATIONS.
missible indications for the production of abortion.   The same may be said
of those  cases of obstinate vomiting which  threaten  a speedy termination
of the mother's life (see page  477.)   On  the contrary, it ought not to be
performed for nervous disorders, and chronic or acute diseases complicating
gestation.  As regards eclampsia, it is rare in the first half of pregnancy,
and  the  slowness Avith which the abortive  measures act at a  very early
period, seem to me to be a formal contraindication.   (See p. 813.)
  To recapitulate, extreme contractions of the pelvis, voluminous, immov-
able, and non-operable tumors of the excavation, extreme dropsy  of the
amnion,  irreducible displacements  of  the Avomb, and  hemorrhages  Avhich
have resisted the employment of the most  rational measures, we consider
to be the only indications for abortion.  Some  authors  have admitted a
greater number, but only for Avant of distinguishing  clearly betAveen  abor-
tion  and  premature labor.
  The only contraindication is the formal refusal of the mother; for with
her alone, after all, remains the right to decide the question.
  Whilst respecting the scruples  of  certain  minds as respects a deformed
woman upon whom abortion has been once practised, I confess that it would
not deter me for  an  instant in a succeeding  pregnancy.  We have no right
to constitute ourselves  judges of the morality and of the antecedents  of the
patient who demands our  assistance.  Even  supposing that Ave have  to do
with  one of those unfortunate  creatures who will trample under foot the
most sacred feelings, and give  Avay all the more  to  their passions, because
they think they can find impunity for their bad conduct in the humanity of
the surgeon, we OAve her none the less our  care; for us,  the only question
to resolve in the second, or third, as in  the first pregnancy, is,  Avhether the
conformation of that Avoman alloAvs us to hope for the extraction  of a viable
child.
  It, therefore, only remains for us to determine  the period at which  it  is
proper to operate, and the  most advantageous methods.
  None but the  contractions  or  obstructions of  the  pelvis permit  the ac-
coucheur to choose the most favorable moment, and then the only  precaution
to be observed is to Avait until  the pregnancy can be certainly determined,
that is to say, between the fourth  and fifth  months.   In  all other cases, it
is necessary to  act as  soon as the gravity of the accidents  have no other
alternative.

  [Modes of Operating. — All the  methods described for the induction of premature
labor may be employed ; but inasmuch as during the  first half of gestation the
womb is but  slightly contractile  and susceptible of stimulation, the  most  active
means should be preferred.   The use of the  tampon, after  Schceller's or Braun's
plan, is often ineffectual; the prepared sponge, although mora efficient, is liable to
act with the most  discouraging slowness, and the same may be said of Kiwisch's
injections.  The two plans which  seem to us the most  likely to succeed  are, detach-
ment of the membranes and puncture of the ovum.
  Detachment of the Membranes. — This is generally  clone with a metallic  sound,
which is passed over  as  great a  surface as possible.   Although the operation is,
apparently,  very simple, it is often really very difficult, and the most skilful  hards
have sometimes been unable  to perform it.
  We produced abortion three times by means of the intra-uterine dilator ; once fol 
SYMPHYSEOTOMY.
1025
obstinate vomiting, and twice on account of extreme contraction of  the pelvis.   In
the first case, the abortion was effected in  a few hours, and the patient recovered.
In a second (contracted pelvis), it was over in  less than forty-eight hours.  This
last case has especial value from the fact that Prof. Dubois had the greatest trouble
in a previous  pregnancy in producing abortion;  douches in great number had been
given Avithout result, several  applications of prepared  sponge  had  been fruitless.
and expulsion of the ovum was only brought about  by introducing large bougies
into the uterus.
  The third case of abortion,  provoked  by the intra-uterine dilator, was both less
perfect and less rapid ;  the patient being a woman affected with osteomalacia.  The
dilator was used Avithout difficulty or  pain during  the fifth month of gestation.
Five days afterward the cervix was, in great measure,  effaced  and  partly opened,
but the instrument still remained Avithin the Avomb.  To stimulate the labor I used
Barnes' dilator, and soon afterward the abortion took place.
  In these three cases the patients recovered without  accident,  so that  the results
were sufficiently  satisfactory to authorize its use in the future.
  Puncture of the Ovum. — As an operation for the induction of premature labor,
puncture of the ovum, notwithstanding the certainty with which it acts,  is liable to
the great objection of compromising the life of  the child, and on this account it ia
almost entirely abandoned.  But, as in  case of abortion the fcetus  is  not viable,
puncture of the membranes is a valuable method.  The only objection to it  is the
difficulty of certainly reaching the  ovum.  The method  is the same  as  for prema-
ture labor.
  Whatever means are employed, it is  to be expected that the expulsion will take
place very slowly.  This will  seem reasonable,  inasmuch as spontaneous abortion
is usually very tardy.]
                         CHAPTER VIII.

                          OF SYMPHYSEOTOMY.

   The relaxation of the pelvic symphyses, and the consequent  separation
of the articular surfaces, which often occur  during pregnancy, have so long
been knoAvn to the profession, that  it  is somewhat surprising the operation
in question Avas  not sooner suggested.   It  should be stated, however, that
certain reflections, and even some facts well Avorthy of attention, are scattered
here and there throughout the annals of our science.   For instance, Severin
Pineau,  Avhen treating of the relaxation of the pelvic ligaments, quotes the
text of Galen, and  seems to  anticipate the Sigaultian operation; since, in
speaking of the pelvic articulations,  he says, Non tantum dilatare, sed etiam
secari  tuto possunt.   In a work published by Delacourvee, a  French physi-
cian,  in 1655, Ave find that,  being summoned  to a  pregnant woman, Avho
died near full term, he divided  the pubic symphysis with a razor, in order
to extract the child more readily.  In  1766, Plenck,  under very similar cir-
cumstances, first performed the  Caesarean operation; but, being  unable to
extract  the head, Avhich Avas  Ioav doAvn in  the  excavation, he  divided the
symphysis,  and  Avas  successful  in  delivering  the child.  But  this early
attempt, instead  of leading  to  the  performance of  this operation  on the
living  female, seemed to have the opposite effect.
  In  fact, it Avas only towards  the  end  of  the  last  century  (in 1768) thai
Sigault,  then a  student of medicine, suggested it to the Academy  of Su*
       65 
1026
OBSTETRICAL  OPERATIONS.
gery, by Avhom it was rejected as a rash proposal.  Not disconcerted by this
reception, young Sigault supported his invention in a thesis at Angers, in
1773;  that is, five years after the presentation of his original memoir; and,
finally, in 1777, he performed his first operation, assisted by Alphonse Leroy,
Avho declared himself its zealous partisan.  The mother and child Avere both
caved ; and, on account of  his success, Sigault, who had been almost reviled
by  the Academy  of  Surgery, Avas thenceforth  covered  Avith honors,  and
regarded as a benefactor of humanity.  The Faculty of Medicine at Paris
even resolved to  celebrate this Avonderful discovery by  having a medal
struck  in  honor of its author.  But, notAvithstanding its  early success soon
gained him  numerous followers, it also stirred  up  new and bitter adver-
saries : and the medical world was for a long time divided into two sets of
enthusiasts, the Symphyseans and the Cozsareans;  but, after their first ardor
had abated, both parties finally settled doAvn in a common opinion, as soon
as they discovered that there had been exaggerations on each side.  Since
that time, the Caesarean  operation and symphyseotomy  have been alike
regarded  as useful operations, applicable to certain particular cases;  and,
so far  from  attempting to exclude either,  the more modern writers have
rather  endeavored to designate the conditions requiring their respective  em-
ployment  ; Avhich, indeed, Avould have been the wiser course at the time of
its first discovery.

  § 1.  Effects of Symphyseotomy.
  Supposing  the propriety of the section  of the symphysis pubis to be
admitted for the moment, let  us ascertain what advantages could be derived
from it.   From the best works published on this subject, it Avould  appear
that Ave cannot hope to gain more than four to six lines in the length of the
antero-posterior diameters of  the superior strait and excavation.   After a
division of the inter-pubic cartilage, the bones of  the pubis separate sponta-
neously from four lines to an inch;  which separation is  produced by the
retraction of the ligamentous fibres, known  as the posterior sacro-iliac liga-
ments.   While this is being  effected,  the  coxal bone  may be considered
as a lever of the  first kind, having its long anterior  arm  bent  near  the
middle; the centre of movement, or fulcrum, is found at the posterior part
of the  articular surface of the sacrum.  During the separation, the liga-
ments situated on the front part of the sacro-iliac articulation become tense
and stretched, or even lacerated, Avhen this is carried to a high degree; con-
sequently, the amount of their resistance greatly influences the  degree of
separation.  Again, if the  accoucheur, by taking hold of the iliac crests,
attempts  to  draAV them asunder, he may considerably increase  the  interval
already existing between the pubic bones; but it Avould be imprudent to
carry this  artificial separation too far ;  because, if carried beyond two inches,
the anterior  sacro-iliac ligaments Avould probably be ruptured, and  the
mother be subjected to very serious consecutive inflammations.  The antero-
posterior diameter of the strait is increased  from two to three lines for every
inch of separation betAveen the pubes; and, since this interval  may amount
to two  inches, four to five lines are therefore added to the length of the
Bacro-pubic diameter.  In addition to which, the  anterior parietal protuber- 
SYMPHYSEOTOMY.
1027
 tince, by engaging in the space left between the pubic bones, diminishes the
 biparietal diameter  to a corresponding extent; and it has been calculated
 that tAvo to three lines  are  gained in this way ; Avhich Avould give a sum
 total in the increased length  of the sacro-pubic diameter of six to eight lines.
   But the sacro-pubic is  not the only diameter  augmented by symphyse-
 otomy ; for the oblique, and more  particularly  the transverse, ones are
 thereby greatly enlarged.  In fact, the researches of Desgranges Avould seem
 to prove that the increase in the transverse direction, throughout the Avhole
 pelvis, amounts nearly to one-half of the separation at the pubis; and that
 the transverse enlargement of the  pubic arch is almost equal to the Avhole
 of this interval.  Whence it  folloAvs that the operation, which Avould appear
 to be  applicable to those cases only in Avhich the contraction  affects the
 sacro-pubic interval, is in reality  especially advantageous Avhen the trans-
 verse diameters of the excavation, or  of the inferior strait, are shortened.

   § 2. Indications for Symphyseotomy.
   The results furnished  by experiments made on the dead body, naturally
 lead to the  conclusion that  this operation is practicable Avhenever five to
 eight lines, added to  the  contracted diameters, Avould prove sufficient to
 admit of a  spontaneous  delivery,  or,  at least, of an extraction of the foetus
 by the forceps.   Such is the view adopted by most practitioners since the
 days of Sigault, and the  extremes  of the operation have been limited to tAvo
 and a half inches for the lowest, and three  and a quarter inches for the high-
 est.   But, at the present day, symphyseotomy is seldom resorted to, and it
 will  be even less so hereafter, Avhen accoucheurs generally shall have learned
 to appreciate  the advantages derivable from the induction of premature
 labor.
   The circumstances  that have led  to the performance of  the  Sigaultian
 operation, are equally strong in favor of the induction of premature labor ;
 and  the results deduced  from experience, the only impartial  judge  in  such
 cases, have already decided in behalf of the latter operation.  For, Avhenever
 a  patient comes under care during the last tAvo months of her pregnancy,
 whose pelvis ranges from two  and a half to  three inches  in  its  smallest
 diameter, Ave ought to bring on the labor before term ; more  particularly if
 a mutilation of the  foetus has been deemed  necessary in a former  confine-
 ment;  and,  on  the other hand, Ave have elseAvhere shoAvn (page 672)  that,
 whenever there is reason to believe that the child's  life  is more or "less com-
 promised by the  previous duration of the  labor, and the  unsuccessful
 attempts resorted to for its  extraction, the accoucheur should  act  as if it
 were really dead.  Hence symphyseotomy  should only be performed, .even
 though the pelvis measures from two and a half to three inches in its small-
 est diameter, Avhen the operator ascertains the existence of  the deformity
 before the membranes are ruptured.
  For, even admitting that it were not better to  sacrifice the infant's life
 than to perform an  operation Avhich  so often endangers the existence and
commonlv the health of the mother, is it ahA'ays  possible,  in practice, to
conform strictly with theoretical principles?  The cases in Avhich a similar
degree of retraction  has  permitted the spontaneous expulsion of the feet as 
1028                 OBSTETRICAL  OPERATIONS.
naturally suggest themselves to the mind; and although these exceptions to
•■he rule are certainly rare, yet they may reoccur.  Consequently, is  it not
prudent,  before alarming the patient, to ascertain, by a proper delay, the
inefficiency of the uterine efforts?  Is not such a delay indispensable for
proving the necessity of the operation ?  In most instances, Avould  it not
require several hours to induce the patient to yield to the entreaties of her
family ?   Would the relatives themselves consent, before the lapse of time
had  convinced them of the  absolute  impossibility of a natural delivery ?
And Avould they not demand a trial of all other  means, before a resort to
such an extreme measure?  Could the accoucheur object to an application
of the forceps, which has so many times, under  like circumstances, been
folloAved Avith success ?   Or could he refuse, had  he, like ourselves, seen  a
living fcetus expelled at term through a pelvis whose antero-posterior diame-
ter measured but three inches?  These uncertainties, hesitations, and forced
delays, Avhich  a firm and resolute physician having charge of an hospital
may escape, are inevitable in private  practice, where we  have the fears of
the family, the resistance on the part of the patient herself, and oftentimes
the anxiety caused by the jealousy of some of our  OAvn brethren, to contend
Avith; during all Avhich, time runs away, the labor is  progressing, the mem-
branes are ruptured, and the  favorable chances for performing the operation
are lost.   It will be said, perhaps the sloAvness of the labor is more dependent
on the feeble contractions than on the disproportion between the diameters
of the head and those of the pelvis; or, perhaps a little artificial aid joined
to the powers of nature will succeed in accomplishing her work.  But while
thus Avavering from hope to hope,  from perhaps to perhaps, the labor reaches
that stage Avhere we  begin to doubt the viability of  the foetus; and, when
such a doubt arises, can we any longer think of resorting to symphyseotomy?
  This operation has been proposed in  other cases, besides those dependent
on a contraction of the pelvis ; as, for instance, for tumors in  the excavation,
for a very large head, or a retroversion of the womb, occurring during the
early months of gestation.  Thus, it Avas resorted  to  by Duret, in order to
overcome  an obstacle to the engagement of the  head, created by the  devel-
opment of an exostosis, about the size  of a nut, on the  first false vertebrae;
as also  in the folloAving case, published  by  Dr. Damman, in  Casper's
journal: A AAroman had been three days in labor, but the head was so volu-
minous that it could not engage in the excavation, notAvithstanding the
perfect conformation of the pelvis; and, having become wedged in the supe-
rior strait, an application of the forceps Avas impossible.  Although the long
duration  of the labor ought naturally to have  created some doubt with
regard to the child's condition, yet M. Damman resorted to symphyseotomy;
the infant was born dead, but he  was fortunate  enough to save the mother.
  The remarks before made with  regard  to this operation  in cases  of de-
formed pelvis, equally apply to those of tumors in the excavation,  and to
those in AA'hich the  excessive size of the  child's head constitutes  the only
obstacle to a spontaneous delivery.  As to its utility or disadvantages when
resorted to for the purpose of facilitating the reduction and correction of a
retroverted uterus, experience is still Avanting.
  In our estimate of the indications for this operation, we cannot conform, 
SYMPHYSEOTOMY.
1029
 aa the reader will see, to the  rules laid down by its partisans ,  because, so
 far from being precise and positive, as  they suppose, these  rules only leave
 the practitioner in doubt and uncertainty.  Laying  aside for a moment all
 theoretical  discussions, and  looking at the question only in its  practical
 point of vieAV,  Ave are led almost irresistibly to the conclusion that, in the
 present state of our science, symphyseotomy is no longer practicable.  For,
 independently  of  the difficulties in  determining its indications precisely, it
 must not be supposed that the operation is attended Avith as little danger as
 Sigault and Alphonse Leroy endeavored to prove; and Ave only need refer
 to the numerous  accidents thereby produced  to sustain the justice of our
 conclusions.  In  fact, these dangers are so great that, according to Baude-
 locque, of  forty-one females operated  upon,  fourteen  died, and  thirteen
 children only Avere born living!  Not to allude to the numberless infirmities
 that embittered  the existence of nearly all the patients Avho survived the
 operation.
   Operation.—This is very simple.  The Avoman, being placed in the same
 position  as  if the forceps Avere to be applied, is properly supported by assist-
 ants ;  the bladder is emptied, and  the  catheter  left in  the urethra for the
 purpose  of  protecting this  canal from the edge of the knife, by pressing it
 toAvards  the right side.  The operator depresses the skin covering the pubis,
 so as to find the precise spot for cutting  down on the symphysis.  This
 being  done, an assistant stretches the skin  upward  as much as possible, and
 the surgeon then makes an  incision through  the  soft parts, commencing
 about half  an  inch  above the symphysis, and prolonging it downwards over
 the centre of the articulation, nearly to the clitoris, and terminating a little
 to the left;  the inter-pubic ligament is  then carefully incised, and, when it
 is nearly cut through, great precaution is requisite not to wound the bladder.
 As soon  as  the section is effected, a separation of the pubes follows ; Avhen, if
 the patient's strength is not exhausted, and the uterine pains are still strong
 and frequent, the further delivery is abandoned to nature;  but in the oppo-
 site case the forceps is applied, or the labor terminated by the pelvic version
 and by tractions on  the loAver extremities.   After the delivery is completed,
 the patient  is cleansed, and the  vessels tied, if any were divided; the pubic
 bones are draAvn together, and the lips of the Avound sustained by adhesive
 strips, charpie, and a compress, and the Avhole retained in situ by a bandage
 around the  body.   The  symptoms  subsequently manifested are to  be care-
 fully combated as they arise.  The perfect consolidation of the symphysis is
 seldom completed under three or four months, even  in  the most favorable
 cases, and instances have been knoAvn Avhere this never occurred, though the
 patients Avere ultimately enabled to  Avalk,  by the formation of  a cellulo-
 fibrous tissue;  Avhich, says  Alphonse Leroy, by filling up  the space in the
 symphysis, restores the solidity of the articulation.
  This process  is the one generally folloAved; but numerous modifications of
 it have been suggested, most of Avhich are  intended for the  better protection
 of the urethra; though none of them, hoAvever, are of much  value.  Attri-
 buting the consequences  that  folloAV in the train of symphyseotomy to the
exposure of the articular surfaces and the  lips of the womb to the external
air, M. Imbert, of Lyons, has proposed  the  division of the inter-pubic carti 
1030
OBSTETRICAL  OPERATIONS.
lage, Avithout involving the skin.   This procedure is feasible  enough; but,
in our estimation, it  can only obviate the smallest part of the consecutive
accidents ; for the various dangers to  Avhich the patient is then exposed, are
far less dependent on an inflammation of  the pubic symphysis than on the
disorders created by  the separation of the sacro-iliac articulations.
  These remarks apply Avith equal force to the division of the pubis, Avhich
Professor Stoltz advises to be performed by the subcutaneous me thud.  But,
after the  opinion I have  advanced with  regard  to  the  operation  itself, it
seems unnecessary to dilate on the different Avays  of performing it; I must,
hoAvever, describe that of the Strasbourg professor, for, although experience
has not decided on its relative merits,  yet it seems to offer the most favorable
chances.
  It consists in the division  of one of the pubic  bones near the symphysis,
by means of a chain-saw, Avithout incising the integuments.  The skin having
been previously shaved, a small opening is made on the mons veneris at the
point corresponding with the crest of the pubis, either on the right or left
side of the symphysis ; a long and  slightly  curved  needle, having the saAv
attached, is then entered at  this opening, and slipped along the  inner face
of the pubis, grazing the bone, and its point is brought out at the side of the
clitoris, betAveen the cavernous body and the descending branch of the pubis
from Avhich the latter arises.  The handle is next fitted on, and, taking the
saw by both extremities, it is moderately stretched between the tAvo hands,
and the pubis is cut through by a feAV strokes.  The divided portions of the
bone immediately separate, and  this separation can be increased almost at
will, or it maybe effected by the direct pressure of the child's head or trunk.
The  pubis  being divided, one of the  handles is removed, the  instrument is
withdrawn, and the  small opening Avhich is  left behind heals up Avithout
difficulty.
  But I repeat, that  the modifications suggested  by  Stoltz and Imbert still
require the sanction of a more extended experience.
                         CHAPTER  IX.

                   OF THE  CESAREAN OPERATION.

  Hysterotomy, or the Caesarean operation, consists of an incision through
the abbominal and uterine walls, for the purpose of extracting the child.
  This section  has been  recommended in cases Avhere a pregnant Avoman
died undelivered, long before it Avas resorted to on the living female; and it
can readily be traced  back to remote sources yvorthy of credit, Avithout con-
founding it Avith the mysteries of the poets, or Avith the marvels of antiquity.
Thus, Valerius Maximus speaks of the posthumous birth of the philosopher
Gorgias; and Pliny states  that the celebrated Scipio Africanus and Manilius
were saved under Numa's laAv, Avhich interdicted the interment of a Avoman,
big Avith  child,  until her belly was opened.  This Avise and prudent laAv  Avas
received  and adopted throughout Christendom,  and it still flourishes vigor*
rtusly in the Roman Church. 
CESAREAN  OPERATION.
1031
  The precise period at which the  operation Avas  first p irformed on the
living patient remains undetermined.  Mansfield, of BrunsAvick, endeavored
to discover indubitable traces of it in the Talmud;  but one of  his contem-
poraries has Avholly refuted such an opinion.  According to M. C. Lage, the
tirst authentic case Avas reported  by Nicolas de Falcon, in  1491; J. Nufer
performed it in 1500, as detailed by Gaspard Bauhin ; and F. Rousset pub-
lished a Avork in 1581, Avhich has since acquired considerable celebrity from
the great  number of cases it contains, all of Avhich were successful.
  The surgeons were so emboldened by Rousset's  monograph, that the
Caesarean operation was often resorted to Avithout any indication Avhatever,
and its popularity became so great at one time, that a contemporary Domi-
nican friar, Scipia Merunia, affirms that it Avas as common in  France as
blood-letting in Italy.  HoAvever, a reaction  soon took place; for Guille-
meau, Pare, Viard, and some other  prominent surgeons having failed in
their attempts, Marchant succeeded in stirring up his countrymen  against
Rousset,  by  founding  some virulent attacks on  these reverses;  and the
Caesarean section Avould have fallen  into oblivion, if Gaspard Bauhin had
not come  to its aid Avith fresh proofs in its favor.
  The interesting and delicate question of hysterotomy Avas again contested
during the whole of the seventeenth century,  and then, as in the preceding
one, its advantages and disadvantages Avere grossly exaggerated ; so that the
following  century arrived  Avithout any  clear  idea  having  been  formed
respecting the operation or its value, OAving to the total  Avant of probity and
justice in the examination of the facts of the case.  In 1749, Simon read a
remarkable memoir on this subject before the Royal Academy of Surgery ;
but  it Avas  characterized by credulity rather than  accuracy.   Since that
period, most of the Avorks on the Caesarean operation  have merely discussed
the indications for its  performance ; but not one of them unless it is Sacombe's
passionate and scandalous dissertation, has  attempted to prove the impossi-
bility of  its proving successful.  Although  the favorable are not very
numerous, yet there  are a feAV that may clearly be considered  as incontes-
table.  In our day, the field for  the Caesarean,  as  Avell  as  for all other
obstetrical operations, has been  limited ; but  this is rather  to be attributed
to the advance of science, and to the eminently practical spirit of the present
age.
  This operation maybe practised on the living female Avhenever the natural
passages through Avhich the child has to» pass are so narroAv, or so obstructed,
that a delivery by the application of the forceps, or  by symphyseotomy, is
Avholly impossible;  and Avhen the mutilation of the child  itself would not
permit its extraction  Avithout  exposing the  mother to the greatest  dangers.
It may likeAvise be resorted to for the purpose of saving the infant when the
patient dies in the advanced stages of  gestation.

  § 1. Cesarean Operation  on the Living Female.
  When practised on the living female, the Cesarean section constitutes one
of the most serious operations in surgery: for three-fourths of its unfortunate
victims have  perished.  This result,  which Wild probably be still  more
unfavorable if the same pains had been taken to bring before the public the 
1032
OBSTETRICAL  OPERATIONS.
unsuccessful, as have  been used to circulate the more fortunate cases, is,
indeed, calculated to alarm the surgeon Avho is obliged  to contemplate per
forming such an operation.
  All accoucheurs agree in the opinion that, when the smallest diameter of
the pelvis does not amount  to two and  a half inches, a delivery; by the
natural passages is  absolutely impossible;  and that we have  then only to
choose  between hysterotomy and a mutilation of  the foetus;  it Avas  stated,
however (page 646), that  M. Depaul mentions  tAvo  cases  in  Avhich  the
children Avere born alive  through a pelvis contracted to two and three six-
teenths  inches.
  Supposing the smallest  diameter measures tAvo and one-eighth inches, and
it has been positively determined that the child is still  alive (for the ques-
tion is no longer doubtful Avhen there is the least uncertainty on this point),
two different measures are presented for our  serious   consideration, namely,
embryotomy and the  Caesarean operation.  All  the French  accoucheurs,
including Dubois himself, are in favor of  the latter,  for he says, "The
Caesarean operation is our only resource, and,  therefore, it must be resorted
to."  (These, p. 71.)
  We are not ignorant of the importance of this question; and it requires a
settled  and positive conviction, on our part, to warrant us  in deciding it
differently from other French  authors ; but Ave are sustained by  the almost
unanimous opinion of the English practitioners, Avho believe that the child
ought to be sacrificed whenever the delivery can be effected by embryotomy.
Long ago, Ave strorigly expressed a desire (in the first edition of this Avork),
to see the views of our neighbors more generally disseminated in France, in
the folloAving Avords:  " And, as to ourselves, our voice will be against  the
Caesarean  operation in all  cases where  it is  not absolutely indispensable to
the mother's safety."  And Ave do not hesitate now to advance  the same
doctrine.  In fact, it cannot  be forgotten that this operation is nearly ahvays
fatal to  the female, even admitting that the statistical  tables exhibit the exact
truth.   For instance, laying aside the details contributed by the surgeons
of Great Britain, who are charged Avith the non-performance of the operation
at the opportune moment, and supposing that the unsuccessful cases have
been as  honestly reported  as the successful ones, an  impartial  examination
of all the facts leads to the melancholy conclusion, that nearly four-fifths of
the mothers have perished ;  (according to Keyser, the precise ratio of mor-
tality is seventy-nine per cent.)  The question then  recurs, does this  fright-
ful  operation save the child?  Or is it at all certain  that we can present to
the mother, as a compensation for all her sufferings,  something more  than a
lifeless corpse?   Unfortunately, this is not the case, and the partisans of the
Caesarean  section are constrained to acknowledge  that they are not always
fortunate  enough to  extract a living child, even when the operation is per-
formed  at the most favorable  moment.  But admitting for an instant that,
if resorted to immediately after the membranes are ruptured, the section
will ahvays save the child, still this, in my opinion, does not compensate for
the dangers to the mother.
  You confess that more than one-half of the females die, but can you aver
that more than a moiety of the children you  save by gastrotomy will live 
CESAREAN  OPERATION.
1033
 long enough to dry the tears shed over their birth?  Read the tables hith-
 erto published on the average pf human life, and then tell me Avhether fifty,
 out of a hundred living infants, attain their thirtieth year.1   Wherefore, it
 is not only the immediate effect of gastrotomy, but also its remote conse-
 quences that  are to be taken into consideration.   This at least is  certain.
 that you sacrifice more than half of the women immediately; and, even
 supposing that every child was  alive at the time of  its birth,  the experience
 of ages has proved, that you will not find one-half of them attain the age at
 which their mothers died.
   The advantage is, therefore, in  favor of embryotomy, when considered
 Avith regard to the mere question of figures.   But the feeble  and uncertain
 life of an infant, who is connected Avith the external Avorld only through its
 mother, avIio as yet has neither thought nor  affection, hope nor fear, can it
 be compared to that of a young Avoman associated with those around her by
 a thousand social and religious  ties ?  Or will the survival of this poor child
 fill up the void left by  the death of its mother ?  And, lastly, can society at
 large  ever hope to receive from  a new-born infant the duties it had a right to
 expect from the adult Avoman?   Hence, family ties and  social  interests all
 militate in favor of the mother.
   In a political, if not in a moral point of view, Ave are clearly justified, says
 Ramsbotham,  in preferring  the strong to the feeble, the sound man to a
 diseased one, and, consequently, the mother of a family to the still  unborn
 infant, Avhenever Ave are placed under  the cruel necessity of sacrificing the
 one or the other.   One  more argument yet  remains in favor of the view I
 adopt: the  most ancient of all the principles of morality, the foundation
 of all medical laAv — is, that we should treat our patients as we would treat
 ourselves or our dearest relatives ; now, Avhere is the physician Avho, if forced
 to decide under such circumstances between the life of his wife and  that of
 the child she still bears in her womb,  Avould hesitate to authorize the sacri-
 fice of the latter ?

   [We may conclude from what has just been  said, that embryotomy and not the
 Caesarean operation, ought to be performed Avhenever the pelvis is large enough to
 allow the cephalotribe to be introduced.  Therefore, notwithstanding M. P.  Dubois'
 authority, we think that the latter  instrument should be resorted to not merely in
 pelves  contracted to two and one  eighth inches, but also in pelves of two inches
 only.   Below two  inches,  the extraction of the mutilated foetus is so difficult, long,
 and painful,  that, besides the  necessary destruction of the child, the mother is
 exposed to great danger.  At this point therefore, there may be some hesitation as
 to the  choice between the Caesarean operation and embryotomy.   We would add,
 howeArer,  that M. Pajot regards cephalotripsy as preferable to the Caesarean opera-

  1 From the investigations of Villerm6, it appears that in France 20-100 of the inhabi-
 tants in the wealthy departments die at one year of  age, and 22-100 in the poor ones;
31-100 in the wealthy departments and 33-100 in the poor ones die  at four years of
age;  :;8-100 in the  former and 42-100 in the latter die at ten years;  and, finally, at
twenty years,  rather more  than  42-100 die  in the wealthy departments, and 49-100,
that is to say nearly one-half, in the poor ones.   Yet these figures  do not  include
children abandoned  by their parents, of whom, notwithstanding the zeal of public
eharity, at least C>0 out of every 100  die in Faris within the year.
  M. Yillrrme's researches are confirmed by those of M Benoiston, of Chateauneuf 
1034
OBSTETRICAL  OPERATIONS.
tion  not only in  a pelvis of two inches, but even in one of one and one eighth
inches, (see Embryotomy.)  Only below  the  last-named dimensions would  this
professor decide to perform hysterotomy.]

  This rigorous exclusion seems to us Avarranted by the facts Ave have  wit-
nessed and the record of results of operations performed in large cities,  and
especially in  great  hospitals.  It is thus  shown that the immense majority
of patients have perished; Ave have, however, to repeat, that for some years
past quite a  number of cases have been published by  honorable physicians
practising in the country or small towns, and that their aggregate results
would make  the  operation much less serious than when performed in large
cities.  This  fact ought evidently to be taken into consideration, and render
less warrantable  the preference we accord to  embryotomy in  the  case of
women  out of the  great  centres of population.  If indeed, it be true,  and
we think it is so because our confreres affirm it, that in the country three-
fourths and even four-fifths of the women who suffered the Caesarean opera-
tion recovered, Ave have no hesitation  in giving it the preference in country
practice, Avhilst maintaining our first conclusion in reference to its perform-
ance in large cities.
  The almost constant failure of the operation in large  cities, such as London
and Paris, as compared Avith the successes obtained in smaller localities, has
suggested to some  individuals the propriety of erecting a  hospital in the
country,  or at least of sending out of toAvn  such patients as it is supposed
will require the Caesarean operation.   This precaution is especially insisted
upon by M.  Guisard, who has just published  three neAV cases of success.
The idea could  not be carried  into  execution very easily, yet I think it
deserves  to be considered, and suggested to the proper authorities.  What
Ave have just stated in regard to the  difference in the results of operations
performed in town  and in the country, is calculated to make a strong im-
pression,  even upon minds  Avhich are  strongly opposed  to M.  Guisard's
proposition.  All Avho have had long experience of  the diseases of lying-in
women, are convinced that most of them originate in the assemblage of a large
number of newly-delivered patients in the same place; and this is especially
true as regards  those whose labors were  difficult, and required  a bloody
operation.   To increase the number of lying-in institutions, and to separate
the patients  as much as possible,  I regard as the surest means of  obtaining
an early convalescence.
   It  must not, hoAvever, be supposed  that by sending to some leagues' dis-
tance from Paris such deformed  yvomen as will require our care at term,
they will be placed in  as favorable  conditions as women who have ahvays
lived in  the  country.   The gravity of the operation is certainly influenced
by the locality in Avhich  it is performed, but so it  is  also by the  health of
the patient;  now we know that in this  respect there  is great difference be-
tween the Avomen of cities and those Avho have always resided in the country.
To afford them the best chance, therefore, these unfortunate persons ought
to  be placed in the best hygienic conditions for several months  before the
end of gestation.
   Supposing the necessity for operation has been fully determined, numerous
important questions arise for consideration, namely, what  is the most favor- 
CESAREAN  OPERATION.
1035
able stage of the labor for its performance?  Has the previous duration of
the labor any positive influence over the result ?  Aud is it better to operate
before or after the membranes are ruptured ?  An ansAver to all these ques-
tions will  be found in the careful examination of the published cases.
  A. Duration of Labor. — The Avhole duration of the labor has been noted
in one  hundred  and  sixty-four  cases;  in sixty-two  of Avhich the Avoman
recovered, and in one hundred  and  two she  was lost.   With  a vieAV of
shoAving the influence of duration as regards  the mother, Ave divide these
cases into three classes, namely :
  AVhere the operation was performed after the labor had lasted twenty-four hours,
    there were   .....    20 successful and 40 unsuccessful cases.
  From 25 to 72 hours, there Avere    .    34    "        21     "       "
  More than 72   "       "    .    .     8    "        21     "       "
                                     62             102
  From this  table, which  is taken from Keyser's excellent Avork, Ave may
conclude that the  duration of the labor Avould appear to have an unfavor-
able influence only when it has continued beyond seventy-two hours.
  But the same remark does not apply to the child; for, taking the same
one hundred and sixty-four cases, in a hundred and fifty-eight of Avhich the
infant's condition is reported, Ave find  that fifty-seven Avere still-born, and a
hundred and one survived;  and, adopting the same division, we have:
   After a duration of 24 hours,   .     42 successful and 16 unsuccessful cases.
   From        25 to 72  '•   .    .    48     "       24
   More than         72  "   .   .    11     "        17
                                   101              57
  Whence it follows that the chances  are less for a living child as the labor
is the more prolonged.
  B. Rupture of the  Membranes. — The time that elapsed after  the  mem-
branes Avere ruptured has been stated in one hundred and twelve cases.   We
shall  likewise classify these under three heads, according to Avhether the
operation was performed:
                                                         As regards the Mother.
                                                 Cases.
    1st.  Before or within 6 hours after the membranes
         were ruptured, .    .    .    .    .    . = 39
    2d. From 7 to 24 hours after the rupture,  .    . = 35
    3d. More than 24 hours after the rupture,  .    . = 38

                                                 112      47       65
  From Avhich it appears  that the operation is so much the more unfavor-
able for the mother as a greater time has elapsed after the rupture of the
membranes.
  The fate of the child is  known  in only one hundred and  six cases;  still
asing the same classification, we have:
  1st.  Before or within 6 hours after the rupture,
  2d.  From 7 to 24 hours after the rupture,  .
  3d.  More than 24 hours after the rupture,
Successful.	Unsuccessful.
20	19
14	21
13	25
Cases.	Successful.	Still-born
= 37	34	3
= 32	25	7
= 37	19	18
106      78      28 
1036
OBSTETRICAL  OPERATIONS.
  C. It is unne eessary to add that, with regard to the fcetus, the  prognosis
is much more unfavorable Avhen an artificial extraction has been attempted
before resorting to the Caesarean section.  Indeed, it must be evident, from
the foregoing facts, that the most favorable time for operating is either before
or immediately after the rupture of the membranes.
  Whenever we  have an opportunity of attending the patient during the
last few days of her pregnancy, it is advisable to prepare  her for the opera-
tion by a suitable regimen, such as tepid bathing, moderate blood-letting,
&c.   But Avhen the labor has actually commenced, the operation is  to be
proceeded Avith as soon as the os uteri is  sufficiently dilated  to permit the
subsequent discharge of the  lochia.  It has been recommended to  puncture
the membranes, lest the waters be effused  into the peritoneal  cavity;  but as
this accident can  very easily be prevented, and  as the distention of the Avomb
is favorable to the retraction of the organ after the operation, this ought not
to be done.   Just before  commencing, the bladder and  rectum are to  be
emptied.  Two bistouries, the one convex, the other having a  straight probe-
pointed blade, forceps, ligatures, cold and  tepid  Avater, a  little vinegar,
sponges, needles armed Avith thread, quill-barrels, strips of adhesive plaster,
some charpie, and compresses, and a  bandage for  the body, constitute the
necessary apparatus.
  The patient is  then laid on a bed of the proper height, and is held quiet
by the attendants; an intelligent assistant is charged Avith the duty of keep-
ing the womb on the median line by placing  his hands over it; and another
presses one hand over the fundus uteri, Avith a view of keeping up the intes-
tines, which are apt to become insinuated  between the  uterine and the ab-
dominal walls.  The surgeon then  makes  an  incision along the median line,
through the skin and subcutaneous fatty tissue, extending from a little below
the umbilicus, doAvmvards to Avithin an inch and a half or tAvo inches of the
pubis ; this incision ought to be at least five or six inches long, and provided
this extent is not obtained within the indicated  points, in consequence of the
Avoman's low stature, it should be prolonged a little upAvards  and to  the left
of the umbilicus.   The operator next divides the aponeurotic fibres of the
linea alba, layer by layer, and thus gets  to  the peritoneum, into Avhich he
then makes  a  small  opening; having inserted the index finger of  the left
hand into this, he directs the probe-pointed  bistoury along  its palmar face
and enlarges the incision. The tissue of the uterus is now carefully incised,
layer by layer, until  the surface  of the membranes or the placenta  is
brought into vieAV ; the bag of waters is then opened by a simple puncture,
and the probe-pointed bistoury is entered  at this orifice, and the incision en-
larged to the extent of five or six inches, directing it rather toAvard the
superior than the inferior angle of the external Avound.  The assistant, who
is charged  with the duty of keeping the  lips of the Avound  apart, must be
very careful  to hold the abdominal and uterine Avails  in  contact with each
other at the time  Avhen the membranes are ruptured.  The extraction of the
foetus is aftenvards accomplished by seizing hold of the first  extremity that
presents.  The uterus retracts immediately  and effects  the  detachment of
the placenta, Avhich is pished tOAvards the AA7ound ; it is then extracted  to
gether with the membranes,  Avhich have been carefully twisted into a cord 
CESAREAN  OPERATION.
1037
Lf any blood has escaped  into the uterine cavityr, it  is removed, as Avell as
any other foreign body that may obstruct the cervix.
  The Avound in the  uterus requires no other attention than that of being
well cleansed.  The lips of the one made through the abdominal Avails are
brought  together at two or three points by the tAvisted suture, taking care
to leave a free space towards its inferior part for the discharge of the fluids
that escape from the abdomen; strips  of adhesive plaster are used between
the points of the suture, over Avhich the uniting bandage is  then  applied;
some  modern surgeons use no sutures, relying Avholly upon uniting bandages
for keeping  the edges of the wound in apposition.  Thus  M. Lebleu (of
Dunkirk) first places beneath  the patient, and opposite the last dorsal and
lumbar vertebrae,  two narroAv body bandages Avith digitated  extremities.
Upon these, so as to come next to-the  skin, are laid tAvo  strips of adhesive
plaster, each four inches wide, but long enough to cross each other in front
of the incision.  Each strip is cut into three from its extremities for three-
fourths of its length.  After the operation, the ends of the  adhesive strips
are applied first to the skin, and  then, as they come near the wound, upon
tAvo thick graduated compresses  placed on each  side.  They are made to
cross  each other opposite the incision, leaving only a  small  open space
beloAV. Charpie, compresses, and the two body bandages complete the dress-
ing.  This arrangement seems to  me Avell adapted to the case.  The Avound
is next covered Avith charpie smeared Avith cerate, and common compresses,
and the whole retained in situ by a moderately drawn body bandage.  The
subsequent treatment is restricted to combating the inflammatory and other
symptoms as they  may arise.
   As one of the means best adapted  to prevent undue  inflammation, Dr.
Met/,  (of Aix-la-Chapelle) insists strongly upon the  use of cold.   As soon
as the patient is placed in bed, compresses saturated in cold water are ap-
plied  to the abdomen, and folloAved in a feAV hours by ice inclosed  in blad-
ders.   Injections  of  cold Avater  are  also  administered, and  the  patient
caused to SAvalloAV small fragments of ice.
   She is herself conscious, says M.  Metz,  of a degree of comfort, resulting
from  the action  of  the cold, Avhich is a sure guide to indicate the  point to
Avhich it  is best to  carry it.  The final  effect of the cold is the production of
discomfort, and  should the  use of it be continued, an  unfavorable  reaction
might result.  Should the cold injections or SAvallowing of ice bring on diar-
rhoea, thev must be stopped and replaced by enemata of starch and lauda-
num.   If, on the contrary, the injections do not soon produce stools, calomel
or castor-oil ought to be administered.
   The use of cold has never  seemed to interfere Avith the  regular  accom-
plishment of the puerperal functions.
   M.  Metz relates  eight  cases of his  own, shoAving  but one death.  Five
others, tAvo being furnished  by Dr. Vossen, one by Dr. Kesselkaul, and two
by Drs. Kilian and Gentz, also exhibit a favorable result.  We have there-
fore tAvelve cases of success out of thirteen  operations.
   For our oavii part, Ave are quite in favor  of adopting the plan of M. Metz,
inasmuch as  we  have tAvice seen neAvly delivered ladies apply in spite of us,
and without the  least inconvenience, cold compresses upon the abdomen and 
1038
OBSTETRICAL  OPERATIONS.
breasts.  We  are not, therefore,  alarmed  for the consequences  which, a
priori, we should have feared from the continued action of cold, yet we are
unable to think the  results obtained by M. Metz as encouraging as he be-
lieves them to  be.  Very probably the  future  will undeceive him  sadly.
Still, Ave have been impressed by the memoir of the Aix-la-Chapelle  physi-
cian, and do not hesitate to recommend a  method Avhich gave him such
results,  convinced as we  are that no serious objection applies to it.
  Several modifications  of the operation have been proposed, all of which
we think it  useless to mention, inasmuch as  the  success attributed  to them
Avas, I believe, owing much more to  the special conditions under which they
were performed than to  the more or less ingenious plans suggested by their
authors.
  There is  one,  hoAvever, Avhich deserves mention, if only  on account  of the
hopes which it  at first  awakened;  it consists in performing the operation
Avithout wounding the peritoneum,  and  is  done by making  an incision a
little above Poupart's  ligament and pushing  up the  peritoneum as for the
ligation of the external  iliac artery.  Through  the Avound thus  made, the
vagina is to be opened.  If the incision of the peritoneum  could be avoided,
effusions of  blood or of sanious or purulent  matter in  its cavity would not
take place, and  the patient be  protected from the  most efficient cause of
death.   This advantage is, unfortunately, so fully balanced by the difficul-
ties of the operation, by  the number of vessels  wounded, and by the inflam-
mations liable to folloAV the extensive separation of the peritoneum, that the
method is noAV entirely abandoned.
   Vaginal Cozsarean Operation. — This name is applied to the incisions Avhich
are sometimes made on the neck or other portion of the uterus that projects
into the vagina.  Having described the operation on page 698, Ave shall not
repeat it here.

  § 2.  Post-mortem  Cesarean  Operation.
  Whenever a physician is summoned to a pregnant Avoman  soon after her
death, he ought to perform it, after having carefully ascertained that the
death  is real;  because the child's decease does  not always precede that of
the mother, and numerous instances are recorded Avhere living  children have
been extracted ten or fifteen minutes, and even half an hour, after the Avoman
died.
  [M. Villeneuve (of Marseilles), in  a  paper published in 1862, reports a number
of cases in which it was certain that the children  had really survived.  Thus four
of them owed their lives to the performance of the  operation  immediately after the
mothers had expired.   Five others were extracted  alive after remaining  in the
uterus from ten minutes to half an hour subsequent to the mother's death.   After
half an hour, the cases  of success became very rare; but there Avere two after two
hours had elapsed, one after two hours and a half, one after three  hours, and one
after four hours and a half.  Although the operation is generally useless at a latei
moment, it ought nevertheless to be performed; because some cases, whose authen
ticity I cannot A-ouch for, would seem to prove  that the child's life may  remain
intact for ten, fifteen,  or even twenty-four hours.
  As it is the object of the Caesarean operation to  save the child's life, it were use-
less to undertake it before it becomes viable, that is to say, before the end of the 
CESAREAN  OPERATION".
1039
sixth month.   The only effect of an operation performed before this time would be
the satisfaction of some religious sentiment.   It ought to be done as soon as pos-
sible, because a few minutes are generally sufficient to terminate the child's life.
Very often, indeed, it succumbs before its mother, or at the same time with  her;
and the operator, after all his mental excitement, almost  always finds his hopes
fruitless.  On  this account,  M. Depaul thinks that auscultation of the fcetal  heart
should precede a decision to  perform the operation.  If it still pulsates, proceed as
rapidly as possible ; but if auscultation gives negative results, the operation Avould
be useless, says the Professor,  and ought to be abstained from.  It is true, that by
following this  advice the post-mortem Caesarean  operation Avould only be performed
under very favorable circumstances ; but then precious time is lost in the necessary
investigations, and the child may, in fact, be living although the  pulsations  of its
heart are not perceived ; so that there is a danger of abstaining without being posi-
tively certain that the child is dead.   It were much better, therefore,  to decide more
quickly than to incur the risk of extracting only a dead body from the cavity  of the
womb.
   I would, however, except those  cases in which the physician reaches the AAroman
as she  is about expiring, and  discovers, first, the normal action of the foetal heart,
and its cessation a few minutes later.  Here, the stethoscope has really been witness
to the death of the child, and I think the operation ought then to  be withheld.
   Before operating, the physician should, by every possible means, assure himself
that the woman  is really dead; inasmuch  as some cases haA'e shown  that this may
be only apparent.  It is always, therefore, a duty to make the incision of the abdom-
inal and uterine walls Avith  the same care as during life, and to empty the bladder
beforehand.   An assistant ought also to apply his hands upon the walls of the abdo-
men in order  to press back the intestines and prevent their exit; without this pre-
caution  the operation would almost certainly be impeded by the annoyance they
would give  to the surgeon.]

   Forcible  Delivery post mortem. — Should the female die during parturition,
he ought to examine the condition of  the genital  organs immediately; for
notAvithstanding the fact that the labor may have but recently commenced,
these  parts, from their diminished  resistance after death, have occasionally
permitted  the delivery of the  fcetus to be effected by the version  or the for-
ceps.   In  fact,  this latter  operation  would  be positively indicated if the
child's  head were  Ioav doAvn in  the excavation; because, in' such  cases, its
extraction  by the Caesarean section would  be rendered  extremely difficult,
if not impossible;  for numerous  recorded  instances have fully tested the
inefficiency of tractions made  on  the foetal trunk through the abdominal
incision.
   [Some cases, within a few years  past, have  even  shown that in the case of a
pregnant Avoman  deceased  before labor  commences, the  cervix may  be forcibly
dilated,  the hand passed into the womb, and the child turned and delivered.  The
fact is, that after death the  muscular fibres relax, and what would  have  been im-
possible Avith a living Avoman becomes  practicable  on the dead body;  still, this
method can  be expected to succeed in exceptional cases only, and even then through
the use of much force and the loss of time.
   Notwithstanding the undoubted advantage, says M. Perrin, which this mode of
delivery possesses as respects the  woman,  and although exempt from the inconven
iences inseparatle from the Oaesaroan operation, the two modes of effecting deliA'ery
admit of no  comparison as regards the great object in view, the rescue of the child,
whose life is  compromised  and about passing  away in its mother's womb.  The
Oiesarean operation enjoys, doubtless, considerable preeminence by the facility and 
1040
OBSTETRICAL  OPERATIONS.
promptness of its execution, and because it  spares the child, which does not incul
from it the slightest risk; whilst in forcible delivery, the manipulation required U
prepare the genital passages involves a loss of precious time, and the force applied
to  the  child either  by version or by the compression  and traction of the forceps,
may either actually kill it or extinguish the spark of life which remains.  (Perrin.
Report published in 1864.) ]
                           CHAPTER  X.
                            OF  EMBRYOTOMY.
  This name is applied to the operation by which the parts of the child are
divided so as  to  admit of their  successive extraction, Avhen it is impossible
to terminate  the delivery in  any other Avay.  In some cases it consists of
simple punctures or incisions  made on the head, chest, or abdomen, with a
vieAV of diminishing its size, Avhile in others the body of the child is divided
into several parts.
  It Avas elsewhere stated  that,  whenever a considerable quantity of Avater
had accumulated in the head,  chest, or belly, the fluid could easily be evacu-
ated by a simple  puncture Avith a  straight bistoury, or  still better by a
trocar; and,  therefore,  Ave need not recur  to the subject.  (See Hydroce-
phalus.)
  Embryotomy is indicated Avhenever there is any insurmountable obstacle
to the spontaneous expulsion  of the child, and where an application of the
forceps proves insufficient to  effect the delivery ; always supposing that the
foetus is dead, or there are good  reasons for  believing that  its viability is
destroyed  by the  length of  the  labor.   This operation  is  resorted to in
England much oftener than in France; for most of the accoucheurs of that
country proscribe the Caesarean  section and symphyseotomy, except in cases
of absolute necessity,  but  they  do  not  hesitate to mutilate the infant, even
Avhen it is still living; and the reader will  have seen, from the foregoing
chapters,  that we fully embrace the same opinion.
  [Embryotomy is not of recent  addition to  the obstetric art, for several passages
exist in Hippocrates relating to it;  but the process is undergoing constant improve-
ment, and  gradually assuming the character of a well-defined  surgical operation.
Embryotomy is performed in several ways, according to circumstances ; sometimes
being limited  to simple perforation of the cranium, to which operation the name
craniotomy is specially  applied ;  sometimes  the head is crushed by means of the
cephalotribe, and  the process is  called cephalotripsy; finally, division of the neck,
or of some portion of the trunk,  may have to be performed.  We  shall, therefore,
give an account,  in three successive articles, of: 1st,  Craniotomy; 2d, Cephalo-
tripsy ;  3d, Embryotomy by section of the neck or of the trunk of the child.

                              ARTICLE I.
                                CRANIOTOMY.
  Under the name of craniotomy have  often  been classed all operations of embry-
otomy which are  performed upon the  head of the child; we prefer,  hoAvever, to
reserve  this name for the simple perforation of the cranium, and  shall, therefore.
use it in this limited sense. 
EMBRYOTOMY.
1041
  Numerous instruments have been  invented for the perforation of the cranium,
but we shall describe only those which are best adapted to the purpose, and which
are the most generally employed.   In the first place, however, we would mention
Fio. 149.       Fig. 150.                             FW. 151.
Mode of introducing and using Smellie's scissors.
 the simple bistoury, which is in every surgeon's hands, at the same time remarking
 that it can rarely be used  except when the head is very low down and  the  fonta-
 nelles and sutures are easily accessible.  Its point Avould be almost sure to  break
 upon the first attempt to penetrate the bone with it, and it would  be very difficult
 to manage at the superior strait.   A common knife may, indeed, be substituted for
 the bistoury, but it would still be a very imperfect instrument, and every one knows
 how acrimoniously Sacombe accused Baudelocque of having used it.  The sharp point
 concealed in the end of one of the handles of the forceps1 would ansAver the purpose
 better, and in the absence of a special instrument may even be found very serviceable.
  Mauriceau sometimes used a hooked knife, with which he incised the head for the
 purpose of allowing the cerebral matter to escape, and  sometimes an  instrument
 shaped like a pike head, which was the original model of our best modern  perfo-
 rators.  Dunes' terebellum is a sort of conical screw, with a deep thread sharpened
 at the edge, excepting the largest turn, which  is left b^unt, in order to protect the
 mother's parts.  The inventor claims for  it the double office of a perforator and a
 traction instrument by which the head may be draAvn down.]

  The instrument  generally  used is that known as Smellie's scissors, Avhich
 is veryr strong, and has its cutting  edges externally; and, being  terminated
 by a sharp point, is admirably calculated for penetrating through the osseous
 vault; Avhen, by opening the handles, the original orifice is easily enlarged.
  M. Hippolyte Blot has latterly had a perforator constructed by M. Char-
 riere, Avhich, I  think, is destined  to  supersede Smellie's scissors, generally
made use of hitherto.  It possesses all the advantages of the  latter Avithout
its inconveniences
  1 Some of the French forceps are so constructed.  (S^e article Forceps.'—Translator.
       66 
1042
OBSTETRICAL  OPERATIONS.
  This craniotome is composed of two blades, which cover each other, so that
Avhen the instrument is closed, the blunt edge of one extends slightly beyond
the cutting edge of the other, and reciprocally.  (Fig. 152.)
  Each  free surface bears at its extremity A, a projection, which gives  to
the point of the instrument a quadrangular form (these projections are bor-
rowed from  the perforator of M. Marchand, of Charenton);  a screAV fixed
on the internal surface of the movable branch  d, enters a notch in the oppo-
site branch, and limits its motion in one direction, whilst the spring c, limits
it in the opposite one.
  The tAvo branches are articulated in  a manner peculiar to M  Charriere
(& tenon), and they are to be opened when the cranium has been penetrated.
         Figs. 152 and 153.                             Fio. 154.
    Fig. 152. Cephalotome closed.                Fig. 154. Cephalotorue incising the cranium.
    Fig. 153. Cephalotome opened.
  Before withdrawing the craniotome, it is allowed to close itself, after which
its extraction from the genital parts is unattended Avith danger either to the
vaginal'mucous membrane, or to the fingers of the operator.
  The principal advantages of this instrument may be summed up as follows:
  1. Great solidity and simplicity.
  2. Introductioi and withdrawal entirely safe, rendering it capable of being
used by the least sxperiencer1 operators.
 
EMBRYOTOMY.
1043
    3. Capability of acting by pressure, and that with a single hand, the other
 remaining at liberty to guide the instrument, keep it in its place, and know
 what becomes of it during the  operation.
    4. PoAver of perforating the bones with the least effort, and, consequently,
 with the least chance of slipping.
    5. It is  easily dismounted and cleaned.
    6. Finally, simplicity of structure, rendering it a cheaper instrument than
 Smellie's scissors, provided Avith their sheath.

    [The instrument commonly used in Germany for perforating the head, resembles
 a trephine  whose croAvn is concealed  in a tube which serves as a sheath.  Kilian's
 perforator is a good specimen of this kind of trephine.   The instrument is applied
 to the head of the child and held there firmly, whilst the revolution of the trepan
 carries it through the scalp and skull, a circular piece of which is removed.  The
 resulting Avound has the advantage  of being  regular, circular, free from spiculao
 which  might wound the vagina, and  so  open  as  to allow the  cerebral matter to
 escape freely.  The  construction of the  instrument is, however,  complicated and
 its application difficult.
   We prefer Blot's perforator to all others, and shall have it chiefly in view whilst
 describing  the operation for piercing the cranium.  After the woman is put in a
 convenient  position, the operator introduces  the fore and middle fingers of the left
 hand into the vagina, and passes them far through the uterine orifice, until they
 reach the head of the child,  Avhere he holds them as firmly as possible.   The right
 hand then grasps the instrument by its handle, and slips the point along the fingers
 of the left hand, which serves as a guide, to the head of the child (Fig. 154).  It is
 advised that a suture be sought for,  or, preferably, a fontanelle, Avhich would be
 more easily traversed than a bony plate ; but, in most cases, it is not  easy to follow the
 recommendation.  On the other hand, the greatest care should be taken to apply the
 instrument directly to the child's head, and  not to perforate  the. circumference
 of the mouth of the womb.  The scalp offers very little resistance,  though it should
 be borne in mind that it is often quite thick when an oedematous swelling happens
 to be hit upon.  As soon as the point of the  perforator comes in  contact with  the
 bones of the skull, it is to be rotated on its axis, at the same time making  strong
 pressure through the  handle, Avhen, shortly, the sensation of resistance  overcome,
 informs the operator that the instrument has passed through the bone.
   Craniotomy is sometimes  difficult on account of the mobility of the head, which
 recedes before the instrument.  When  this is the case, an assistant ought to make
 strong pressure Avith  his hands on the hypogastric region, in order to fix the head
 upon the  superior strait.  It is important also to  be  aware that  an  inadvertent
 moA'ement may cause the instrument  to slip and wound the  mother's parts.  To
 aA-oid this slipping, the perforator ought to be guided as far as possible in the direc-
 tion of  the axis of the superior strait, perpendicularly to the part of the head to be
 opened, and, preferably, too  far forward  to  too far behind.   The handle is to be
 held firmly by the  right  hand, whilst  the point, carefully supported by the tAvo
 fingers  of the  left  hand, is prevented from  swerving  in  any direction,  and from
 sliding  betAA'een the scalp and the bones of  the head.   It could  only be through
 singular and culpable negligence that the sacro-vertebral angle should be mistaken
 for the head, and the perforator  be implanted  upon it.   Without  anticipating an
 error of this kind, it would be well to  effect the perforation at a point rather near
 to the pubis, inasmuch  as, when the instrument is  passed too far back,  the point
 reaches the bones in an oblique direction, and slips more readily.
  When th? point of tlie perforator is within  the cranium, the entire  point  of the
lance is pushed in boldly ; then the movable handle is to be depressed in order to 
1044                  OBSTETRICAL  OPERATIONS.
 separate the blades, which are next to be moved in every direct /on, so as to treak
 up the brain throughout.  This act facilitates the issue of the cerebral matter, and
 by destroying the fcetus instantaneously,  spares  the accoucheur  the harrowing
 spectacle of a mutilated child still  breathing at its  birth.
   In order to withdraw the instrument, the two blades are allowed to come together,
 and  the lance-shaped head  soon re-enters the opening which  it made.  If  it be
 thought desirable to enlarge this opening, the movable handle is now again to be
 depressed, when the edge will cut widely  through both the bone  and the scalp.
 We ought to say, however, that  it is rarely necessary to do this, and that almost
 always the instrument is withdraAvn without enlarging the original puncture.   The
 abstraction of the instrument is immediately followed by a discharge of blood and
 cerebral matter.
   It is more difficult to perforate the cranium when the face presents,  but the same
 rules are to be followed  as in the  preceding case ; being careful, however, not to
 engage the perforator in the  bones  of the face, where it might get involved Avithout
 reaching the cavity of the skull.   When possible, the instrument should be passed
 through the forehead or  directed into the orbit, which serves as a sure guide.   If
 the lower part of the face only were accessible, and the mouth open, the palatine
 arch might be traversed  and  the cranium entered behind the nasal fossae, as I once
 saw done by Professor Dubois.  Lastly, in breech presentations, when the trunk is
 disengaged and the head retained by a contracted  pelvis, perforation  may be indi-
 cated ; to accomplish which, it is usual to apply the instrument to the occiput or to
 one of the parietal bones.
   Craniotomy has the advantage over almost all  the other operations, of being
 practicable when the mouth of the womb is  not fully dilated, for it may be under-
 taken when opened just  sufficiently to allow the instrument to pass.   Under these
 circumstances it would  be impossible to apply  the  forceps or  the cephalotribe.
 The advantage is here  invaluable ;  for it is well known that, in cases of deformed
 pelvis, the  orifice often dilates very slowly indeed.
   As a single  operation, craniotomy has much  to recommend it.  It allows  the
 discharge of cerebral matter;  the  cranium, being emptied under the uterine con-
 traction, is lessened in size and flattened, so  that it sometimes passes the contracted
 part without requiring any further  intervention.  To  facilitate the accomplishment
 of this result, after the perforation  is made,  water may be injected into the cavity
 of the  skull, bringing  aAvay in  its reflux  the greater part of the cerebral  sub-
 stance.  Although this injection was very  customary formerly, it is  now rarely
 done, because we have at hand powerful mechanical  means of crushing the head,
 should that be deemed necessary.
   Craniotomy is an extremely useful operation ; of itself, it fulfils all the indications
 in a certain number of cases, provided we  are willing to Avait  patiently until the
 head is emptied and moulded to the form of the contracted part.  Often, however,
 it is,  alone, insufficient, because the reduction of size of the  cephalic extremity
 affects, for  the most part, the vault of the cranium only; leaving its  base, which
 is more thoroughly ossified and thicker, with its normal dimensions.  AVe would
 also add, that the expulsion of the  fcetus can be accomplished only Avhen the con-
tractions are powerful, and  then  after a long  time.   Under these circumstances,
therefore,  it often  becomes necessary to  extract  the  head, for which  purpose  the
whole array of  crotchets, tractors, and bone forceps have been devised.
  Of all these latter instruments, the most dangerous was the crotchet, and its  use
has been very properly abandoned.  It was sometimes fixed upon the external parts
of the cranium, and sometimes carried within it through the opening made by  the
perforator.   Its point was then directed  to  the part upon which it was desired to
fix it, getting as near as possible to the base of the skull;  the occipital bone, mas-
toid processes, the sphenoid and petrous portion of the temporal, giving it a suff.- 
EMBRYOTOMY.                         1045
ciently scare hold.  Being satisfied  that it was  firmly attached, tractions  were
made in the direction of the pelvic axis ; but  notwithstanding every precaution,
and the skill of the operator, the instrument would often  slip and Avound severely
the maternal organs.   It ought now, therefore,  to be entirely laid aside.
  Tractors and bone  forceps are advantageously substituted by the cephalotribe,
so that when craniotomy has been  performed, cephalotripsy is  had recourse  to in
the majority of cases, provided the mouth of the womb is sufficiently dilated to
allow the operation to be performed.

                               ARTICLE  II.
                                CEPHALOTRIPSY.
   Cephalotripsy, also called cephalothalsia, is an operation having for its object the
crushing of the head  of the foetus, in order to render it possible to extract it.   Not-
withstanding some scattered passages which show that the idea of crushing the
fcetal head had been entertained long since, the operation is of recent date.   The
conception could indeed hardly have been realized  until after the forceps had been
invented, because  by making the blades of this  instrument stronger and closing ita
handles with power,  the head  may be reduced  in size and even  partly crushed;
in fact, the forceps of Coutouly, Assalini, Delepech, and  Lauverjat acted in this
way. Nevertheless the forceps, even Avhen its handles were approximated by means
of a screw, could be nothing more than a very imperfect crushing instrument.
   It was  necessary, therefore,  to contrive a special apparatus for the purpose, and
this was done by A. Baudelocque, nephew  of the celebrated accoucheur of the
same name.  He  gave the first  account of his instrument in 1829  and used it
Bhortly afterwards successfully in the  case of a woman whose pelvis Avas contracted
to three inches in  its antero-posterior diameter.]

   The honor of its  invention, notwithstanding  several  rival claims, is due to
M. A. Baudelocque.  It  is composed of tAvo long branches, the blades of
Fio. 155.                         Fia. 156.
The ombryi tomy or cephalotribe forceps.
comparison of these two figures will furnish an idea of the amount of separation obtained at the boat
                of the blades (Fig. 156), by means of the regulating screw. 
1046
OBSTETRICAL  OPERATIONS.
which are devoid of fenestra, and, besides, are far less curved than those of
the ordinary forceps, so that, when closed, they can  pass through a diameter
not exceeding  two inches.  The two branches articulate with each other
near the middle, and Avhen they are  joined, the  blades can be tightened at
pleasure, by means of  a screw passing through the ends of the handles, and
worked by a powerful lever.
  Even as  it is  now  constructed,  Baudelocque's  embryotomy forceps  is
certainly a very useful instrument;  but as I have elseAvhere proved (Revue
Medicate, May, 1843),  it presents some disadvantages Avhich  render its ap-
plication difficult and often even dangerous. For instance: 1. It is too straight
to accommodate itself to the curvature  of the pelvis, and it is  therefore
applied Avith difficulty  to the sides of the head.   2. As the  clams are nearly
plane, they open like a pair of  scissors, and do not incase the head, as the
concave blades of the ordinary forceps do; consequently, they are liable to
slip, and thus  give rise  to  serious accidents.  3. Tractions made by it are
very often ineffectual,  even  when Avell applied to the head; because it ne-
cessarily draws in a direction different from the axis of the superior strait,
OAving to the absence of curvatures in the edges of  its blades.
  As the  difficulties and dangers attending its use  are not imaginary, I
have endeavored to  prevent them, by suggesting a modification in the em-
bryotomy forceps generally employed, although Avell  convinced that the
failure of  an operation is very frequently more dependent on the operator
himself than on his  instrument.  With  this vieAV,  I  had an instrument
made by M. Charriere, which differs in two important  particulars from those
hitherto constructed, and which  seems to obviate the various disadvantages
I have just enumerated.
  We  stated above that  the  absence of  curvature in the edges  interfered
very seriously with the seizure of the head, which is found more  anteriorly
than in well-formed  pelves,  both in  consequence of the  pelvic contracti u

                                 Fig. 157.
The embryotomy forceps applied and locked.
and  its own elevation; hence, Ave  have given a  curvature to  our forceps
slightly exceeding that of Levret's.  This, however/did not require a great
effort of the imagination,  for we have only impressed the same modification 
EMBRYOTOMY.
1017
of the embryotomy forceps that Smellie and Levret long since gave to the
one invented by the Chamberlens.  This curvature is intended to fulfil the
indication of accommodating the shape of the  instrument to  that  of the
curved canal it has to traverse.
   The slipping of the head during the tractions is principally OAving to the
fact, as averred above, that the blades, from  being nearly plane on their
internal surface, do not properly embrace this  part, and that, opening like
a pair of scissors, their yvidest separation is  found at the points.  Here the
difficulty yvas considerably greater, because the internal  surface of the
clams could not be hollowed out without greatly increasing the interval  at
their middle part, and, consequently, Avithout rendering the instrument in-
applicable  to  a host of cases where Baudelocque's  might  be  successfully
used.  After mature reflection, we  propose  the  folloAving as its second and
most important modification:  namely, to make a much Avider entablature
at the joint; while, in other respects, the length and Avidth of our forceps
correspond Avith Baudelocque's.   This increased Avidth at the  articular part
permits the base of the blades  to be removed from each other laterally by
means of a regulating screAV, that can be turned at will;  the point of which,
by Avorking on the pivot, will  permit a greater separation at the base than
at the points  of the blades.   Hence, it  is  evident that Avhen  the head is
once embraced by the instrument, it cannot slip from  the extremity  of the
clams during the tractions, because  the interval is much less here than  at
the base  or even than at their middle part.   In a word, the embryotomy
forceps hitherto employed  resembles a cone Avhen half opened,  the base of
Avhich is at the points of the blades, and  the apex at the articulation; but
ours,  on  the  contrary, may, under the  same conditions, be compared to a
cone having its base at the articular part, and its summit at  the extremity
of the blades.
   [The handle at the end of Baudelocque's cephalotribe was powerful but awkward,
besides requiring considerable time for the screwing up and unscrewing ;  some-
times, also, it struck against  the limbs of the patient, so that on all these accounts
it became  desirable  to substitute some better arrangement for it.  In M. Chailly's
instrument,  the handle was  replaced by a strap which wound around  a metallic
axle.  Beside this improvement,  its edges were sufficiently curved to correspond to
the axis of the pelvis.   In order to preA'ent  slipping, the ends of the blades were
bent in such a way that one overlapped the other, the  included part being thus
grasped in a manner which makes  escape impossible.
  Prof. Depaul's cephalotribe has at the ends of the blades two  hooks, projecting
slightly from the internal surface, which implant themselves in the  head Avhen the
instrument is closed, and thus render slipping difficult.  Instead of the crank for
closing the  blades, there is  a Vaucanson chain stretched  transversely from one
handle to the other,  which is put in motion by a key and pinion.   The branches
are kept together by means of a ratchet.  The manner of Avorking it  is very simple:
the instrument being applied, the chain is passed through the opening in the end
of each handle ; then the key  is applied  and turned until the blades  are sufficiently
approximated, after Avhich the extraction is proceeded Avith.  To detach the instru-
ment, it is  only necessary to raise the ratchet, when  the chain instantly becomes
free, and is removed very quickly.
 M. 11. Blot invented an  instrument whose  branches  are brought together by
means of a removable screw which may be attached at will on the  end of the left 
1048                 OBSTETRICAL  OPERATIONS.
handle, and then  pushed through a bifurcation of the right handle.  Tht handles
are then approximated by a nut which traverses the screw.
  In Locarelli's cephalotribe the handles are brought together by a screw which
passes freely through an opening at the end of the right handle, and then enters a
nut made in halves and hinged, placed at the end of the left handle.  When it is
wished to disconnect the instrument, the  hinged nut is opened and the  i?crew is
immediately free.  This instrument allows the two branches to be brought together
and  separated  more rapidly than any other.  The right branch  of  Locarelli's
cephalotribe is, besides, very slightly curved, to allow of its application  behind  the
pubis, the other branch being applied behind.  The head  of the child is thus com-
pressed from before backward  in the direction of the antero-posterior diameter,
which is almost always contracted.
  The cephalotribes most used in Germany  are  those of  Hiiter, Scanzoni, and
Braun, whose chief peculiarity consists in the effecting of the compression  by
means of an endless screw between the branches of the instrument and  parallel to
it.  The handles  are embraced by a metallic ring, as may be seen on certain pin-
cers used by mechanics, and the screw, by moving the ring up or down, separates
or closes the handles as desired.
  It is not  our intention to treat here of every case to which cephalotripsy is appli-
cable, whether the necessity for it depends upon the mother or upon the child; but
we shall undertake to examine the consequences of the application of the cephalo-
tribe  upon the head of the fcetus.   As a compressing and crushing instrument,  the
cephalotribe possesses considerable power ; and there can be no doubt that the head
is broken up by it with great ease, regardless of the direction in wrhich it is seized;
but whilst it is flattened in the direction of one of its diameters, the others are sen-
sibly  lengthened,  which is a fact Avorthy of attention.  The experiments of Ilersent,
who wrote  a very interesting  paper on  this subject, show that all the diameters
except the one included between the blades of the forceps are lengthened,  on  an
average, about seven sixteenths of an inch, Avhen the cephalotribe is applied, with-
out the previous performance of craniotomy.  In a second set of experiments  the
cephalotribe Avas  used after opening the cranium, Avhen the same increase of all  the
other diameters than the one seized was again observed ; but in the latter case,  the
increase, instead  of being seA'en sixteenths of an inch, did not average  more than
from  one sixteenth to three  sixteenths of an inch.   These experiments will  not be
lost sight of when we come to consider whether it will be worth while or  not first
to perform  craniotomy Avhen the use of the cephalotribe is decided upon.
   The crushing of the vault of the cranium only would not be sufficient in many
cases of extremely contracted pelvis, and amongst the various objections made to
cephalotripsy it has  been questioned whether the base of the skull was ever really
broken up  by that operation.  It is evident that the effects will vary according to
the manner in which the  head is seized, but Ave are able to assert that the base of
the skull is often  really broken up.   There can be no doubt that this was the case
with  two heads upon Avhich we ourselves performed the operation, and which  are
now in the obstetrical  museum founded  by Prof. Depaul at the hospital  of  the
Clinique.   We would add, that on more than one occasion we crushed not only  the
base of the skull,  but even several of the first cervical vertebrae.
   The compression  and crushing of the head, although  considerable, still haA'e
limits which it is well to be acquainted with before undertaking the operation.   It
is well known that deformities of the pelvis, in consequence of the absolute impedi-
ment which they  present to the expulsion of the foetus, afford the most  positive as
well as the  most  frequent indication for the performance  of cephalotripsy;  but it
ou°"ht to be equally well known that beyond a certain point the contraction of  the
pelvis' itself makes  the operation difficult, or may even render it impossible.  The
foregoing considerations are the  Tore opportune as the advantages and innoeency 
EMBRYOTOMY.
1049
of the cephalotribe f »rceps have been generally overrated in the acceptaLce of the
inventor's claim that it might always be efficiently and easily applied, provided the
sacro-pubic diameter would measure more than one inch and eleA'en-sixteenths of an
inch in length.  Hersent, on the other hand, as the result of his experiments on
the dead body,  fixed the extreme limit at two and a half inches, and Avhen the con-
traction was  greater than this, did not believe that  cephalotripsy could  be per-
formed successfully  unless the child was very  imperfectly developed.  Experience
has proved this idea to be erroneous, and  most accoucheurs unite in the belief that
unless the child be very large,  success may be looked for in a pelvis which mea-
sures no more than two inches in its antero posterior diameter.  Still it should be
well understood that a contraction so great as this renders the manipulation of the
instrument very troublesome, whilst the operation  is long and difficult and the risk
to the patient very great.  Ought it therefore  to be decided that under two inches
cephalotripsy is so serious an undertaking that the Csesarean operation should be
preferred to it?   Prof. Pajot protested against this opinion, and, undeterred by the
difficulties, declares  in a  paper published  in  the Archives Generates de Medecine,
that he considers cephalotripsy as  proper  not  only in a  pelvis of two inches, but
even in one of one inch and one-eighth of an inch,  and admits of no limit save that
which renders impossible  the introduction of the instrument.
  But we ought to add that a favorable result under these circumstances would be
impossible Avere it expected to  extract the head betAveen the blades of the forceps;
M.  Pajot, therefore, after crushing the skull, unlocks the instrument and withdraws
the branches separately without making any traction, leaving it to the uterus to
mould the head upon the  contracted part and  effect its expulsion.
  M. Jacquemier had already examined this side of the question when he Avrote as
follows : " The  agency of the cephalotribe forceps is rather one of compression than
of extraction.  In many cases, it is capable of crushing the head when it Avill be
incapable of  dragging it through  the  contraction.  Still, under the latter  circum-
stances it may prove of great service, and  either attain or powerfully concur to the
attainment of the end proposed.  For when the instrument is withdraAvn, the head
is really supple, plastic, entirely reducible  in every direction^ which is a condition
completely at variance with that which it has when still retained within the jaAvs of
the closed instrument, a fact to Avhich  sufficient attention has  not been paid.   If
left to the expulsive efforts of the Avomb, it may still be  able  to pass the obstacle
after becoming moulded  to the form of the pelvis ;  extended where the latter is
larger, and flattened where it affords the least space."
  The cephalotribe maybe applied at once upon the head without previous perfora-
tion.   The head is then crushed, and the cerebral matter is forced from the cavity
of the cranium  under the scalp, when the latter remains intact, or escapes altogether
when it happens to tear.  At other times  the brain finds exit through the orbits,
the nostrils, or the mouth.  Baudelocque thought  this kind of evacuation was all
that Avas necessary, and even regarded the preservation of the integrity of the scalp
as one of the advantages of his method.  What we have said of Hersent's experi-
ments shows  that the reduction of the size of the head is greater Avhen the cranium
is perforated  before the crushing;  therefore craniotomy is noAV almost always per
formed before using the cephalotribe;  and as  it is certainly the preferable course,
we  do not hesitate to advise  it.  It is true that it has been charged with favor-
ing the formation and projection  of splinters of bone, Avhose  points are liable to
lacerate the  maternal tissues ; but are not these splinters as liable to be formed
when the head is crushed without previous perforation?  We have already wit-
nessed a great number of  cephalotripsies, and observed  how very rarely this incon-
venience occiirre 1.   The  matter has made an undue impression, and the argument
draAvn from  the  .production of  spiculas seems to  us  far more availing  in  theory
than itf practice, The fact is, that the wound made  by the perforator is almost 
1050
OBSTETRICAL  OPERATIOl "S.
always included between the blades  of the instrument, which shield the vagina
whose  walls they keep apart; so that if projecting points of bone were detected,
nothing Avould be more easy than to  remove them, either with the hand or strong
pincers, before making any attempt at extraction.
  Therefore, except under peculiar circumstances, the cranium should be perforated,
after which cephalotripsy should be performed under the same conditions and with
the same preparations as required by an application of  the common forceps at the
superior strait.  The rules which should  guide the surgeon in the introduction of
the cephalotribe are precisely those  prescribed for the  forceps;  therefore, the in-
strument should be warmed, greased,  and each  branch held and  introduced like a
branch of the forceps, in order to be placed on the sides of the superior strait with-
out regard to the direction  in which  the head will be seized.  In this application,
however, difficulties must be expected to be met with, due  to the  faulty conforma-
tion of the pelvis ;  the blades are liable to be turned aside and  are  sometimes
twisted around so as to bring the concave  surface outside.  Very often, long con-
tinued trials are required before they can be placed regularly in position.  No force
ought ever to be used, for, as the instrument is heavy and  its end quite narrow,
though rounded, the uterus might easily be torn  by any sudden  movement.  The
first branch is generally pretty easily applied; there is more trouble in finding a
passage for the second, and it is sometimes necessary to Avithdraw the first branch,
and invert the order of introduction.  When the head is firmly pressed down upon
the superior strait, a free space should be sought for through which to slip the end
of the instrument.  Generally, however, the head is movable and recedes before the
blades, which  fail to grasp  it unless care be taken to hold the head motionless by
an assistant, who does  so by making strong pressure with  his hands on the hypo-
gastric region.  At other times, the permanent contraction of the uterus upon the
head occasions another kind of difficulty.  To overcome them all, the best plan is
to introduce as far as possible the hand which serves to guide the blade, and then,
in order to avoid unnecessary suffering to the woman, the second  blade can be slid
along the same hand.   This was Hatin's plan and is recommended by Chailly; we
think it a good one in some cases, although we would not make it  an ordinary rule.
   The very first thing to be done is to grasp the head firmly and to crush its base
if possible ;  but to effect this the instrument must be made to enter very deeply,
lest a. portion only of the head be seized and the crushing be imperfect.  Almost all
authors recommend, besides, that the handles of the cephalotribe be pressed very far
back against the perineum, in order that the blades shall have a forward direction,
because,  as is well known, in deformed pelves the sacro-vertebral angle projects and
presses the  head toward and against the pubis.   This counsel  ought  not, in my
opinion, to be  too strongly  urged, for I think I have observed that Avhen too closely
followed, the vault only of  the  cranium has been crushed.   I explain this failure
by supposing  that in most strongly marked cases of contracted pelvis the fcetus is
often doubled  up in such a way that the craniai vault corresponds with the anterior
abdominal wall, whilst the  base and neck look backward toAvard the sacro-vertebral
angle.  ' Therefore, in practising cephalotripsy,  after having  passed the  blades  in
very deeply, I have no objection  to their remaining near  the promontory ;  in  so
doing I have often succeeded in crushing the base of the  skull  and first cervical
vertebrae at  the very first attempt.  Still, it were not -easonable  to lay down posi-
tive rul3« in regard to this  point,  because the foetus is  ot always  similarly situated
in reference to the circumference  of the pelvis.
   The cephalotribe is locked in the same way as the Creeps, and  the same  difficul-
ties in doing it are liable to be  met Avith.   The  crushing is next proceeded with by
turning the  handle, chain, strap, or screw, by which the  arms of the instrument are
brought  together.   This stage of the operation ought  to be executed slowly and
gradually, in order to force out +he cerebral matter, without lacerating the scalp, 
EMBRYOTOMY.
1051
and causing the projection of spiculae of bone through the points of ruptaie.   The
operator knows that the head has been well seized and emptied of its contents as
far as possible, by observing the free discharge of brain externally.  The degree of
approximation of the  handles also indicates the amount, of flattening of the skull,
and he often hears, or Avhat is  still  more  significant, feels, the crepitation Avhich
declares the crushing of the bones.  Difficulty is liable to occur from the mobility
of the head, which evades the instrument by rising above it or escaping before or
behind the  blades.   The head, unfortunately, slips easily from the  grasp of the
instrument on account of the narroAvness of its blades and their being so slightly
curved upon the flat;  on this account, M. Chailly recommends that after perfora-
tion the excerebration be performed by a forceps which fits better the rounded form
of the head than  the cephalotribe; the latter  instrument being only used upon an
already flattened  head.  The plan,  however, is objectionable on  account.of the
greater number of manipulations required.
  When the head is grasped at last, the cephalotribe is to be closed as far as possible
before proceeding to extraction; slipping is indicated by the great facility with Avhich
the  handles can be brought  together or the instrument withdrawn ; in AA'hich  case
there is nothing to be done but to make a new attempt after changing the direction
of the blades.
  When the head is crushed, which  will  be knoAvn by the degree of closure of the
handles, which ought to be  almost in  contact, the state  of  the parts ought to be
carefully ascertained, and if any spiculoe  project remove them.   A  few tractions
will next show whether the  head is securely held, and if so,  the delivery will be
proceeded with by drawing gently.  Here it must be  remembered, that although
the  head is flattened between the two blades, its other diameters are lengthened;
and  as the cephalotribe is almost  always applied to the  two extremities of the
transverse  diameter,  the  elongation 'takes place from  before backAvard,  that is,
from the pubis to the sacro-vertebral angle, making it almost impossible to bring
the  head down into the pelvis  without changing its  position.  To do this, the in-
strument is gently turned round far enough to bring the lengthened  diameter of
the  head into correspondence with the oblique diameter of the pelvis ; but it would
be better still to turn it further until it has gone one-fourth  around upon  its axis,
since in this position the flattened part of the head corresponds Avith the sacro-pubic
diameter, which is almost always short, and the  lengthened diameter to the trans-
verse one of the pelvis, which is generally wide enough to allow it to pass without
difficulty.
  In the majority of cases, moderate tractions only are required to bring the head
into  the  excavation.   It ought then to  be again turned, so as to bring its  long
diameter in an antero-posterior direction, and the two blades are drawn out  in
correspondence Avith the tAvo ischio-pubic rami.  Should difficulty be encountered,
a feAV trials will soon indicate the best direction to be given them.
  If the  head is very firmly grasped, its  size  lessens during the  tractions, and it
moulds  itself, so to speak, upon  the shape of the contracted  part;  but, unfortu-
nately, the instrument is  not ahvays well applied, or the stricture is considerable,
so that in spite of the utmost care the cephalotribe loses its hold and slips upon the
head.  The tractions  ought  then to cease at once ; otherwise there would be danger
of tearing  the scalp,  and the  instrument should be  unlocked  and withdrawn.
Under these circumstances the expulsion of the child might, it is true, be left to
the efforts of nature,  but we think it preferable to proceed  at once to  a second or
even third  application in order to crush  the head completely.  Therefore, the in-
strument ought to be reintroduced Avith  all the precautions which we have given.
Still greater care, indeed, should be used ; the hand must be introduced very deeply
in order to  guide the blades, whose ends  often come in contact Avith  the inequalities
of the head or foldings of the scalp  produced by the first operation.  It should be 
1052
OBSTETRICAL  OPERATIONS.
attempted, also, to seize the head in a new position in order to crush it, so to sptak,
in every direction.  The unfortunate tendency of the instrument  to get into the
groove which it made the first time, is one of the greatest difficulties to be contended
with.  These successive crushings followed by tractions, constitute the usual method
of performing cephalotripsy as we have almost always seen it done by Prof. Dubois,
and is the out preferred by M. Chailly and described by him in his book.
  It does  not appear to us that moderate tractions, even though they may be kept
up, are likely to be injurious;  contusion of the parts being no more liable to occur
than when the head is impelled  by powerful contractions of the  uterus.  Spiculoa
are not often formed, and if they should  be, care will be taken to remove them.
The plan of successive applications and  tractions is, Ave think, a good  one, and
that which we prefer.
  But what is to be done when several applications of the instrument have failed.
to remove the head?   We think that it would be imprudent to repeat the attempts
more  than three or four times, and if unsuccessful, the woman should be allowed
to rest for several hours.  The operation, in fact, ought to  be resumed  as often as
required, without being continued-too long  at a time.  Whilst the patient is rest-
ing, the uterus contracts,  the head  adapts itself to  the opening of the pelvis, and a
subsequent attempt is often more successful than it would have been a few  hours
previously.   This mode of proceeding was  characteristic of M. Dubois'  practice,
and was, so to speak, the secret of his great success.  Herein cephalotripsy is com-
parable  to lithotrity,  successive  operations being less dangerous than  long-con-
tinued efforts.
   Cephalotripsy, as  just described, has become an every-day practice.   M. Pajot
asserts  that  it is a  good one, and of undoubted service  in cases of moderate con-
traction ; but, says he, in extreme  cases, such as range from two and five-eighths
inches to an  inch and one-eighth, the  operation  is unanimously  conceded  to  be
extremely dangerous; so  much so that  it may be said, with considerable justice, to
be quite as hazardous to the mother as the Caesarean operation, and that without
the compensation offered by the latter, of the  possible and sometimes probable pre-
 serA'ation of the life of the child.  Below two and five-eighths  inches, M. Pajot
thinks it dangerous  to make traction, and would have the operation repeated Avith-
 out it.   As  in  cases of extreme  contraction it is impossible  to deliver  the fcetus
 without mutilating  it, perforation  will  be performed as  soon as possible, in order
 to favor the dilatation of the orifice, and the cephalotribe  will be applied as soon as
 the dilatation is sufficient  to allow  it to be introduced.  M. Pajot describes  his
 method of performing the operation as follows:—
   " The first crushing having been executed with the necessary care, and the head
 being firmly held, I attempt, Avith great caution, to rotate the instrument so as to
 make the reduced dimensions of the head correspond Avith the contracted  diameters
 of the  pelvis.   I try then very  gently to turn it either to the right or left, as may
 be most easy, and if considerably resisted  on either side, I abstain from any fur-
 ther effort.  Formerly, I was more persevering, but experience has taught me that
 the Avomb almost universally succeeds, and  often very shortly, in moulding the new
 form given to the head by crushing, to the shape of the canal, at the  same time
 imparting to it the movement of rotation performed Avith such difficulty by  tho
 instrument, the effect of the  contraction of the womb upon the entire bulk of  the
 fcetus being to  turn it more certainly and Avith less danger than the cephalotrioe
  would do.  When the head is crushed  as much as it can be,  I unscrew the instru-
  ment, unlock it, withdraw it  gently, without having exercised the least traction,  and
  immediately proceed to a second, and, if the  case requires  it, a  third crushing
  without any traction.   The woman is then  put to bed, and a light broth prescribed
  for her.  According to the state of the patient's pulse, the general appearance,  her
  quiet or excitement, as  also the weakness or strength  of the contractions of th« 
EMBRYOTOMY.
1053
womb, I would repeat the crushing operation every two, three, or four hou -s. allow-
ing two or three introductions of the instrument for each time. When called early,
I have  not yet had occasion  to exceed  four of the stages, whilst one or two have
sometimes been sufficient.  The head having been thus  repeatedly crushed, the
body generally presents difficulties which one or  two crushings usually suffice to
overcome.  Such is the method which I have termed ' Repeated Cephalotripsy with-
out Traction.'"
  Whatever plan be pursued, when the head has cleared the vulva, slight tractions
are usually sufficient to effect the delivery of the trunk : the latter, however, some-
times resists, and the crushed head affords  a very insecure hold, so that it is often
found useful to tie a fillet around the neck,  and endeavor to bring doAvn the arms,
as much for the purpose of lessening the size of the shoulders as with the object of
using them  for purposes of traction.  When all these manipulations have failed,
the cephalotribe  is again  inserted, in order to crush the chest, and it rarely hap-
pens that one or two applications do not effect the desired result.
   The difficulty caused by the trunk, therefore, is rarely  so great that it cannot be
overcome; but in spite of all that can be done, it is sometimes impossible to ex-
tract the head; and then the AA'omen either die undelivered, or are delivered  by a
resort to turning.  These  last facts are  certainly worthy of meditation, and  haA'e
recently been commented on by my friend,  Dr. Bertin, in his inaugural thesis, of
which I have some knowledge.  Dr. Bertin thinks that moderate tractions  only
ought to be made with the cephalotribe, and should  the  head not come down, he
proposes  to go after the feet  and effect delivery by pelvic version.   Under these
circumstances, the latter operation has undoubted advantages, which are recapitu-
lated as follows  in the thesis Avhich I have mentioned:  " When the  head is once
crushed, as it is  possible to do by one or two applications, provided the blades of
the instrument are properly placed, and especially passed high enough, all those
dangers will be avoided Avhich result from the too frequent introduction of an iron
instrument into organs which are congested and  often in a state bordering on  in-
flammation.   There is no  cause for apprehending those disorders Avhich are  liable
to be caused by  the contusion of soft parts pressed between the subjacent  bony
canal, and the debris of the  skull, notAvithstanding  the  integuments which coA'er
them.  To extract the child, it is  necessary to get a firm hold of the lower limbs,
which may enable us to guide it  more readily through the  contracted pelvis, and
bring its longer  diameters into correspondence with the longer diameters of the
maternal passage.   Very poAverful tractions also may be  made without risk,  inas'
much as  the  mother's parts  are  compressed only by the soft parts of the fcetus.
The head, being  no longer clasped by the  blades of the instrument, is at liberty,
through the imbrication of the bony fragments, to mould itself freely upon the canal
to be  traversed,  and should  the  arms be  raised,  they will be  situated alongside
of a head which  has been flattened and  converted into a soft and movable pouch."
   I agree with  Dr. Bertin, that pelvic version, resorted  to after cephalotripsy, is
destined to be of very great service; but, unfortunately, it  can only be indicated
in exceptional cases.  Thus,  it would be impracticable to perform it through a
pelvis contracted to less than two  inches (see Version), and even when the  pelvis
will allow the hand to  pass readily, it is liable to be  arrested  by spasmodic 3on-
traction of the Avomb.
   Ail that has been said concerning cephalotripsy in vertex presentations applies
to presentations of the face, and we Avould only obser\-e that if it should seem diffi-
cult to perform craniotomy with certainty, the cephalotribe should be applied  with-
out resorting to perforation.  As regards cephalotripsy after the trunk has  been
delivered, Ave have already seen that presentation of the base of the skull does not
preclude perforation, a^id it were  hardly necessary to insist upon the rule to pass
the blades beneath the trunk, as when the forceps  are applied, for the simple rea- 
1054
OBSTETRICAL  OPERATIONS.
son that  no one could possibly think of introducing them in front, unless the occi-
put should be behind, and  the chin  in relation with the symphysis  pubis.   Cases
of retained head after detachment of the body will be treated  of in the following
article (see page 1058),  and we have nothing special to add in this  place  to what
is there said on the subject.  The ordinary rules of cephalotripsy will  be sufficient
to  guide the operator, but  it will be  more necessary than ever to fix  the head by
depressing the walls of  the abdomen.
  Numerous objections  have been raised to the operation of cephalotripsy; thus,
independently of the difficulties which attend it, and which we  have pointed out,
it is said that the length of time which it often demands, and the frequent manipu-
lations, exhaust  the women and render them  liable  to very severe inflammations,
besides inflicting sometimes fatal traumatic  lesions.  It may be added, that some
of the patients have recovered Avith  A'esico-A'aginal fistulas.  Can any  better reply
be made  to these charges than that nobody denies the gravity of the operation, and
to ask what better can  be  done ?  Such as it is,  cephalotripsy is often and  unde-
niably successful ;  Hemming, one of its  latest detractors, himself  publishes sta-
tistics which prove  better than any  argument, the. services which  it is capable of
rendering, viz.:  that out'of 200 cases, there were 161 recoveries and 39 deaths.
  Dr. William Jones gives, in his excellent  thesis, the following results  collected
by him in the hospital of  the Clinique at Paris, during the years 1857, 1858, and
1859.
  In contractions of the pelvis above 3f inches, out of three cases' of cephalotripsy,
one was fatal.
  From 3£ inches to Z\  inches, out of seven operations one fatal case.
  From 3£ inches to 2$-  inches, six cases, all recovered.
  Below 2$- inches, eight cases, only  three saved, and five deaths.
   We thus have a  total  of  24 operations, giving 7 fatal cases and 17 recoveries.  It
is impossible to overlook  the gravity of cephalotripsy in  contractions below 2|
inches, inasmuch as for eight operations there were five  deaths; whilst above 2$
inches, for sixteen  operations, there were  fourteen successful.
   Cranioclasm. — Notwithstanding the advantages of cephalotripsy, the operation
has, thus far, met with little favor in England, without any apparent good reason for
so decided a repugnance in a country where craniotomy is so generally recognized.
                    Besides the real objections already mentioned, the cephalotribe
       Fig. 158.       has been condemned on account of its considerable size, and its
                    introduction into the genital parts made a subject of ridicule.
                    This, however, being a poor argument, we hope  that the preju-
                    dice will  soon disappear; in fact, we think  that we find an
                    evidence of concession in the instrument devised and described
                    by  Simpson, under the name of the Cranioclast.   (Fig. 158.)
                     The cranioclast, although much smaller than the  cephalotribe,
                    is, like it, intended to crush the bones of the head. It has two
                    branches, which cross each other at  the point of  articulation;
                    but the blades,  instead of being curved, are almost  straight;
                    one of them, which we shall term  the male blade, is solid and
                   very thick, whilst the other, or  female blade, is provided Avith
                    an  elongated fenestra which receives the  male blade when the
                    instrument is closed.   A firm grasp is  insured  by the form of
                    the wooden handles attached to it.
                     Although  a more  complete  instrument,  the  cranioclast  re-
                    sembles such bone forceps  as  those of Mesnard, Stein, Boer,
                    and Davis.  It  is  used as follows.  Craniotomy  having been
 performed, the female blade is passed between  the  head and  the pelvis, and the
 male blade pushed into the.cranium through the perforation which  was previously
 
EMBRYOTOMY.
1055
made.   After locking the instrument, enough  force is applied to the handles to
crush the part seized, and to disjoint  the bones by a twisting motion.  Repeated
applications  to different parts  of the circumference of the cranium are almost
always  requisite.   To effect extraction,  direct traction is sometimes all  that is
required, whilst at others it is necessary to turn the cranioclast. several times upon
its axis in order to roll the walls of the head, made soft and flexible by crushing,
around  the blades.
  Simpson claims for his instrument the following advantages :  The cranial bones to
which the blades are applied are made soft and flexible, so that the contractions of
the womb are often  sufficient  to  expel the head.   No  bony fragment capable of
wounding the genital parts projects  beyond the scalp, which remains uninjured
and completely protects  the  mother's  organs.   The size of the head is so  far les-
sened as to  become  less difficult to extract than  the  trunk and shoulders.   The
crushing of the bones of the head always leaves sufficient hold for the instrument
to preArent its slipping during extraction.
  Unfortunately, experiments upon the dead body, and operations attempted upon
the  living by others  than  Simpson, have not proved so satisfactory.   In  the  first
place, it is not easy to apply the instrument, because of the absence of a curvature
corresponding to the  axis of the pelvis, and it is so short that the locking has to be
effected  in the vagina if the head is  rather  high up ; now, under these  circum-
stances, it is  far from easy  to effect the  locking.  The  crushing  is, besides, very
imperfectly performed ; although the bones are broken, they are rarely disconnected
from their fellows,  and still form with  them a resisting structure;  s'piculae of bone
have also been known to perforate and project through the scalp.   AVe shall extend
our  criticism;  no  farther, havingfcaid  enough to show that the cephalotribe has the
advantage as a crushing instrument, leaving the cranioclast far behind in the com-
parison.  We ought,  however, to state  that the latter instrument has really appeared
to us to take a very firm hold of the bones of the head,  a quality  not to be despised
when it is  required  to  deliver a recently crushed  head.  In a certain operation
rendered difficult by an extremely contracted pelvis, after having crushed the head
in every direction,  we Avere brought  to a  stand by  the difficulty of extracting it,
the cephalotribe having several  times  lost its hold.   It  became a question  whether
the expulsion should  be  left to  the powers of nature, but before  deciding to do so,
the cranioclast was applied and the head delivered  at the first attempt.
  The Saw Forceps. — After making trial of the cephalotribe, Van Huevel found
fault with it because it lengthened all the diameters except the one situated  between
the blades.  He therefore  concluded that it Avould be very difficult for the  head to
engage  if it were above the superior strait, and if locked in the pelvis, the elongation
of the diameters could hardly fail to bruise the soft parts of the lesser pelvis.  He
denied the possibility of being always able to rotate  the instrument so as  to bring
the  lengthened diameter to correspond with the  normal diameter of the pelvis,
observing, also, that the  head can never be  crushed from before backward; that is
to say, in the  direction of the usually  contracted diameter.   We  have already dis-
posed of these objections, which,  nevertheless,  induced  M. Van  Huevel to invent
his saAv forceps, which may be compared Avith  the  cephalotribe, although differing
from it  in its mode  of action.  AVith this new instrument he  divides  the  head be-
tween the blades of a  forceps, so as to enable him to Avithdraw the pieces separately
without violence.  The least traction  detaches  them, and they neither bruise nor
wound the genital parts.
  The  saAv forceps  is composed:  1. Of an ordinary forceps,  each blade of which
bears internally two tubes  flattened in opposite directions, and soldered together,
the   side of  one against the surface  of the other,  so  that  their horizontal  sec-
tion  represents an overturned >-2.   They are bent from without  inward, like the
forceps  itself,  but are set in a straight line from below upwards.   The internal of 
1056
OBSTETRICAL  OJERATIONS.
the tubes, placed lengthwise of the blades, incloses a strip of steel which conducts
the saw; the external, which is directed across the instrument, lodges the prolonga-
tion of the chain.   They communicate by a  large slit, Avhich divides the  internal
and external walls of the former throughout its length,  and the internal side only
of the latter.  The forceps articulates by  entablature, with a movable pivot; upon
the base of the latter turns a. support perforated with a hole,  in which is inserted a
grooved key.
  2. Of a clock chain, toothed as a saw in the middle of its length for the space ot
eight and a half inches, and provided with transverse handles, one of which can hi
unhooked.   This chain passes through the upper opening of two steel strips, which
are flexible above, and thicker and toothed below, and Avhich, by entering the inter-
nal tubes, conduct the saw between the blades of the forceps.
  3. Of a long key, with grooves and collar,  like that of Heurteloup's instrument
for crushing calculi, entering into the  hole  of the support  upon the base of the
articular pivot, and  fitting into the teeth of the conducting strips.   The extremity
of the handle is split, and serves to turn the  pivot of the forceps, as also for draw-
ing out separately, with one of the two points, the strips from their sheaths.
  Setting aside technical details, Van Iluevel's instrument may be described as a
forceps, each branch of which has on  its inner face a gutter  running from one  end
to the other, and of two strips of  steel, both having an eye at one end  through
which a chain-saw passes (just like a thread Avith a needle at each end).  After the
forceps are applied, the two slips to Avhich the chain-saw is attached are pushed
into their respective grooves.  The saw is  thus brought into contact with the head,
and embraces it to a greater or less extent, according to  the  distance to which the
steel slips are pushed in.  Motion is given to  thesf slips by means of a grooved key,
which fits into the teeth with which the slips are provided.
  The mode of operating is described by Van Huevel as  follows.  The instrument
should only be applied when the woman  cannot be  delivered either naturally, or
with the assistance  of the vectis, forceps, or by turning; the  neck of the womb
should also be dilated, and  the membranes ruptured.   Before operating, a  bed
should be prepared  Avith a straw mattress, and a mattress folded double ;  bolsters,
pilloAVS, napkins, and bedclothes, make up'this part of the provision.  The woman
lies upon her back,  Avith the hips brought down to the edge of the  mattress ;  the
legs and thighs  are flexed, and  held apart by two aids, one on either side.  The
forceps are warmed slightly, and greased externally.
  Suppose the head presents, no matter  in what position.  The  operator takes his
place before the woman, and inserts first  on the left side of the  pelvis, the male
branch,  introducing it as far as possible into the uterus, and one of  the assistants
holds it, whilst the other is  passed in  on the  right side.   When  the forceps is
articulated, a few tractions are made, in order to be certain  that  the head is well
seized.  The surgeon gives the  handles of the instrument to the assistant on his
right, whilst he surrounds it Avith a ligature.   Then immersing the ends of the con-
ducting blades, armed with  the saw, in  oil, he introduces both of them into their
respective sheaths until they touch the head of the foetus.  He next passes the  key
beneath the left thigh of the patient,  and  engages the grooved end in the  opening
of the support; the assistant takes its handle in his right hand, and  turns the  key-
slowly on  its axis, whilst the operator  puts  the saw in motion.  Care should he
taken to prevent the chain from twisting, and, as far as  possible, to make the trac-
tions in  the direction of the guiding tubes.   Unless the  key  is turned very slowly,
the saw will be  arrested by pressing too strongly  upon the  bones of the head.
Should this occur, the assistant  must reverse the motion of the key slightly,  and
afterward continue the manoeuvre  until  the operation is completed.
  When the section  is finished,  the  key is taken out, and the handle of the chain
unhooked, that it may be withdrawn ; the conducting blades are also removed, and,
Dually, the branches of the instrument  itself, after their disarticulation. 
EMBRYOTOMY.                         1057
   At this stage of the operation, if the woman is not exhausted, and expulsive pains
 make their appearance, the rest is left to nature, being careful to ascertain the dis-
 position of the segments by the touch.  A part of the brain escapes, the sawn edges
 override each other,  the two portions of the cranium, especially the  posterior one,
 become  flattened, in  consequence of their being traversed by  flexible sutures, and
 the foetus is eventually expelled.  AVhen, on the contrary, the woman's  strength is
 exhausted,  the detached portion of the head is seized Avith the abortion forceps or
 a pair of pincers, and therewith extracted.  Should it happen that, in consequence
 of the blades of the forceps not having been  introduced far enough into the pelvis,
 the  division was not thoroughly effected, the adhesions  should  be  broken up by
 means of tAvisting and other motions communicated by the pincers ;  as soon as the
 segment is  detached,  both it and the remaining parts will pass without difficulty.
   However, should any trouble be experienced  in  extracting  the fragments, there
 is no reason why another  section, different from the first, should not be made, by
 giving  another direction  to the forceps.  The  already  divided cranium  can be
 depressed Avithout difficulty, and therefore cannot prevent the  diagonal application
 of the branches.  This second operation leaves the skull divided into four unequal
 portions capable of  being compressed  in any direction, and  extracted  without
 difficulty.
   It is not,  however,  always necessary to unlock the instrument  in order to with-
 draAV it, for after the  head is saAvn through, it is sometimes only necessary to make
 a few tractions Avith the instrument to cause a completely detached segment of the
 head to be delivered ;  occasionally, also, the entire head is withdrawn.   If the resist-
 ance be greater, the instrument must be unlocked as mentioned.
   The saw-forceps, though very often used in Belgium, has  been rarely tried in
 France, and even then has failed in skilful hands.  Dr. Verrier, however,  defends
 it in his inaugural  thesis,  in which, after mentioning twenty-nine of  Van Iluevel'a
 cases, twenty-three of which were successful, he reports fifteen cases derived from
 Drs. Simon, Marinus, and AVasseige.  Eleven of the fifteen were entirely successful,
 two died in consequence of lesions existing previous to the entrance of the patients
 into the hospital, and two from peritonitis occasioned by the long duration of the
 labor.  It is plain that these facts prove  the saAAr-forceps to be a good instrument
 and  comparable with the  cephalotribe, though they do not prove it to be superior.
 To extend the comparison  between the two instruments,  it may be added, that the
 saw-forceps, like the  cephalotribe, requires a certain field for action ; its blades in
 their widest part measure one inch and five-eighths, and those operators who have
 used it most frequently do not venture to advise it in  contractions below  an inch
 and three-quarters.
  A great objection   to the saw-forceps  is its great cost, its  complexity  and the
 minutias which have to be  attended to  during the operation.  The movement of the
 chain-saw is not accomplished very easily, and it is liable  to be jammed  or broken.
 Another serious objection is, that it requires an experienced assistant:  as the motion
 of the conducting blades should accord perfectly with that of the chain, it is neces-
 sarv that both  operators should act in unison.  Finally,  the greatest defect of all
 in the saw-forceps is its inefficiency as  an extracting instrument and  the frequent
 necessity for using bone forceps, in spite of all the objections to their employment.
 Nevertheless, there is cause for regret that the practical  use of the  instrument is
not better known in  France, as Avant of  experience prevents our estimating its
advantages or disadvantages at their just value.  (Extracted from the Traite* d'Ac-
couchement of Lei oir,  See,  and Tarnier.) |
       67 
1058
OBSTETRICAL  OPERATIONS.
                           ARTICLE III.
                   SECTION OF THE NECK AND BODY.
   We shall  not describe decapitation performed  after the body has  been
delivered, because, Avhen it becomes necessary to perform it voluntarily, the
process is as  simple as possible, Avhether a scalpel or scissors be used for the
purpose.
   But this is not the only case in which the separated head is left behind in
the uterus, for it will  presently appear that a similar course  is adopted in
certain trunk presentations;  or, the  same thing may happen from igno-
rance or stupidity.  In all cases the head has to be delivered, and its extrac-
tion is exceedingly painful Avhen the  pelvis is much deformed;  for it  then
presents by its base, the'reby rendering  perforation  more  difficult.   Under
such circumstances, it  has been  recommended to attempt to turn  the head,
so as to bring some portion of the cranial vault to the superior strait, Avhich
of course should be done Avhenever  possible.  The excessive mobility of the
head singularly favors the  slipping  of the  perforator, and  exposes  the
mother's parts to laceration.   The  best Avay of preventing  this accident, is
to direct an assistant to place both hands over the hypogastric region, and
fix the head there by making considerable pressure at that point.
   But the difficulty is not  brought to  an  end by  the perforation of the
cranium, for even then  the embryotomy forceps will often become necessary if
the contraction is excessive; and, OAving to the mobility of the part, its applica-
tion is very imperfect, and it is likely to slip at the first tractive effort.  The
trouble in getting hold of the head is not merely dependent on its mobility,
because, when  the  inclination of  the superior strait is  very great,  it is
situated above the pubis, and therefore  cannot be reached by the instrument,
Avhich  is necessarily directed posteriorly, in consequence of its  moderate
curvature.
   It was to this  that I attributed the  failure of the  attempts  made on one
occasion by M. Paul Dubois, at the Maternite.  The Professor, being Avorn
out by several hours of fruitless manipulations,  had the kindness to permit
my assistance.   I introduced the right hand, and got hold of the loAver  jaw,
which I attempted to draAV doAvn, but Avithout any better success, as the  base
of the cranium Avas arrested by the symphysis.  I found that the failure of
my tractions  Avas owing to the fact of their  being directed too  far  down-
wards  and forwards.   I then substituted a blunt hook  for the finger, and
fixed it on  the lower jaw, Avhen, by depressing the handle of the instrument
posteriorly, so as to make it operate doAvnwards and backwards, I Avas  soon
fortunate  enough to get the head into the  excavation, from Avhich it was
readily  delivered aftenvards.
   Most of  the difficulties met Avith in this case might certainly have been
prevented,  by using the instrument just described, invented by myself
   Division of the  neck or  body is generally performed Avithin the genital
passages, the operation being  sometimes the  only  means by Avhich   the
operator can  prepare the way for delivery in body presentations.
   Version, in fact, is  not  always  practicable  in trunk  presentations; for
instance, where  the membranes have been ruptured, and the Avaters dis- 
\
EMBRYOTOMY.
1059
charged for some time, and the shoulder is Ioav doAvn in the excavation, the
forcible contraction- of  the  uterus  may render introduction of  the  hand
and  version }f the fcetus absolutely impossible.  In such  a  case, Ave have
nothing to do but to wait for spontaneous  evolution, if the child is living;
but  as soon as it is dead, Ave must  promptly relieve the mother from  the
dangerous consequences  of a prolonged labor.
  To amputate the arm under such  circumstances is altogether  useless,
because its presence cannot  incommode the operator; and, besides, it may
afterwards prove very serviceable by favoring the tractions ; it is on the body
Ave have to act, and of the various  plans  suggested for the  purpose, those
described  by Celsus and Dr.  Lee are the only ones that appear practicable.
In cases of this kind, Celsus had recourse to decapitation; and I have knoAvn
this  plan to be employed by  M. Dubois on several different occasions.   He
acts  in the'folloAving manner: Having ascertained the exact situation of the
child's neck, he  introduces the whole  hand  into the  uterus (the left  one
when the  head is at the  right side, and the right one when it is at the left),
and, hooking the index finger over the cervical region, he endeavors to draAV
it doAviiAvards, so as to make this part more accessible; should the finger  not
prove sufficient, the blunt hook is advan-
tageously  substituted for the same purpose               Fia-159-
(see  Fig.  159).   A pair of long scissors,
having thick and Arery sharp blades, and
moderately curved  on the side, so as to
correspond Avith the axis of the pelvis,  is
then guided up to the infant's neck along
the palmar surface of the hand previously
introduced ; then the blades are opened a
little, and a small portion of the neck  is
cut,  then a second,  and thus, by repeated
small incisions, its  Avhole extent is grad-
ually divided.   When   the  decapitation
is completed, he draAvs on the arm which
is  usually found in the vagina, in this
A\av  extracting the trunk Avithout much
difficulty;  and afterwards he delivers the
head in the manner above stated.
  The decapitation is not ahvays feasible,
at least Ave could not succeed in effecting
the section in  a case to Avhich Ave  Avere
called by  Dr.  Lcvuille.  The head and
neck Avere  so  high, and the  uterus so
strongly contracted, that it Avas not  possible to get the hand and scissors far
enough up to embrace the neck properly; after several fruitless attempts,
Ave determined to perform the operation recommended by Doctor Lee, but,
before doing so, concluded to try the pelvic version.  The right  hand  Avas
passed in as far as the breech, but it could  not reach the feet;  the forefinger,
curved like a hook, grasped the buttocks, and whilst this hand Avas pulling
ou the breech, the side of the  foetus,  which had already engaged in  the
Mode of using the blunt hook in the trunk pre-
    sentations, to bring down the neck. 
1060
OBSTETRICAL  OPERATIONS.
 excavation, was pushed upwards and to the right  by  the fingers  of the
 other hand.  By operating in this manner for  five or six minutes we Avere
 fortunate enough to bring  down  the pelvic extremity, and  thus terminate
 the labor favorably as regards the mother.  The lying-in presented nothing
 unusual.          ,

   [Decapitation only, is capable of fulfilling all the indications when, in a case of
 presentation of the  body,  it is impossible to turn.   It has been objected  to  on
 account of the difficulty of performing it, and various instruments have been devised
 with the view of making it  easier.  A small knife shaped like a pruning-hook, fixed
 in a long and strong handle, may be used ; or else a special instrument recommended
 by M. A. Baudelocque.   Ramsbotham, Sen., also invented a sort of blunt hook with
 a concealed  blade in its concavity, which, after the instrument is applied to the
 neck, becomes detached and severs it like a guillotine.
   Van der Ecken proposed cutting through the neck with a chain-saw.  For my
 own part, I had made  by Charriere a blunt hook, in imitation of Belloc's  sound.
 After the hook is  applied, the spring passes through it behind the neck and comes
 out at the vulva.  A cord is then attached to it which will include the neck when
 the hook and spring are withdraAvn.  My idea was to use the thread for the pur-
 pose of drawing through the chain of a linear ecraseur, by which to effect the divi-
 sion of the neck.   The only difficulty Avould be found in the passing of the spring
 around the neck, but I am so well satisfied that it would often  be impracticable, that
 I believe the plan could be  adopted in a few special cases only.  Prof. Pajot devised
 a blunt hook containing a groove and tipped with a leaden ball, to which is attached
 a piece of Avhipcord  lying in  the groove.   The hook  being introduced, the cord is
 loosened  and the  leaden  ball is supposed to drag it by its weight  into the A'agina,
 after having passed behind the child.  To effect the division, M. Pajot proposes using
 the cord as a saw  by grasping the ends and drawing  alternately upon one end and
 the other with a rapid motion.  The thread is passed  through a Avooden speculum
 in order to protect the vagina.  It must be confessed that it is a rather curious way
 of effecting an operation of the kind, yet the possibility of doing it cannot be denied,
 inasmuch as it has been repeatedly accomplished by M. Pajot on the dead body in
 the presence of his  pupils.  The difficulty, however, does not lie  here, but  in the
 passage of the ball, which, I think, wx>uld be found no easier than in the case of the
 spring just now spoken of.
  Of all  the instruments contrived for the purpose, that of M. Jacquemier  is,  in
 my opinion,  the best adapted to the object in  view, and the  most  readily applied.
 It  consists of a blunt hook  with a Avooden  handle.  The hook  is included for its
whole extent in  a sheath.    Hook and  handle are  constructed with a groove,  in
which slide a series of connected blades which are put in  motion by raising and
 depressing alternately the little handle to which  they are  attached through the
 medium of a rod running the entire  length of the hook.  M. Jacquemier operates
as follows:  The hook inserted Avith  its  sheath being passed around the neck, he
introduces the blades into the grooves and pushes them on by means of the handle
until they project from  the concavity  of the hook.   A to-and-fro motion then being
communicated by  the little handle, soon  divides the  soft parts down to the  spina]
 column.  The operator  now withdraws  the blades and substitutes for them a saw
of the same size.   AVith it, the bones are cut through without trouble, and it is with-
 drawn in order to  complete  the  section of the soft  parts with  the cutting blades,
 which are again placed in the instrument  for the purpose.  Both the instrument
 Sind its manipulation are, as  is seen, somewhat complicated, but  it performs well
 on the dead body, and doubtless would be  serviceable in practice.   (See the draw-
 ing of this '  istrument in Atlas by Lenoir,  See, and Tarnier.) J 
EMBRYOTOMY.                       1061
  Dr. L^e's method consists in separating the arm from the body, as also in
perforating tin thorax and abdomen; then, by fixing the  bli nt hook on the
pelvis or lower part of the spine, he makes use of sufficient force to bring the
child down double, and thus effects its delivery by a mechanism very similar
to the spontaneous evolution.   Perhaps it would be better to folloAV Davis's
plan, and divide the trunk in tAvo, and afterAvards  extract the parts sepa-
rately.1   This method should  never be resorted to except when the section
of the neck is impossible.
  In a case in Avhich  version could not  be effected, M. Parmat resorted to a
process  someAvhat resembling that of Dr. Lee's, except that he did not first
amputate the arm,  this very properly seeming to him  an  altogether useless
preliminary.  Making use of  the  blunt hook which terminates the handle
of the forceps, he passed it beyond the false ribs, and  then turning it forcibly,
so as to bring its extremity in contact with  the integuments of the fcetus, he
perforated with  it the walls of the abdomen,  if unable to reach the ribs, so
that in Avithdrawing it,  it  hooked  into the  loAver border of the thoracic
parietes.
  Then, by means of tractions with the branch of the forceps, he succeeded
in communicating to the trunk a motion similar to that which it performs
in spontaneous  evolution.  The  head  and  shoulder ascended gradually,
whilst the pelvis approached the vulva  and was finally delivered.
  This quite simple method is  certainly preferable to Dr. Lee's, and in many
cases might be substituted for the decapitation of the  fcetus.
  1 M. Payan, of Aix, resorted to Davis's  operation in one instance, where the  trunk
was low down in the  excavation: but the plan  certainly did not originate with him.
[Oez. Med., p. 521, 1840.) 
PAET  VIII.
 OF  THE  HYGIENE OF  CHILDREN FKOM  BIRTH  TO  THE
                      PERIOD  OF WEANING.

    HAVING carefully detailed the services to be rendered by the accoucheur
     to the child immediately after its birth, we have noAV, in order to com-
plete the study of subjects which must subsequently claim his  attention, to
treat of the physical education of children.   As the full details into Avhich
we  have entered have already brought  the  Avork up to a considerable size,
we are obliged to curtail greatly Avhat Ave had proposed saying in regard to
the hygiene of early childhood.  The old and classic division of Halle might
be advantageously applied in this place,  so that, if space allowed, we Avould
treat successively of the ingesta, applicata, percepta, etc., &c.  But, inasmuch
as we are obliged to limit ourselves  to a someAvhat detailed a'ceount of ali-
mentation, we shall treat of the other parts of infantile hygiene in a general
Avay only.
  Although the existence of the neAV-born child is generally styled indepen-
dent, its physiological connection Avith the mother is not entirely severed by
the delivery.  It does not immediately cease  to derive nourishment from the
maternal organism;  for although  no  longer  connected Avith  the uterus,
nature has prepared another organ for the elaboration of the fluid designed
for its future support.  This fluid is  the milk.  The function  by Avhich it is
secreted is called lactation, and  the  mode in which it is taken  by the new-
born child is termed suckling.
                          CHAPTER I.

                             LACTATION.

  As stated  Avhilst treating of the phenomena of pregnancy, the  breasts
begin to enlarge from the first month of gestation.  Their active vitality,
under these circumstances, soon gives rise  to the secretion of a sero-lactes-
cent fluid, Avhich becomes more abundant  as  the term of gestation draws
near.   To this fluid, Avhich is viscid and yellowish, the name of colostrum is
applied.  Under  the microscope, it presents the appearance  of  globules,
much smaller than the ordinary milk globules,  united together by a viscid
matter.   Some irregular milk globules are scattered amongst them.  Pecu-
liar bodies (granular corpuscles), more or less globular in form, yelloAvish/
and varying from "003 to '019 inches in diameter, are also observed.
  M. Donne  asserts, that there is an almost constant relation  between the
composition of this fluid secreted during pregnancy, and that which  Avill be
                                                            1002 
LACTATION".
^063
exhibited by the milk  after delivery;  in other Avords, the examination of
the colostrum  and its principal characters  will enable us to judge of the
probable  abundance  and  quality of the milk.   In reference to this,  M.
Donne divides Avomen  into three classes:  1. If  the  amount  of colostrum
secreted is so small that barely a drop can be obtained by the best directed
pressure, if it contains but very feAV minute, imperfectly formed milk globules,
and a very limited number of granular corpuscles, the milk Avill almost) cer-
tainly be  scanty, poor,  and  insufficient for the  nourishment of the child.
2.  If the  Avoman secrete an abundant, but fluid, Avatery, and  easy-flowing
colostrum, resembling a thin solution of gum-arabic, — if it no longer pre-
sents striae of  a thick, yelloAv, and viscid matter, and if it be poor in milk
globules and granular corpuscles, she may have a greater or less amount of
milk, but it Avill be poor,  Avatery, and  unsubstantial.   3. Lastly, when the
colostrum is obtained readily and in abundance, Avhen  it contains a more or
less thick yelloAv matter, and  resembles someAvhat the rest of  the fluid as
regards consistency and color; when the microscope  shows it  to be rich in
milk globules, Avell formed, and of good size, and containing granular cor-
puscles in greater or less amount, Ave may be almost certain that the woman's
milk Avill be both rich and abundant.
   This examination may be made with  especial prospect of advantage about
the eighth month......It is Avell, however, to  be aAvare that certain acci-
dental  causes, such as cold, or moral  affections, may occasion a momentary
discordance Avith the results of experience (Donne).
   For the first days folloAving the delivery,  and until  after the milk-fever,
the fluid secreted by the mammas retains the properties of colostrum, but is
more abundant than during pregnancy.  AVhen the  milk-fever comes on,
the milk  globules begin to present a more  definitely rounded  contour, and
are more  regular. Some histologists assert that the granular corpuscles dis-
appear  about the ninth day; but M.  Godez states, that he has often met
Avith them after the fifteenth day, and even after  the tAventieth, though only
in the milk of moderately good nurses.  They generally become more rare
as a longer  time elapses  from the period of the milk-feA'er, and they dis-
appear the more quickly, or, in other words, the milk is sooner  formed when
its quality is good and  the woman  in a satisfactory condition.  The fact of
their remaining after the  first fortnight is  an indication of an  indifferent
nurse.
   After the milk-fever is OA'er, the mammary secretion generally tends more
and more to  assume the  characters of true  milk.  The latter  is a white,
opaque fluid, of a SAveet, sugary, and very pleasant taste.  Of all the fluids
of the economy, it approaches  the  nearest to the  blood in composition, and
like it, separates into  two parts upon standing.   One of these  parts is solid
and the other  fluid.   The  solid part, which is held in  suspension, is formed
of globules of fat or butter; the other  holds in solution a special, azotized,
and coagulable animal matter (caseine), sugar of milk, salts, and  a little
yellow  matter.
  These  several parts, says M. Donne, Avhen mingled  together, are not dis-
tinguishable by  the naked  eye ; but if a drop of  milk  be spread out upon a
plate of glass, and examined through a  microscope magnifying  two hundred 
1064
HYGIENE OF  CHILDREN.
diameters, a multitude of rounded, transparent granules, brilliant as little
pearls, will be discovered svAumming in a limpid fluid.  These small granules,
Avhich are rather less than "0003 inches in diameter, are the milk globules,
and are formed of a fatty matter or butter.   In pure  and  unmixed  milk,
nothing besides these small globules is visible, and this purity of the milk is
a certain indication of its good quality.
  The amount of globules is liable to variation, their greater or less  abun-
dance  representing with considerable precision the  richness or poverty of
the milk; that is to say, the more of these globules  the  milk contains, the
richer and more substantial is it, the caseine and sugar being themselves in
proportion to the amount of milk globules Avhich represent the fatty matter
or butter.
  Not only does  the milk vary in richness in different individuals,  but it
varies  greatly in the same woman according to the time Avhen drawn, her
state of health or of disease, and  the hygienic conditions in  which  she is
situated.  We shall hereafter have to study these variations when endeav-
oring to judge of the  characters by which  to determine whether a Avoman
is or is not a good nurse.
  The lacteal secretion is, as Ave have  said, intimately connected Avith the
function of generation; still  it must not  be supposed that it can only take
place in pregnant or recently delivered  females.  It has  several times been
knoAvn to occur in consequence of frequent  excitation of the nipple.  Thus
Belloc relates, that a domestic who Avas obliged to sleep in the same chamber
with a recently Aveaned child, being annoyed by its cries, took it into her
head to put it to her OAvn breast.   In a very  short time she had  milk enough
to satisfy its appetite.  Mrs. B----, says George Semple,  mother of nine
children, the youngest of Avhom Avas thirteen years old, lost her daughter-in-
law a year before, she having died four days after her delivery.  After her
death she took charge of the  infant, which was thin and puny, besides being
so complaining and hard to pacify that after passing several sleepless nights,
she allowed it to take her breast.  Not more than from thirty to thirty-six
hours had elapsed,  before Mrs. B. was astonished to find her breast become
painful and enlarged, and immediately afterward the secretion of milk Avas
established as freely as had been customary after her confinements. For an
entire year, the child nursed at the same breast which had given suck to its
father twenty-four years before.  Baudelocque mentions a little girl eight
years of age Avho presented the same peculiarity; and the following  case is
related by M. Audebert:
   Angeline Chauffaille, sixty-two years of  age, and Avho had not had chil-
dren  for tAventy-seven years, undertook to  nurse  her granddaughter artifi-
cially.  From time to time, in order to amuse it, she presented it Avith her
nipple ; but Avhat Avas her surprise Avhen she  suddenly found  both  her breasts
full of an apparently good, healthy, and nutritive milk!   She continued to
nurse it for a year, and the secretion  had not entirely ceased after the child
had been Aveaned tAvo months.  At this juncture, her daughter again became
a mother; her milk  dried up, and the grandmother was able to nurse  the
second child.   (Audebert, Gaz. Med., p. 250, 1841.)
   The duration of lactation varies greatly even in Avomen Avho do not suckle, 
LACTATION
1065
In  some, it lasts several months in spite of all that can be done to put an
end to it.  I have just delivered, for the third time, a young lady who had
an  abundance of milk, after her first two confinements, for the space of three
months, and this although her courses returned in six weeks.  The secretion
of milk in nurses sometimes lasts long enough to enable them to suckle two
and three children successively.   A lady in every way worthy to be believed,
says Desormeaux, assured me that she had knoAvn a woman to suckle five
children consecutively, which must have involved a lactation of at least six
years' continuance.  I find  among my notes the following  case, the origin
of Avhich I am, unfortunately, unable to discover: A woman had so abun-
dant a  secretion of milk for the forty-seven years succeeding the birth of
her first child, that she was not only able to nurse  six of her own children,
but seven others also.  She ahvays menstruated regularly during the lacta-
tion, and at eighty-one years of age her breasts still  yielded a small quantity
of milk.  On the other hand, the lacteal secretion often  begins  abundantly,
then  declines,  and  ceases Avithout our  being able to  discover the cause.
Many gradations are observable betAveen these extremes, but  the average
duration of lactation in women is from twelve to eighteen months.
   The quantity of milk varies still  more than the duration of the secretion,
even Avhen no account is taken of the hygienic and moral influences, which
have an undoubted influence over it. One woman, in other respects healthy,
may barely be able to supply the amount required for the nourishment of a
single child, whilst another may be able to suckle several at a time.  Haller
says that women have been known to furnish  in a single day a pound and
a half,  or  even two, three, or four pints  of milk;  in one case, the woman
gave three pounds  more  than was required for her child.   Unfortunately,
it is difficult to knoAV beforehand what the  quantity of  milk will be.   The
results  obtained by M.  Donne  may, indeed, enable us  to form  a probable
diagnosis, but are far from being certain.   Even when  the  flow of milk is
well established, as in the case of a nurse for example, it is very difficult to
say what will be its  amount.  The nurse's age, and the size and form of the
breasts, are doubtless  matters  of importance, but  still insufficient.  Gen-
erally, Avhen nurses are too young, as under  eighteen or twenty years of age,
or too old, as  over forty  years, they give a less  amount of milk.  Finally,
it Avould seem that in certain women the amount of milk increases with the
birth of every  child, inasmuch as they have it in  much  greater quantity
after the second or  third confinement than after the first.  Women of a
lymphatic  temperament, also, have less milk than others.
  Is the quantity of milk affected by the kind and amount of food ? Although
such is not proved to be the case in the human species, the fact is too well
established as regards the females of the superior animals, not to lead to the
same conclusion as respects Avomen.  For my own part, I kneAV a nurse
Avhose flow of milk yvas  sensibly increased after several times partaking of
ground lentils.
  The quality of the milk may be sensibly affected by numerous circum-
stances which have next  to claim attention.
  A. The health of the nurse is a matter of the highest importance.  Chemical
analysis shows  that in diseases of any kind the proportion of solid constitu- 
1066
HYGIENE OF  CHILDREN.
ents increases at the same time that the proportion of water decreases.  Ac-
cording to the  analyses  of  MM. Becquerel and Yernois, this fact is more
observable in chronic diseases than in acute febrile affections.  Noav, as M.
Bouchut judiciously observes, this increase in the proportion of the solid
principles of the milk is an unfortunate alteration, causing the child  to be
frequently affected with indigestion and consecutive enteritis.   The milk of
Avomen  suffering from chronic diseases, phthisis for example, exhibits great
alteration of the milk globules.  Every one knows that Avhen an acute affec-
tion appears in a recently delivered female, the breasts are scarcely SAvollen
Avhilst  the disease  lasts, and even after  recovery  the lacteal secretion  is
sometimes but  imperfectly established.  A slight and evanescent  affection
during lactation appears to have but little influence, Avhich is far from being
the case Avhen it is  more  severe and  prolonged.  The secretion  sometimes
ceases, and even Avhen it continues without presenting any appreciable alter-
ation to our means  of investigation, the state of the child, which is observed
to become rapidly  emaciated, and to  digest badly, indicates  an alteration
of the milk  as certainly as the best chemical reagent.  An inflammation,
an acute  irritation  of an important  organ, or a considerable discharge of
some kind, lessens it, or even stops it altogether.  The diseases of the  breast,
the inflammatory engorgements, phlegmons, and glandular abscesses, merit
especial attention, not only  because they diminish the secretion  of the dis-
eased organ considerably, but because they communicate dangerous proper-
ties to  the  milk.  Nothing more than a  simple engorgement is needed to
produce a reformation of the granular corpuscles and  a  viscid condition of
the milk; and  should an abscess be formed, the microscope shoAvs its pres-
ence even before the exploration of the breast distinguishes  the collection
of pus,  by exhibiting the characteristic globules of that fluid  Avith their
granular  appearance, their opacity, and the  property of being completely
dissolved  in alkalies and of resisting the action of ether.
  B. Moral affections, such as fright, anger, disappointment, &c, undoubtedly
have  a very great  influence upon the quantity and  quality of the milk.
Often have I been astonished, after  choosing nurses with abundance of
milk, to find the secretion  cease  a few days  after  having given  up their
OAvn  child for  a strange nursling;  and several, Avhom I  had discharged
simply  because they had  no  more  milk, returned  a  feAV  days  after in
excellent  condition.  SorroAV, at  being removed from  their  country and
separated from  all that are dear to them, especially the relinquishing of
their  children,  may often  account for this  momentary suppression.  A
violent  emotion is  often found to occasion an engorgement of the breasts,
or else their sudden subsiding.  Children are often rendered sleepless, and
affected Avith colic and diarrhoea, sometimes even yvith convulsions,  in con-
sequence of violent  anger of the mother.   A nurse in the Hospital Cochin
Avas very  irascible,  and indulged in high discussions Avith her  neighbor.  On
one occasion she was more angry than  usual, and her child had violent
convulsions on the  morroAV.   She left the hospital, but returned again some
months after.   Similar scenes were again  enacted, and folloAved by the same
effects as regarded the nursling.  This Avoman had already lost her first tAvo
children by convulsions 
LACTATION.
1067
  C. Influence  of the Genital Functions. —1. Menstruation.   Most  women
cease to  be regular whilst they are  nursing.  Others have their courses to
appear after four, five, or six  months, and some again  menstruate as regu-
larly and freely as usual.   Various opinions are held respecting the influ-
ence of menstruation upon the lacteal secretion, and the diversity is certainly
due to the  fact  that this  influence varies greatly in different individuals.
There can  be no doubt that, Avhilst  it is slight in some cases, it is very de-
cided in  others.  In endeavoring to  judge of it, much greater regard must
be had to  the  state of the health of the child, than to the microscopic or
chemical examination of the milk.   Some authors have manifestly been
led  into error by asserting that the appearance of the courses Avas a matter
of indifference, for there are certain alterations of the milk Avhich escape the
closest examination, but Avhich are nevertheless indicated by the effect Avhich
they produce upon the health of the  child.
  The milk of animals is very different in the rutting  season from  what it
is at other periods; and this fact should have led to an anticipation of Avhat
takes place in  women, whose menstrual epochs have the strongest analogy
Avith the  period of heat.   The folloAving points are proved by experience in
relation to nurses Avho have their courses : Some, in consequence of the uter-
ine  discharge in connection with that from  the  breasts, fall into a state of
debility and marasmus; some have their milk to diminish in quantity, and
to become more serous ; the child too  emaciates, although their general health
does not appear to be sensibly affected.   Under  either of these circum-
stances, the rarest of all, it is true, the mother ought to relinquish nursing.
The milk of some Avomen does not appear to be altered, nor the  nutrition
of the child to  suffer, except  during  the Aoav of the menses ; in which case,
the mother's deficiency may be temporarily supplied by the use of coav's
milk diluted.   Finally, in many cases, the children's health  is in  no Avise
disordered, either during or after the menstrual period.
  There  are certain substances whose excess in the blood is necessary to the
nutrition of the child, phosphate of  lime for example,  Avhich are in great
part eliminated by the menses;  nor  Avere it, perhaps, unreasonable to trace
some relation of causality between the rachitis of children and the  regular
occurrence of the menses during the greater part of lactation.
  A fact mentioned by Godey Avould seem  to prove that, contrary to Avhat
is generally observed, the mammary secretion may be excited by menstrua-
tion.  A Avoman, thirty-two years of age, entered  the Lourcine  Hospital to
be treated  for  uterine hemorrhage.   At tAventy-five years of age she was
suckling her OAvn child, but took another one  to nurse at the  same time.
Her business soon obliged her to give up this double nursing, and  the secre-
tion of milk  ceased Avithout any functional  disturbance; a month after, her
courses  reappeared, and Avith them  a  slight SAvelling of the breasts, Avhich
discharged a small  quantity of milk.  At each succeeding period, the lacteal
secretion appeared in greater abundance, and ajfter some  months became so
great that the painful distention of the mammae obliged  her to have them
draAvn by another Avoman, as  also to  use pumps to assist in their disengorge-
ment.  Each menstrual return since then has ahvays been accompanied by
a secretion of milk, though in much smaller quantity, which c< incided re- 
1068
HYGIENE  OF  CHILDREN.
markably Avith the uterine hemorrhages for  Avhich she had been treated
eighteen months previously, and for Avhich she of late entered the hospital.
  2. The supervention of pregnancy during lactation is almost always  an
unfortunate circumstance.   It  is very rare for the quantity of milk not to
be considerably diminished, or at least to, lose  a great part of its  nutritive
qualities.   The child almost ahvays wastes aAvay in consequence, nor, for
my own part, have I ever knoAvn a single woman Avhose child did not suffer
from  it.' I have  se\reral times  been  consulted by young  mothers, whoso
children, put out to nurse at several leagues distance from  Paris, were sen-
sibly emaciated;  and I  have ahvays  been able to determine, or  at  least
elicit an acknoAvledgment, that the subsidence of the breasts were occasioned
by pregnancy.  I, therefore, do not hesitate to  regard pregnancy as incom-
patible  Avith  proper nursing.  It is true that cases are  recorded of Avomen
who did not leave  off nursing throughout the entire duration of a neAV preg-
nancy, and  Avho even, like  the one mentioned  by Van Swieten,  gave the
breast to a child of a year old during  the early pains of labor ; still, these
cases are so exceptional as not to invalidate the general  rule which  we  have
laid doAvn;  and besides, it is not stated whether the Avoman who acted thus
and had fine children, suckled them exclusively, Avithout frequently admin-
istering in addition cow's milk and  often soups or broths.
  3. Sexual intercourse, of  itself, I should regard as of  little danger, unless
it should be repeated too frequently, or with too much ardor; in which case
it might act like any strong moral affection.  It might doubtless result in
pregnancy, Avhich  should be avoided, and on that  account is interdicted to
mercenary nurses.  The case is much  more difficult for women who  nurse
their  own children.  For, on the one  hand, there are certain constitutions
which might suffer from a  complete abstinence, and, on the other, there are
certain  conjugal exigencies which it is impossible not to  satisfy.  Only great
prudence and reserve should, therefore, be recommended.
  d. Effect of certain Alimentary or  Medicinal Substdnces. — A multitude
of daily observations shoAV that the smell, taste, and even the color of certain
substances may be communicated to the milk:  this is the case Avith garlic,
beets, turnips, the bitter taste of  Avormwood, and the peculiar coloring-mat-
ter of madder and saffron.  This peculiarity of certain substances by Avhich
they communicate a portion of their  properties to the milk  has long been
taken advantage of in  therapeutics.   Thus, Haller cured certain  colics in
children by causing the nurses  to eat the fruit of the Anisum pimpinella.
Certain purgatives, as rhubarb and gratiola, purge the  child Avhen adminis-
tered to the mother.  Iodide of potassium and the proto-iodide of mercury,
when taken by the latter, cure the former simultaneously of congenital or
acquired syphilis.
   A  neAA'-born child, says M. Godey, refused to take  the breast for  three
days, and  the pump had  to be used three times in consequence.  Finally,
it concluded to suck, and immediately aftenvard vomited  the greater part
of  the  milk ingested.   The same thing occurred for several days in succes-
sion.    During the night, it took the breast of another  nurse Avho had been
delivered  for a  month, and no longer vomited.  The mother's milk Avas
 ibundant, but very serous ; under the microscope it  presented numerous 
NURSING  OF CHILDREN.
1069
granular corpuscles and very small milk globules.  Nitric a;id produced in
it, after a feAV minutes, a  lilac rose  color, Avhich Avas  retained  under the
microscope by the masses of coagulated  caseine.   This woman had inhaled
ether during her  labor, and it  is a question whether that penetrating fluid
may not have affected the mammary secretion, so as to produce  the  disgust
and  regurgitation remarked in the child.   It can only be determined  by
further observation.
                          CHAPTER  II.

                        NURSING OF CHILDREN.
   It must be evident from what we have stated, that everything is Avonder-
fully prepared at the time of delivery for enabling the mother to suckle her
child; but inasmuch as all  are not equally fitted  for fulfilling the latter
duty, several kinds of nursing have been distinguished, each based upon the
source of the milk designed for the neAV-born child, as also upon the mode
of its  administration.   Generally, the  mother  supplies  her infant Avith its
first nourishment, and her lacteal secretion is entirely sufficient to satisfy all
its demands.   The mother may possibly be unable in some cases to furnish
of herself all the milk that her offspring requires, and be obliged to supply
her insufficiency by food from other sources.  Sometimes she is altogether
incapable of  suckling her child, Avhich  is then  confided to another nurse.
Finally, there are cases in Avhich,  notwithstanding  the impossibility of
nursing on the part of the  mother, she is unable to secure either a Avet-nurse
or an animal, and is compelled to have recourse to artificial nourishment.
   The order  Avhich we  shall  follow in  describing the various modes of
nursing is based upon the varieties just indicated, and we shall treat succes-
sively : 1, of nursing by  the mother ;  2, of mixed nursing; 3, of wet-nursing;
4, of suckling by animals; and 5, of artificial nourishment.

                            ARTICLE  I.
                       NURSING BY  THE MOTHER.
   The mother's  milk, being designed by nature  for the nourishment of the
enild, is  certainly the best adapted  to  its requirements.   Therefore, Avhen-
ever the female  is in good health, Avhen her strength is not prostrated by
any serious disease, Avhen the antecedents of the family are such as to remove
all doubts on the score of hereditary influence, there is every reason Avhy she
should yield to  the promptings of nature.  There is no necessity for being
so strict toAvards the mother, as regards vigor of constitution, quality of the
milk, and development of the breasts, as it is  proper to be in choosing a
nurse.   Were Ave, in fact, to regard those Avomen only as capable of nursing,
who have the robustness and strength Avhich we require in mercenary nurses,
Ave should be almost obliged to relinquish the idea of seeing the majority of
females in the upper classes suckle their own children.   We often find  per-
sons of this  description, Avho  have  but little milk, and that of medium
quality, Avho yet raise very fine children ;  and what is singular, if these very
same Avomen  should nurse another child, it is found to become emaciated for
waut of sufficient nourishment. 
1070
HYGIENE OF  CHILDREN.
  Without admitting that suckling protects  neAvly-delivered Avomen  from
many diseases to Avhich they are liable Avhen  they do not nurse, and whilst
acknt wledging that it exposes  them in a special manner to fissures of the
nipple, and to engorgement and abscess of the breast, I  regard it as so im-
portant to the child  that I make it a point to  recommend it in the absence
of any formal contraindication, such as, a very lymphatic constitution, the
presence of skin-disease, or of  predisposition, hereditary  or otherwise, to
phthisis pulmonalis.
  When a pregnant woman  proposes  suckling her child, the physician is
often consulted in regard to her fitness for the  task, and the  future qualities
of her milk.  This question  is  usually very difficult to  answer.   Still, by
taking in consideration the state of the  constitution, the  changes  which the
breasts undergo, and the quantity and  quality of the  sero-lactescent  fluid
which  they  furnish, (see Lactation,) we may  be  able, in the majority of
cases, to form a tolerably correct opinion.
  Sometimes the anticipations of the physician seem to  be at fault  during
the first weeks subsequent to  delivery.   There are some individuals,  Avho,
having commenced nursing in opposition to the advice of their accoucheur,
and  finding their  milk  abundant  at the outset, think themselves excellent
nurses and make light of our fears ; but, as M. Donne observes,  this abun-
dance at the first is not ahvays  a surety for the future: the least  promising
women often have considerable milk at the commencement, and the first
milk is always rich enough for a new-born child. Everything seems to go on
well, and it is not until after the lapse of six Aveeks or two months, that the
diminution of the milk, the emaciation of the child, or the disordered health
of the mother, begin to be perceived.

  § 1. Precautions to be observed  in relation to  Women  who pro-
pose  Nursing.
  Most  of the preliminary precautions  have reference to the conformation
of the nipple.  The varieties which it presents  may call for the employment
of some preparatory  measures, and  even, in some cases, constitute a formal
contraindication to the nursing.  Thus, certain women  have a very short*
nipple, so that it barely reaches  the level of the breast, whilst in others, its
place is occupied by a depression  rather than a projection; lastly, in some,
the nipple is  extremely sensitive  even  before pregnancy, and during the
cold season becomes chapped and  fissured.  When the nipple does not pro-
ject at all, and especially when its  place is occupied by  a depression, suck-
ling Avould prove so difficult for the child and  so painful  to the mother, that
I advise its  relinquishment  altogether.   Although the means  employed
hitherto for drawing out, and, as  it Avere,  moulding the nipple,  are some-
times effectual Avhen it is only too  short, they rarely succeed in  making it
project Avhen it does not exist at all, and often give rise to serious accidents.
Thus it has been recommended :
  1. To titillate the nipple frequently during  the tAvo last months of gesta-
tion ; but this is  irritating,  often  becomes painful, and has finally to be
given up.
  2. To use nipple shie Is.   These are little concave plates of turned wood; 
NURSING  OF  CHILDREN.
1071
 having a small excavation  in  the  centre for the reception of the  nipple.
 The patient applies this plate when she is dressed, and draAvs the gusset of
 her corset so as to press strongly upon it.  The compression being applied
 on  all parts except the nipple, causes it to  project strongly, so that after
 Avearing it for tAvo or three  months, the nipple is lengthened to the extent
 of three-eighths of an inch.   When the mere application of the shield is not
 found to ansAver, a pump is adapted to its  extremity, each strode of the
 piston of which draAvs upon the nipple and occasions it to project.  But as
 the skin of  the nipple is subjected to incessant rubbing against the sides of
 the shield, it is liable to become inflamed in consequence.  The same remark
 applies to  the species of A7ials, furnished Avith a narroAv opening, which  is
 applied upon the nipple, and provided Avith a long curved tube, Avhich ena-
 bles the Avoman to produce tractions by exhausting the air with her mouth.
    3. Direct and repeated suction is, doubtless, the  best means that can be
 employed.   This may be performed by the husband or an intelligent servant-
 maid.  In the Avant of a sufficiently accommodating individual, a large
 puppy may be used, first taking care to wrap up  its paws.  The reason why
 suction is the best means that can be used is, that the gutter formed by the
 tongue keeps the  nipple extended, and prevents  the oscillating movements
 communicated by the pump.  Besides, when  the  nipple is moistened by the
 saliva, it  becomes more supple  and extensible.   After  this suction, says
 Li-ardien, the nipple is to be Avashed with warm Avine, in order to give firm-
 ness to the cuticle.   The Avashing  completed, they should be covered with
 tubes of white wax or gum-elastic, to keep them elongated and protect them
 from rubbing.  To make the nipple-covers of wax, a piece of this substance
 is put for some time in warm Avater, in order  to  soften it, and its centre is
 next depressed Avith  the finger  or a thimble to a sufficient extent to receive
 the nipple.
   The extreme sensibility of this part in some Avomen who have never had
 children, also calls for the use of  some means of  hardening, of tanning a
 little, the skin Avhich covers it.   This is easily effected by the use of lotions.
 consisting of alcohol and Avater or astringent solutions, continued for several
* months.
   These  precautions, judiciously employed,  often render  nursing possible
 ami even easy, Avhich Avithout them Avould have been impossible, or at least
 very painful at the outset.

   § 2. Rules op Nursing.
   Everything being' properly prepared, the  mother is about to suckle her
 child.  Now, in order to present in a regular manner the practical precepts
 •vhich should govern the nursing, it will be useful  to divide the time of its
 continuance into  several  principal periods, Avhich, being characterized  by
 peculiar phenomena on the part of both mother and child, give rise to special
 judications.  We shall  divide the nursing into three periods : the first ending
 ivith the milk-fever, the second  extending  beyond  the term  of six months,
and the third until Aveaning.
   First Period.—The first  period is of very short duration, constituting, so
 co speak, the transition stage betAveen the intra-uterine nutrition, Avhereby 
1072
HYGIENE  OF  CHILDREN.
the child derived the nutritive elements ready elaborated from the maternal
economy, and the suckling, properly so called,  by which it still receives,
indeed, a special nutriment from the mother, but one Avhich  has to undergo
elaboration in its own intestinal canal before being assimilated.  The phe-
nomena which mark this  period are, in fact, preparatory on both sides:  on
the part of the mother, Avhose milk  gradually loses the characters of colos-
trum, to assume those of a more nutritive fluid ; and on the part of the child,
Avho gradually becomes accustomed  to, and skilled in the performance of
the neAV function, and who also  finds in the fluid  provided by the mother,
purgative qualities, Avhich clear out the intestinal canal,  and thus prepare it
for the digestion of more substantial food.
   As we have already stated, the colostrum secreted by the  mammae at the
time of delivery, or  shortly after, is sufficient  in quantity to satisfy the  re-
quirements of the child.   It may,  therefore,  strictly speaking, be  put at
once to the breast, and  the doing so Avould in  many cases be attended Avith
no inconvenience Avhatever.   The efforts Avhich  it  makes to suck are gen-
erally sufficient to excite or  increase the secretion of milk in primiparse.
Still, as the mother's strength is often exhausted  by the  pains of labor, and
she needs a season of rest and quiet after several  sleepless nights, it would
be cruel to oblige her to nurse her child immediately, there being really no
occasion therefor.  On  this account, it is customary to defer it for seven or
eight hours, after Avhich time she is presented with her child.   But as the
latter Avould be inconvenienced by remaining so long Avithout food, it is well
to give it a few dessertspoonfuls of Avarm  sugar  and water,  about an hour
after its birth.  This should  be repeated every two hours at the soonest, or
every three hours at the latest, until it is convenient to the mother to put it
to the breast.  This mode of procedure has the  advantage of clearing the
mouth and fauces  of the mucus Avhich so often obstructs them.  Should the
mother from any cause  be unable  to give  it suck for several days, a substi-
tute should  be prepared, by adding about one-quarter  of the amount  of
cow's milk to the sugar and water.
  Some persons have imagined that  the putting  of the  child  to the breast
might be deferred  Avith  advantage for twenty-four,  thirty-six, or even forty-
eight hours ; and some authors Avould even  have us  Avait until the milk-fever
is over.   This plan is liable to several  serious objections.  Thus, the child
is deprived during all this time of a fluid Avhose  nutritive qualities are per-
fectly suited to the  condition of the intestinal  canal,»and Avhose laxative
properties enable us  to dispense Avith the  purgatives  so often  required  to
expel the meconium in  children  Avhich are brought up artificially.  On the
other hand, the sucking of the child facilitates the Aoav of the milk, prevents
the inordinate SAvelling  of the breasts  and the pain Avhich  so often results
therefrom;  it  gives  form to the nipple, Avhich is seized Avith much greater
difficulty when the breasts are SAvollen and  tense,  and obviates the milk-fever
almost entirely.  Therefore, "in the  interest of both mother and child, we
think it right not to nurse immediately after delivery, but also not to post-
pone it longer than from six to twelve hours.
  Before putting the child to the breast for the first time, it is important to
wash  the nipple with warm Avater, in order  to remove  the  concretions  of 
NURSING  OF  CHILDREN.
1073
 sebaceous matter which may have collected in the bottom of the groores in
 which the  lactiferous ducts discharge.   The Avashing has the additional
 effect to  moisten it, make it more supple, and  render it  less unpleasant to
 the child.
   It is necessary at the outset to put the nipple in the child's mouth;  for as
 it is guided only by a blind instinct, it takes  anything presented to it, and
 might seek for  a long time without success.   Most children perform very
 well at the first attempts; but this is not always the case, for, independently
 of the difficulties due to  the shape and size of the breast and nipple, which
 difficulties we shall speak of hereafter, there are others depending upon the
 manner  in which the  breast  is  presented to  it: thus, the face of the child
 being applied  against the  breast, if care be not  taken,  its nose will be
 stopped at the  same time that its  mouth is filled by the nipple, and, being
 unable to breathe, it AvithdraAvs from the breast.   Therefore,  it should ahvays
 be seen  to that the nostrils are  kept free.  At other times, the nipple, in-
 stead  of being grasped by the upper surface of the tongue, into the concavity
 of which it should  be received,  is placed  beneath  the point of that organ
 upon  the floor  of the buccal cavity, Avhence  suction is impossible.  Levret
 mentions a remarkable  disposition of  the tongue, Avhich  is curved  into  a
 gutter, and adheres to the palate;  in this case, it should be  detached Avith a
 spatula.   The  motions of the tongue are sometimes hindered  by shortness
 of the fraenum, Avhich also  prevents  it from being  projected fonvards.  In
 this case, the framum should be  cut.1
   As  other circumstances AA'hich  may render nursing difficult or impossible.
 should be noted certain sublingual tumors, hare-lip Avith division of the hard

   1 The frsenum linguae is sometimes, but  more rarely than those accoucheurs seem to
 think who cut it  in most new-born children, too long from before  backward, at the
 same time that it  is too short  from  below upward.   The point, being then arrested
 against the lower parietes of the mouth, remains behind the. alveolar ridge, and can
 hardly be put forth between the lips.  When  the child cries strongly, the tongue is
 seen to be held downward and forward by a transparent partition, which prevents it
 from being raised and carried forward.
   The  operation  to be performed is of the simplest character.  The  head of the child
 being held slightly backward, an  assistant pinches  the nose to  oblige it to open its
 mouth.  The fraenum is engaged in the slit of the plate attached to the grooved director,
 and then raising the tongue  forcibly,  the surgeon, holding a pair of blunt scissors in
 his right hand, divides the fraenum at a single stroke,  taking care to direct the point
 of the scissors downward ami the farthest possible from the tongue.
  The accidents to  which the operation is liable are:  1, the falling backward of the
 tongue into the pharynx, witnessed three times by J. L. Petit, and which would  have
 suffocated the child had not  the organ  been promptly restored to its position by the
 finger ; 2, hemorrhage from  wounding the ranine veins.   It is the more important to
 iletect and suppress the  hemorrhage, as it. would be kept up by the constant move-
 ments of suction or deglutition.   It is remedied either by touching  the bottom of the
 wound  with a fluid  caustic or by cauterizing the injured vessel by means of a stylet
 heated to whiteness ; or, lastly,  by Petit's  bandage,   fhis consists of a fork of wood,
 an inch and a quarter  in length, covered with linen, one  end of which rests against
 the symphysis of the lower jaw, whilst the other embraces the apex  of the wound  It
 is held  in place by a small bandage placed across the mouth, assisted by another turn,
then crossed below the jaw, and carried up  above the ears, to  be fastened to tho
child's cap.
       68 
1074
HYGIENE OF  CHILDREN.
and soft palate, and  the facial hemiplegia which so often folloAvs the use of
the forceps.  As  the latter accident is generally evanescent, the artificial
nursing need be but temporary.   The sublingual tumors should be incised
or extirpated as soon as possible.   The division of the hard and soft palate
renders suckling almost always impossible.
  Some children, either from congenital debility, or from sloth, or Avant of
activity, seem as  though they would not take the trouble to suck.  After
putting the nipple far back in the mouth, the mother should be directed t(
move it about, in order to tickle the tongue and solicit its action.   With the
same  object, the  nipple  might be pressed a little, so as to project a feAV
drops, or Avhat is better, since this is  difficult in  primiparae,  a piece of  linen
dipped in SAveetened Avater  should be squeezed upon the base of the nipple,
which would conduct the fluid between the lips applied to its extremity.
  NotAvithstanding all these efforts, certain children seem unwilling to make
any attempt to suck, neither do they indicate any Avant by their cries, but
sleep  almost constantly.  The  mothers are gratified by this  repose of the
child, Avhich affords them opportunity of enjoying the quiet Avhich they %o
much need, and are careful not  to  disturb it  by putting  it to the breast.
But  Avhen  it awakens after a longer or  shorter time, or Avhen, becoming
anxious on account of its prolonged sleep, the parent takes it up, it is found
to have lost all its  energy, cries very feebly, and is unable to suck.   No
time  should then be lost  in endeavoring to stimulate it in every manner
possible.   It should be undressed, placed before a warm fire, and rubbed
actively with flannels either dry or moistened with camphorated spirits.  It
should be obliged to  take the nipple  if possible,  and not succeeding in this,
it should be put to a nurse, whose milk  Aoavs freely, and Avho can gradually
express a feAV spoonfuls into its mouth.  These  poor children can generally
be restored in this manner; but we are often obliged to let them remain for
a fe\v days  Avith  a Avet-nurse, Avhose milk  flows  so freely as scarcely to  re-
quire any effort at suction,  before returning them to their mothers.
  The condition just mentioned is far from  being uncommon;  and, for my
own  part, I have  several times had charge of children who, in this way,
have  inspired me with the  greatest anxiety. Therefore, Ave should ahvays
advise the  mother never to alloAV more than  tAvo or  three hours to pass
without giving drink or suck to her child, and, at any rate, ahvays to waken it.
  The first attempt at sucking soon  fatigues it, which is explained both by
its weakness, and the effort Avhich  it is obliged to make.  Thus, during the
first tAvo days, it can hardly perform more  than four, six,  or eight regular
and continuous suctions,  before it is obliged to stop and begin again after a
feAV moments. The interval between each attempt is generally longer as the
child becomes Aveaker, either on account of its increased debility, or because
it has nursed so recently.   Sometimes it even falls asleep upon the bosom
after some  efforts, and has  to be aAvakened  by striking it lightly upon the
cheeks, buttocks,  or  feet.   The acts  of  sucking  are occasionally so distant,
that  the child  may  remain in this Avay at  the  breast for half an hour, or
even longer.
  Now, this sIoav nursing  may become very painful to the  mother.   In
France, Avomen generally sit up  in  bed for the purpose, and when obliged 
NURSING  OF  CHILDREN.
1075
to remain bng in that position they find  it very fatiguing.   It is j recisely
to avoid this that I would desire to popularize the practice that I have seen
adopted Avith the greatest success by American Avomen, namely, to lie on the
side corresponding to the one  on Avhich they intend to  nurse, and placing
the child lengthwise with the breast, alloAV the nipple to fall into its mouth.
They may retain this  position for  a long time Avithout experiencing any
fatigue.
   During the first days, it is very important to watch the child very closely
whilst at the breast, so as to be sure  that  it really sucks and  swalloAvs the
milk.   Either because the milk comes Avith  too  great difficulty, or because
the child Avill not, or cannot, make the necessary effort, it is  seen, indeed, to
make  certain motions of the cheeks resembling  suction, and  yet does not
SAvalloAv.  If a finger be placed upon the larynx, Ave shall be able to tell by
its movements during deglutition whether  the latter is accomplished.  Be-
sides, a sort of rustling sound is often heard produced by the passage of
fluid from the mouth into the oesophagus.
   When the child has been put to the breast from  the  first day, the milk-
fever Avill rarely  be considerable.  The frequent emptying of the breasts by
the child also prevents them from becoming distended and painful.   Some
women, hoAvever, have so much milk at this time, that the  mamma? are
exceedingly SAvollen and the nursing  becomes, temporarily, more annoying
to the mother and difficult  for the child.   It is more  troublesome to the
mother, because the sucking gryes pain, and the swelling of the gland extend-
ing even to  the axilla, causes suffering Avhen  the arm is brought doAvn to the
chest, \vhich has  to be done in order  to hold the child properly;  it is more
difficult for the child, because  this extreme distention renders it less able to
seize the nipple.   The SAvelling of the mamma; effaces or depresses the latter,
until it can no longer be grasped by the lips of the child.   When this occurs,
it is often necessary to empty the breast by means  of a  pump.   The Avith-
draAval of a  certain amount of milk relieves the pain caused by the SAvelling,
and restores the nipple to its usual length.
   As the child obtains but very little  milk at a time for  the first few days,
it should be put to  the breast at very short intervals.   Still, it  is Avell  to
accustom it  to a certain regularity in the time of taking its repast.   Children
ahvays  suffer from irregularity in their meals, sometimes leaving too  long
an interval  betAA'een them, and sometimes introducing  a fresh  portion of
milk into the stomach before giving them  time to  digest  what' they had
recently taken.   Without pretending  to mathematical precision, Ave would
state that the new-born child ought to nurse  at intervals of about two hours
at the shortest, an(J. of three hours at the longest.   When  it is  feeble, or
born prematurely, and therefore able to take but very small  quantities at a
time, the intervals might be shortened.  We must, I think, allow it to judge
for itself of the amount that it shall  take  at each time,  except under pecu-
liar  circumstances.  What Avould be  plenty for  one,  Avould  be insufficient
for another,  besides,  as  children are  capable of rejecting the  surplus from
their stomachs, there is no great harm in allowing them to tf.ke rather more
than they really need.
  Second Period. — When the milk-fever is  over, the breasts are in full 
1076
HYGIENE  OF  CHILDREN.
activity,  and from that time commences  the nursing properly so called
Although it is unusual  to have to contend any longer Avith  the  difficulties
mentioned as pertaining to the preceding period, there  are yet some precepts
which may be usefully applied.
  The first care to be taken before giving the child suck, is to be sure that
it really needs it, for it  ought never to be put to the breast for the sole pur-
pose of stilling  its cries, as, unfortunately,  most young mothers are nearly
certain to do.   The fact is, the cry is not ahvays to be taken as an expres-
sion of suffering or of real Avant.  The child cries as Ave speak; very often, it
is  simply an act whereby it  indicates  its individual existence, and  is so
habitual  during its earliest days, that it sometimes seems to indulge in it as
a matter of enjoyment.  Some children cry without any appreciable reason,
and yet, notAvithstanding their continual agitation, and often long sleepless-
ness, do not  seem to be any the worse for it.  Such  children the nurses com-
monly call bad, and the epithet is tolerably Avell deserved.
  To judge Avhether the cries of a child  are indicative of a  desire to nurse,
we  should take into consideration the  other signs which accompany them,
as also the time of its last repast.  The cry of hunger  is generally attended
with active movements  of the upper extremities.  The child turns its head
from right to left, and opens its mouth as  though seeking for the breast;  it
seizes eagerly the end of the finger, or any  soft and round body that may be
placed between its lips,  and sucks at it repeatedly.
  When the proper moment arrives, before presenting  the breast, the nipple
should ahvays be moistened  either Avith  a  little milk  or saliva.  Then, the
mother holding the child jn her arms and resting its head upon one of them,
puts the nipple in its mouth, taking care to press lightly upon the areola so
as to project a little milk, and intimate, as it Avere, to  the child, that it can
suck Avith advantage.  These precautions are  hardly necessary except during
the earliest weeks, for after this it throAvs itself upon the breast and seizes it
so powerfully as to make it a painful operation.  In some cases even, so far
from exciting  it, it is necessary to restrain its avidity by withdraAving the
nipple from  time to time, as when, not  having nursed for several  hours, it
SAvalloAVS in  a rapid and gluttonous manner.
  The mother should put it to both breasts at the same meal; they are thus
kept disengorgecl, and by dividing the service, the nipples  have time to rest
from the effort of suction Avhich often irritates and inflames them.   The child
is also thus early accustomed to nursing from both sides. If, as often happens,
it appears to prefer one side in particular, and refuses to nurse from the other,
that breast  should be  first presented  which it seems to  prefer  the  least.
Hunger Avill soon overcome its repugnance, so that after some hesitation it
will conclude to take the breast Avhich it Avould  have refused if presented
the last.
  It is well  to watch the child attentively Avhilst nursing, at least during the
first weeks.   It will then be ascertained Avhether the sucking is apparent or
real by observing the motions of the larynx during deglutition, as also by
hearing the sort of rustling of Avhich Ave have spoken.   The  amount of milk
which it takes can be judged of more certainly by noting the length of time
which it rests though still retaining the nipple in its mouth.  It often  sleeps 
NURSING  OF  CHILDREN.
1077
after nursing;  the Avarmth which it receives from the mothei whilst lying
in her arms, and the sort of enjoyment which it finds in keeping hold of the
nipple, also, Avhen it has sucked quite recently, the repletion of its stomach,
all tend to in /ite slumber.
   As  soon as the  child is discovered to be sleeping, it  should be  aAvakened
at once and caused to suck agajn, if there is reason for thinking that it has
not had enough; but when the contrary is the case, it should be taken away
immediately and laid in its cradle.  The infant soon contracts the habit of
falling asleep and sleeping with the  nipple in the mouth, and ere long it
becomes impossible  to put it to rest otherwise.   It is plain that the practice
must be fatiguing to the mother, especially at night.
   It is very difficult to determine  the quantity of milk  that  it  should be
allowed to take at each repast, and hoAv  long  it ought to  be  permitted to
suck.  The latter will evidently vary Avith the abundance of the milk, the
ease Avith which it Aoavs, and the length of time that the child rests.   As Ave
have said, there is no objection to alloAving it to become satisfied  in the ab-
sence of special indications suggested by  disease.
   The child should be nursed less frequently as it grows older.   After the
first tAvo or three Aveeks, it Avill be sufficient to give it the breast every three
hours, and if the  milk is  of good quality, the intervals between the repasts
may be still further lengthened towards the third or fourth month; this dis-
tribution  must, hoAvever, be someAvhat modified  in the  day or the  night.
The intervals of nursing at night  must be greater from  the beginning, so
that it shall suck  but three times from ten  o'clock in the evening to  five or
six o'clock  in the morning.   After a month, even the intermediate  repast
may be relinquished.  If the child sucks but little at a time on account of
debility, and therefore seems to require the breast oftener, a little diluted
cow's milk may be given  once or twice in its stead.
   There can be nothing absolute as regards this determination of the hours
for nursing; for although Ave  have recommended that the child's sleep be
interrupted in order to give it food, this  should not be done at a more ad-
vanced age.   A child of from tAvo or three months old  will ahvays aAvaken
spontaneously when  it feels the Avant, artd the dangers that we have spoken
of are no longer to be feared.  Therefore it may be alloAved  to sleep on.   Still,
these precepts should be conformed to, for by leaving a proper interval be-
tween  the repasts, the child  receives sufficient food, it has time to digest
Avhat it has taken, and the acid  regurgitations, and the passage of curdled
but otherAvise unaltered milk, the sure indications of  a  bad digestion, are
avoided ;  besides  this, it  has  the advantage  of  preventing the  enormous
embonpoint, the puffy cheeks, and dead  hue of the  skin Avhich sometimes
•'ndicate a Aveak constitution.
  This plan is  attended with the happiest  results, especially for Avomen of
the upper classes, for whom  sleep, and  that undisturbed, deep,  and suffi-
ciently long, is  even more necessary than food to the reparation of their
forces.  Most of the nervous Avomen of large cities should have at least six
or seven  hours  of good  uninterrupted sleep, under the  penalty of being
obliged to Avean their children  very early; then, after having nursed the
child y bout five o'clock in the morning,  they may take another nap  of tAvc 
1078
HYGIENE OF  CHILDREN.
or three hours, if they require it.  It Avould be a great mistake, says M. Donne,
to suppose that the children suffer from this  system.  When observed from
the beginning, they sometimes become accustomed  to it, Avithout  having any
trouble in sleeping as long as their mother,  and they never suffer from the
coav's milk that is given to them.   They are thus trained to take the bottle,
so that should anything aftenvard oblige the  mother to suspend nursing tem-
porarily, there Avould be much less difficulty  in engaging them to accept the
artificial nourishment, for Avhich children who  ha\'e never  knoAvn anything
but the breast sometimes manifest an invincible repugnance.
  Sleep is so  necessary to nursing  women, that not only should they never
give suck, but, Avhenever possible, the child should be kept from its  mother
at night.   Having  obtained an  intelligent and faithful nurse,  she should
be intrusted Avith the care of Avatching over the child, giving it drink at night,
and taking it to the mother only at stated times.
  Third Period.—As the object of the  first period Avas to prepare the child
for receiving a special elementary nourishment, it is proposed in the latter
gradually to remove it from the mother, and  so  accustom it to all kinds
of food ; in a word, to render its existence entirely independent.  Therefore,
the office  of the physician is limited  to determining  the  period  at Avhich
other food may be added to the mother's milk, as also the time Avhen it may
be proper  to wean the child entirely.
  Practitioners are  far from being  unanimous in relation to the period at
which other food  than the  mother's milk  should be given to the child.
" Nurses from  the country," says Desormeaux,  " are usually in the habit of
giving to their children a §ort of pap made of fine wheat flour and coav's milk,
after the first week;  they are impressed  Avith  the idea that this food relieves
the colic, to Avhich neAV-born  children are very subject.  Whether.it  really
has this effect, or Avhether the digestion,  by being  made still  more difficult,
throws the child into a kind of torpid condition, it is often  observed to be
more  quiet after taking it;  at the same time it produces a favorable  change
in the color and  consistence of the excrements.  On the other hand, Avhen
the children are confined to the mother's milk, provided it is  sufficiently
rich and abundant, they are not more subject to flatulent colic than others.
From all this I am disposed to infer that the first  method,  when prudently
folloAved, is without inconvenience in the majority  of cases,  whilst in  certain
others it  may be advantageous.  Nevertheless, I am persuaded that the
latter is the best and surest, especially for weakly children."   Desormeaux's
conclusion seems to me to lack  precision, and I  only quote it here for the
purpose of opposing the tendency it might have to encourage certain pre-
judices which, unfortunately, are  but  too  widely prevalent.  The paps,
soups, &c, which are given to children  in certain countries almost as soon
as they are born, are at least useless  and often dangerous.   There are, doubt-
less, strong  and robust children who may s Aval Ioav them Avithout inconven-
ience.  But Avould they have thriven less had  they been confined to their
mother's milk?  This is Avhat I deny, and have at the same time no hesita-
tion In asserting that such a regimen Avould prove dangerous to the greater
number.
  When the mother is a good nurse, that is  to say, when the performance 
NURSING  OF  CHILDREN.
1079
,)f her duties does not fatigue her, and the milk remains unchanged in qual-
ity and  amount, the child should be restricted to it as far as possible for the
first six months, with the exception of the additions mentioned for the night.
We shall see hereafter, when treating of the mixed method, ay hat the reasons
are which may lead to a modification of this rule, and to which I shall submit
unreservedly Avhenever a hired nurse  is concerned.   Desormeaux  thinks
that the air of large cities is generally less pure and stimulating than that
of the country; and therefore, that the  child should be supplied sooner with
a species of nourishment capable  of supplying, to some extent, the deficien-
cies of the air.  He adds that the same is true as regards children brought
up  in low and moist places, as also for those of a lymphatic temperament,
or whose parents are feeble.  Neither can  I agree on this point Avith the
celebrated  accoucheur.  Doubtless, Avhen the bad constitution of the chil-
dren is due to the mother's  weakness or the defective quality of  her milk,
coav's milk, and not broth or pap,  should  be substituted for it; but I  cannot
think that a residence in cities, or in  low and moist places, is  a sufficient
reason for an earlier administration of food, which is unnatural to the child.
Infants living under bad hygienic conditions suffer from a susceptibility on
the part of the intestinal canal, to Avhich the robust children of the country,
whose digestive poAvers are far more developed, are not liable.   To give a
feeble and  delicate child food of difficult  digestion is  to task the alimentary
canal beyond its powers, and could  only result in incomplete elaboration
and imperfect assimilation; fortunate indeed Avould it be, should it not give
rise to chronic enteritis, with its attendant diarrhoea and emaciation.
  Kinds of Food.— Farinaceous  substances  ouglrt to be  prepared, such as
wheat, and rice flour, potato starch, and arrow-root, in connection Avith milk,
so as to form a well-cooked pap of variable consistency ; Avheat flour slightly
dried in the oven, taking care to avoid  roasting or browning it, Avhich would
injure a portion  of its  nutritive elements, is generally chosen.   This flour,
Avhich contains a.large proportion of gluten,  is very nutritious.  The articles
mentioned may,  hoAvever, be varied to suit the taste and  condition  of the
child.   Thus, rice cream would be preferred if the child were somewhat de-
bilitated, potato starch as a refreshing  diet, and arroAv-root as a light food.
Panada, made of Avell-baked Avheaten  bread, dried in the oven  and  then
reduced to a coarse poAvder, forms an excellent diet.  It is boiled for several
hours Avith  a sufficient amount of Avater, and aftenvard passed  through a
silk or hair sieve.
  About five or six dessert-spoonfuls of these preparations may be given at
first every morning.  Before long, they may be administered twice  a day,
besides  having added  to them  sliortly, semoule or vermicelli, Avell  cooked.
When the child is  seven or eight months old, it may take chicken-broth or
light soups.   A little later, it can  have the yolk  of a boiled  egg, carefully
rejecting the white, and finally, it may be allowed to suck a  piece of fowl,
or,  preferably, a bone of foAvl, also a crust of  bread Avhich it  can chew and
swalloAV only after  having moistened it sufficiently with saliva.
  The Avater reddened with claret and  sAveeteued  slightly, Avhich  M.  Donne"
recommends giving after the age of six  months, should, I think,  be Avithhelq
rather longer, and even then ought to be  administered very carefully. 
1080
HYGIENE OF  CHILDREN.
  As the child becomes  accustomed to other food, it seeks the breast with
less  avidity, although still retaining  a  marked  predilection  for  it.   The
mother can then suckle  it less  frequently without disadvantage.  ToAvard
the seventh or eighth month, she need nurse it but four or five times a day
and  still later, two or three times, in the meanwhile ceasing to give  it  the
breast at night altogether.
  This  progressive diminution  habituates  the child to doing without  the
breast, develops its taste for other food, and also decreases  the Aoav of milk:
so that Aveaning becomes easier  for the child and less troublesome to  tne
mother.
                           ARTICLE  II.
                               WEANING.
  At what age ought the child to  be weaned f  The natural  period is that at
which the first dentition is accomplished; for not until then is the child pro-
vided with the organs necessary to the mastication and  insalivation of  the
food.   But  it often happens that the first dentition is not completed for a
year or a year and a half, and  it is very unusual to defer taking the  child
from the breast so long as this.  The delay would be attended Avith serious
disadvantage to both  mother, and child;  the mother  would become  ex-
hausted by her long nursing,  and her milk finally lose  its good qualities;
besides  this, the children themselves, after' a  certain age, seem to require
more substantial food; some, in fact, retain a pallor and puffiness of  the
features, as Avell as general debility so long as they continue to  nurse, and
assume  a rosy hue, a lively and  happy expression, and firmness of flesh, as
soon as they become accustomed to a more nutritious food.
  When care has been  taken to habituate the  child  to something else
than milk from the time it  is six or seven months old, but little difficulty
will  be experienced  in weaning it completely; and nursing may be given
up Avithout disadvantage, as soon as dentition  has made considerable pro-
gress.   Still, I  think it  very important to take into account the greater or
less rapidity and facility with Avhich the evolution  of the teeth is accom-
plished. As a general rule, weaning  is not to be thought of before the child
has from eight to ten teeth,  Avhich would be about the age of twelve or six-
teen months.  But if the dentition  is delayed, painful, or accompanied by
some of the affections to Avhich the child is liable in its second year,  there
is an advantage, Avhilst giving the child  other food, to keep it at the breast,
allowing it to suck at least tAvo or three times a day.
  It is, indeed, an invaluable resource dining the sufferings of painful den-
tition.   The child then refuses  other kinds of food, and will take nothing
but the breast, so that it Avould be very difficult to nourish  it if weaned
prematurely.  Therefore, a system Avhich at once provides it with food and
alleviates  its sufferings, must  be very  desirable.   In cases of retarded and
painful dentition it Avould be prudent to continue the nursing till the child
is eighteen or twenty months old.
  To fix  upon  any particular period for weaning, says M. Trousseau, is
simply  absurd, and for this reason:  Weaning should ahvays be suborduiate
to dentition.  The fact is, the period of  the first dentition, from the appear-
ance of the first incisors to that of the last molars, is fraught with peril to 
NURSING  OF  CHILDREN.
1081
the child.  It is subject to a multitude of disorders affecting the abdomen,
the chest, and the  head, especially the former.  Now, as the so-called dis-
orders of digestion  are the most frequently observed, it is  important to be
provided Avith a  diet Avhich the child shall not refuse, and which can neither
aggravate its condition, nor  give rise to any other disease.  But dentition
lasts for  three years: must the  suckling be continued all  that  time ?  No,
not absolutely ;  Ave should be guided by the following rules ;  they are very
easily remembered.
  The teeth are  evolved in groups.  How do they appear ?  There are several
6eries, as folloAvs : in the first, appear the two loAver median incisors; in the
second, the four  upper incisors ; in the third, the four first molars and usually
after  them the  tAvo lower lateral incisors; in the fourth, the four canines;
and finally, in the fifth, the four last molars.   These are the deciduous teeth.
  Let us next see how the groups make their appearance:
   1. The first incisors come  through at an interval of from one to fifteen
days, though generally on the same day;  and when  these tAvo first do not
appear Avithin tAvo  or three days of each  other, the dentition is  irregular.
When this is over,  the child  rests;  a fact of immense importance as regards
therapeutical measures.   It  rests from three to six months.   The tAvo first
teeth usually appear betAveen the seventh  and eighth  month, and the child
has aftenvard at least six Aveeks of quiet.
   2. The four upper  incisors are a month in coming  through.  First the
middle, and then the lateral  ones appear, and that betAveen the tenth and
twelfth month.
   3. From the tAvelfth to the fifteenth month, those of the third series come
through: then the child rests for four or five months, during all which time
the evolution of teeth  is suspended.
   4.  BetAveen the eighteenth and tAventy-second month, the four canines make
their appearance, and are three months in coming through, after Avhich there
is a very long repose.
   5. Lastly, the child gets its four last molars.
   It is Avell to knoAV that the teeth appear in groups, inasmuch as the child
is sick during the period of a dental evolution.  It coughs and has fever, but
after the teeth  are  through,  recovers Avith astonishing  rapidity.  Thus it is
throughout the entire period of dentition.   Now,  what is the right time for
Aveaning ?  Evidently it should be in the interval betAveen one evolution and
another,  and about seven or eight days after the teeth are through, and Avhile
the organs are  in a state of  rest.   We have  thus an  advantage of several
months,  Avherein the child can be accustomed to a neAV diet.
   After  Avhich of these evolutions is it best to Avean the child?  After that
o,f  the canines, ns being  the  most dangerous: the latter appear singly, and
are the only ones Avhich are croAvded.   The others meet Avith no impediments,
and none but the  canines are  embraced by the neighboring  teeth, Avhich
they are obliged to press asunder.  Therefore it is that the  cutting of these
teeth is accompanied Avith more severe symptoms.
   When it is decided to Avean a child which  has been for some time accus-
tomed to eating, it  is generally better to do it at once than to leave off nurs-
ing gradually ;  for by continuing to alloAV it to suck only  once or twice  iu 
1082
HYGIENE OF  CHILDREN.
the twenty-four hours the milk becomes altered, and might prove injuri us.
It is, however, advisable to begin at night,  and, without  considering it  a
matter of great importance, I Avould prefer the spring or summer to winter
for commencing.
   The mother ought, as far as possible, to give up her child to another per-
son, Avho should supply it Avith drink, and  render it all necessary attention.
Some children, so long as they knoAV that their mother is near them, refuse
to take any other  food, and  it is hard for a parent to resist  the tears and
entreaties of her infant.  Should it be impossible for the mother to put away
her child, she ought to try to disgust it by covering  the  nipple Avith some
substance of disagreeable taste and odor, such,  for instance, as aloes or mus-
tard.   I have rarely failed to succeed with the latter, for  most children
reject the breast with  disgust after having once tasted or even smelled it.

                          ARTICLE  III.
                     REGIMEN  OP NURSING WOMEN.
   We have but few remarks to make  in  relation to the precautions which
should be observed by a young Avoman Avho proposes nursing her child.   A
good  diet is indispensable  for Avomen who have to support the fatigues of
nursing.  Rich  and  succulent food,  beef-broth, Avhite and  dark  meats,
Avhether roast or broiled, should, doubtless, form in great - measure the prin-
cipal  elements of the meals; still, they ought not to be debarred from vege-
tables, milk, chocolate, and broiled preparations of the various farinaceous
substances.  They should avoid highly seasoned  ragouts, and an excess of
salt, pepper, vinegar, and other strong  and  indigestible condiments.  The
usual  drink  should be claret and water; the use of pure Avine,  alcoholic
liquors, and coffee, require  great discretion, and it Avere far better to  abstain.
from  them altogether.
   The number of meals  should generally be governed by  the habits of the
individual.  It is well, hoAvever, that they should not be too far apart, nor
so copious as to give rise to indigestion.
   We have already insisted on the propriety of the mother's obtaining a
sufficient amount of sleep, and  revert to it  only for the purpose of fixing
attention upon its importance; for Avithout it, most of the females in large
cities Avould find it impossible to nurse.
   A nursing mother ought to breathe a pure air, avoid dampness and cold,
and take a sufficient  amount of exercise.  The warm  bathing Avhich some
persons prescribe, I approve of Avhen not  too  long continued, and only for
the preservation of cleanliness.
   A residence in the country certainly is one of the best hygienic conditions
both for herself and child,  which often finds in frequent insolation and pure*
air a  substitute for deficiencies in the quality of the milk.
   The breasts should be carefully protected from the  air, especially at the
outset, and the child  should not be suckled in a cold and damp garden.   I
have  knoAvn  several  ladies to be attacked Avith  inflammatory engorgement
of the breasts from a neglect of this precaution.
   The  chest ought to be kept constantly covered with a piece of soft linen
folded in several  thicknesses, and changed as  soon as  it becomes moist, 
NURSING  OF  CHILDREN.
1083
 When the breasts are Arery large, they should be supported by c.arsets with
 ample gusgets ; for the mere weight of the glands is sometimes sufficient to
 render them painful and give rise to engorgement.
   Some Avomen have so much milk, that Avhen the child sucks on one si le,
 it escapes freely from the other.   To prevent the linen  from becoming too
 much moistened in this Avay, the  nipple is sometimes introduced into the
 neck of a sort of very flat bottle, Avhich receives the milk as it escapes.
   Finally, nursing Avomen  cannot be too  strongly  recommended to avoid
 sadness and violent moral  emotions;  Ave have already explained at length
 the effect Avhich they might produce.  " It may be said, in a general Avay,"
 M. Donne remarks, " that calmness and equanimity are  what young Avomen
 most frequently lack."   So  essential a  condition is this,  that I take into
 deep consideration the nervous condition of the mother Avhen judging of the
 propriety of her nursing, and if she is too  excitable, I prefer intrusting the
 child to a  Avet-nurse.  A mother Avham the least cry of  her child fills Avith
 anxiety, and who  cannot see it fretful  or  in pain  Avithout being overcome,
 Avill hardly fail to make a bad nurse.   A child is rarely  brought up Avithout
 suffering  some derangement or other of  its health, and  sometimes  even
 serious  disease.  It is precisely on such occasions  most  important to have
 the milk perfectly pure, Avhich  it never can be from the  breast of a mother
 who AviU not, or cannot control her emotions.

                          ARTICLE  IV.
 OF THE CIRCUMSTANCES AVHICH MAY RENDER  NURSING BY THE MOTHER
     DIFFICULT, AND OF THE ACCIDENTS THAT ARE LIABLE TO INTERFERE
     AVITH IT.
   § 1. Impediments to Nursing.
   We have  already treated of such malformations of  the  nipple as may
 sometimes be remedied by timely interference.   There  are some, however,
 such as the absence of this part, and its entire imperforation, Avhich render
 nursing impossible; but even  those  of  the kind first  mentioned, such  as
 shortness of the nipple, may make it equally impracticable, Avhen uot dis-
 covered until after the birth of the child, and Avhen about' to put it to the
 breast.
   The shortness of the  nipple may be only relative, that is  to say, though
 long enough  for a strong child accustomed  to sucking, it  is  too short for the
 new-born  infant, who cannot take it, or is  unwilling to  do so.  In  such
 cases, it is  Avell before putting the child to the breast to render  the nipple
 rather more projecting  by titillating it with the fingers, drawing it out by a
 pump, or haviijg it sucked by a puppy, an adult person, or, still  better, by
 a child from six Aveeks to tAvo months old.   The latter is  preferable Avhen it
 is  reasonable to suppose that the difficulties resulting from the shortness of
 the nipple  are increased by the Aveakness or the uiiAvillingness of the child.
A strong and vigorous infant, furnished  by another nurse,  Avould be able to
take the breast of  the recently delivered  female, and give  shape to the nip-
ples, whilst, on the other hand, the neAV-born child, deriving its nourishment
with ease and in  abundance from the breasts of the nurse,  grows rapidly
Btreuger, becomes  accustomed to sucking,  and after a feAV days may be re- 
1084
HYGIENE  OF  CHILDREN.
turned to the mother, who is then able to present it Avith properly formed
breasts.  Care  should be taken not to select too old a child; for, knoAving
its nurse, it Avould be unwilling to take the breast of another Avoman.
  Finally, as a last resort, the artificial nipples, in their most modern  and
improved form, may be tried.   Those made by M. Charriere  of softened
ivory, I think preferable to any others.

  § 2.  Erosions, Excoriations, Chaps, Fissures, and Cracks  op the
Nipple.
  These various  affections,  implicating  the nipple  or  its  base, bear  the
strongest resemblance to each other, and hardly differ except in  extent, and
more especially in their situation.
  Excoriation, of which erosion is but the  first degree, is a small, superficial
wound of the skin, in which the  derm is laid bare by  the removal of the
epidermis.
  When it has become  so large and  deep as to destroy the surface of the
derm, it constitutes an ulceration.
  It has no special seat, but may affect the entire surface, or only one or a
feAV points of the  nipple.  Its surface is often of a bright red color, granu-
lated, and frequently SAvollen ; sometimes it is ahvays moist, at others covered
with thin scabs.  Occasionally, sucking is followed  by a slight  effusion of
blood.
  The chap resultsi from the drying up, and imperfect removal of  the epi-
dermis, the dried  cells of which resemble  small scales.
  The fissure is an  elongated ulceration, generally  deeper than the simple
excoriation.   It forms at the bottom of the furrows, and takes  their direc-
tion ; usually, and then  too it is the  most painful, it occupies  the groove
separating the base of the nipple from the rest of the skin.
  Cracks are an exaggeration of the fissures, from Avhich they almost ahvays
originate.  They differ from the latter by the cracked, swollen, and extremely
sensitive condition of the surrounding skin.
  Inflammation of the skin  of the nipple  is the usual cause of the erosions,
excoriations, and  ulcerations which succeed  them; though  in some cases,
according to M. Deluze, (Inaugural  Thesis,) they are formed in the follow-
ing manner: When  the child seizes  the nipple, it  is placed in  a gutter
between the  tongue and the palate, so that all the efforts at suction are
brought to bear upon the extremity of the nipple towards Avhich the fluids
tend ; as this part is supported by nothing, it gives way, and  a small, bloody
streak can be detected upon it after nursing.   In some cases, the only effect
of the suction is to raise the  epidermis, and form a sort of pouch  or red spot,
beneath which a slight ecchymosis is  discoverable ; finally,  either  in conse-
quence of another act of nursing, or  spontaneously, the raised portion of
epidermis dries  and falls off, and excoriation folloAvs.
  The extension of the latter into the grooves of the nipple gives rise to the
fissures.
  Simple excoriation is far more common than fissures produced at once or
by rupture.   Thus, of 17 cases observed at the Clinique by M. Deluze, there
were but 4  cases of a spontaneous character. 
NURSING  of children.
1085
   I regard exposure of the nipple to cold, when yet Avarm and moist after
 sucking, as the most frequent cause of chapping.  Fissures and cracks may,
 no doubt, also take their origin in inflammation or the impression of cold,
 inasmuch as  they so often  follow ulcerations and  chaps; but besides this,
 they may often be produced mechanically, by the violent tractions upon the
 nipple during the act of sucking.
   They occasionally appear after the child has taken the breast tAvo or three
 times.  The sucking first produces acute pain, folloAved by violent smarting.
 A superficial  examination of the breast discovers nothing; but if the nipple
 be draAvn upon gently, so as to Aviden the  furroAvs Avhich traverse it, a slight
 redness with serous effusion  Avill be found at the bottom of one or several of
 them.  The fissure is not yet formed, but soon makes its appearance after a
 few more nursings; as each application of the child to the breast tends to
 increase it, a  true crack is  shortly formed, which  becomes covered Avith a
 scab or crust,  beneath Avhich it is common ■ to find a  small  amount of ex-
 travasated blood.
   However produced, these accidents generally  occur  in  the early days of
 lactation.  The normal sensitiveness of the nipple is not as yet  blunted, nor
 has the skin covering it had time to become accustomed to the  pressure and
 tractions Avhich it is destined  to undergo.  HoAvever,  although these ulcers
 or cracks rarely occur after  the tenth day, I have known them to be formed
 at a much later period, in Avhich case they seemed to me to have been  occa-
 sioned by the  biting of the  child, and sometimes by an aphthous inflamma-
 tion affecting  the latter.
   These slight accidents are generally suffered by Avomen  Avho nurse for the
 first time: such as have a fine and  irritable skin,  Avhose  breasts were very
 sensitive even before pregnancy, those  Avhose nipples  are  badly formed, or
 who wait for several days for the milk  to come  before putting  the child to
 the breast, thus obliging it to grasp the nipple more strongly with its lips, and
 to make greater effort to extract  the milk, are peculiarly exposed to them.
   Slight excoriations and ulcerations are  generally  supported Avithout much
 trouble; which is far from being the case Avith the fissures and cracks, Avhich
 are commonly exceedingly painful.  Those situated  at the base of the nipple,
 I have thought, occasion the most suffering.  When we remember the painful
 sensations resulting from the cracks  that  are liable to  form  on the median
 line of the loAver lip in Avinter, we may  easily imagine  the effect of those on
 the nipple.  The evident tendency of each act of suction is to  separate the
 margins  of the little ulcer.   Notwithstanding her desire to nurse the  child,
 the mother dreads the approach of the stated times, and instinctively recoils
 Avhen the babe is brought for the purpose.  At the moment of seizing the
 nipple, she is often compelled to cry out, and  continues to  groan for several
 minutes.  Generally, the sensation is less acute after the first few moments,
 but is reneAved Avith  dreadful intensity Avhenever  the child recommences
sucking after having stopped,  and especially when it seizes the  nipple  again
greedily; after having relinquished it altogether.  The suffering  is sometimes
so intolerable,  that  these unfortunates are observed to  bite their clothes or
coverings, to avoid crying out, Avhilst others writhe or are even affected with
convulsive movements. 
1086                HYGIENE  OF  CHILDREN.
   If the crack is deep and the suction strong, some blood flows frorn the edga
of the AA'ound.   This becomes mixed with the milk and is swalloAved.   Should
the child vomit, it  is found in  Avhat is  throAvn up, but if not, it is  expelled
in the stools, and  leaves its mark on the diaper.   The physician should
remember this fact, for he is often •consulted by parents Avho inquire in great
alarm  the  meaning of these bloody passages.   The  explanation is almost
always to be found  in fissures of the nipple, of which the Avoman had  not,
perhaps, complained hitherto;  but should he neglect making the examina-
tion, he might suspect hemorrhage of the boAvels, and thus help to continue
fears Avhich are really Avithout foundation.
  The irritation affecting the fissures is very often propagated to the skin of
the nipple, thence  to the areola or the cellular tissue which  lines it,  and
next, more deeply  to the  gland itself or to the interlobular tissue, thus
giving rise  to abscesses of the areola, or to those of a phlegmonous or glan-
dular character.  On the other hand, the suffering is sometimes so severe that
the mother avoids nursing from the affected breast as  much as possible, thus
helping to produce its engorgement and the abscess to which it gives rise.
We Avould add, finally, that in consequence of the  long detention of the
milk in the ducts,  it becomes  deteriorated, and assumes the characters of
colostrum.
  The  sufferings  occasioned  by these ulcerations  of the nipple,  and  the
serious accidents which often result from them, shoAV, evidently, that they
ought to be prevented, and when they exist, to be cured  as soon as possible.
  The difficulties in nursing  due to the shortness and malformation of the
nipple  being generally the cause, the  best  prophylactic means are those
already mentioned.   The delicacy of the skin, and the extreme sensitiveness
of the nipple, Avill be advantageously treated by  astringent lotions, frequently
applied  during the  latter months of gestation.  Without having any great
confidence  in the value of ointments for producing  this result, M. Dubois
made some experiments for the purpose of testing them.  He caused fric-
tions Avith the folloAving compositions, to be made for a  month before delivery,
viz., tannin, one drachm ; lard, one ounce ;  or Avith a mixture of equal parts
of cocoa butter, oil of SAveet almonds,  and tannin.  For  my oavh  part, I
prefer the astringent lotions ;  they have not, like most  fats, the inconvenience
of soiling the linen, becoming rancid, and sometimes of irritating very deli-
cate skins.
  Like M.  Trousseau, I am convinced that when the woman begins  nursing,
the best prophylactic measure is simply to wash the nipple Avith a fine sponge
as soon as the child quits the breast.  Its saliva is  acid, and should a little
caseine  remain behind, nothing more is  required  to  produce excoriation.
It is Avell to make these  lotions Avith  a slightly astringent solution.  They
should, hoAvever, be done quickly, so as to expose the breast to the air for
the shortest time possible, and the nipple ought to be covered at once with
a little hood of lead with a hole through its extremity, in order  to  protect
it from the contact of cold air and the friction of the  clothing.
  The use of prophylactic measures cannot  be insisted on too strongly, for,
unfortunately, the  curative means hitherto employed  leave  much to  be
desired.  They are, however, numerous, and I  knoAV of no  disease  against 
NURSING OF  CHILDREN.
1087
 which so many ointments, solutions, &c, have been recommended ; but here,
 as  is ahvays the case in therapeutics, abundance means dearth; there is
 much less seeking when an infallible remedy is at hand.
   In order to account for the popularity which some of these preparations
 have enjoyed, it is only necessary to be aAvare that happily, in a great number
 of instances, these fissures or excoriations get Avell  of themselves.  The poor
 mother gradually becomes accustomed to the pain; she continues to nurse,
 and Avhen  the cracks are not very deep, and especially Avhen not situated at
 the base of the nipple, they undergo spontaneous cicatrization.
   The cessation of nursing is the best  remedy of all; but it  must  be con-
 fessed that this is too discouraging to certain mothers Avho attach great im-
 portance to suckling  the child.   We shall therefore mention  some of the
 chief topical applications Avhich have been  used Avith a certain amount of
 success.
   M. Trousseau  recommends, that  when excoriations  or fissures  appear
 around  the  nipple,  that lotions with warm water should first be practised,
 and folloAved by a weak solution of nitrate of silver.  If these are not suffi-
 cient, a  solution  of sulphate of copper or of zinc may be employed; and,
 finally, Avhen the affection persists, he Avould have recourse to the Avhite pre-
 cipitate  ointment, viz.:
      White precipitate,1      ....      4  grains.
      Lard,    .      .      .       .      .     .      2  to 4 drachms.

   I have used  this ointment Avith some success at the  Clinique.  It is neces-
 sary to clean the breast well  before putting  the  child to it, and to reneAV
 the ointment immediately afterward.  Although  I have observed nothing
 which could be attributed to absorption of  the ointment, there is reason to
 fear lest the health of the child  might  suffer if the breast is not carefully
 Avipedf
   M. Dubois appears to  have tried, Avithout advantage, the  oil of  cocoa,
 nitrate of silver, collodion, and creasote.   The first acts like any other fatty
 matter,  by protecting the Avound from  contact Avith  the air.   Collodion,
 which promised much in  the Avay of shielding the diseased surface from the
 action of the infant's mouth, and  of preventing the dragging of the lips of
 the wound,  whilst  permitting the nursing to  continue, has failed.  The
 saliva gradually detaches the  solidified  lamina of this substance, and not
 unfrequently it is loosened by the cutaneous perspiration.  The application
 of creasote is very painful to the mother, and  its smell is so repulsive that
 the child refuses to take the breast.
  Cauterization Avith the nitrate of silver sometimes succeeds Avhen the pen-
 cil is  finely pointed and carried to the deepest part of the ulcer; but almost
 alwavs  upon condition that the  nursing shall  be suspended immediately
 aftenvard.  This,  hoAvever, is not practicable when both breasts are affected ;
 it  exposes  greatly to engorgement when it  can be done; and  facts  which
have  come under my observation, incline me strongly to believe that the

  1 The white precipitate (precipite blanc) here alluded to,  is the same as the pre-
cipitated calomel of the Dublin Pharmacopoeia: not the white precipitate (hydrargyrum
aniinoiiiutum) of  the United States  Pharmacopoeia.—Translator, 
1088
HYGIENE  OF  CHILDREN.
cauterization itself may  give rise to  phlegmonous  inflammation  of the
breast.  Finally, I would add, that if nursing is resumed too soon after the
ulcer is cicatrized, it Avould open again upon the first suctions.   It is, there-
fore, upon the Avhole, useless Avhen the nursing is continued, and uncertain,
and often dangerous, when the latter is interrupted.
  Mr. Startin, a  London physician, has recently extolled the  use  of gly-
cerine, or the SAveet principle of oils.   It is  a substance produced abun-
dantly during the saponification of  fats, and especially in the manufacture
of stearine candles. Glycerine does not evaporate at ordinary temperatures ;
on the contrary, it absorbs moisture from the air; it is soluble to any extent
in water, so that it  may be  easily removed from the  part  to  which  it is
applied.
  The following are Mr. Startin's formula? against excoriations and fissures:
    R.—Gum Tragacanth (pure)......    2 to 4 drachms.
        Lime Water,........4 ounces.
        Distilled Rose Water,     ......    3    "
        Purified Glycerine,.......1 ounce.
      M.  A soft jelly, to be used as an ointment or embrocation.

  Against fissures of the nipple :
    R.—Biborate of Soda,.....half a drachm to a drachm.
        Purified Glycerine,      ....     half an ounce.
        Distilled Rose Water,                     1\ ounces.
      M. S.  For lotions to the affected parts.
  All these measures may be greatly assisted by the use of artificial nip-
ples, which should be  had recourse to Avhenever the child will submit to
them.   To  overcome  the repugnance which some evince for their employ-
ment, it is Avell to fill it Avith Avarm milk before applying it, so that the milk
Avill  Aoav  readily into  the mouth with  the  first  suctions.  The child  soon
becomes accustomed to it, for whilst emptying the artificial nipple, it'forms
a vacuum, and draws  out the mother's  milk gently.   If the  child  can  be
prevailed on to accept it, the artificial nipple Avill almost ahvays be  suffi-
cient of itself when the fissures and cavities are situated upon the free por-
tion of  the  nipple, especially Avhen the former  are parallel Avith its  length.
Unfortunately, the case is very different Avhen the fissures have a transverse
direction, and especially Avhen situated at the base.  The artificial nipple, it
js true,  protects  the natural one against the direct contact Avith the lips and
tongue  of the child, but  is incapable, in the  latter case, of preventing the
separation of the edges of the Avound.
  If, notAvithstanding  all these precautions, nursing is  so painful that tne
mother defers suckling too long, and there is danger of engorgement, pumps
for extracting the milk artificially will  have to be made use of.  I should
give preference to the one invented  by M. Tier, and  called teterelle, for  its
action is but slightly painful to the mother, and the loAver chamber receives
the milk, Avhich  may  subsequently  be  given  to  the child.   A  new instru-
ment, for the same purpose,  was presented to the Academy of  Sciences  by
Dr.  Lamperiere, of Versailles, but not having seen it operate, I  am un-
qualified to judge of the many advantages claimed for it by the inventor.
  Besides these altogether local lesions, there are some other accidents Avhicb 
NURSING  OF CHILDREN
1089
may require nursing to be given up, either because they injure the milk or
deteriorate the general health of the mother.

  § 3.  Circumstances which may  interfere avith Nursing.
  Whenever the mother suffers an  attack  of  acute disease shortly after
delivery, the secretion of milk is generally so far suspended as no longer to
be sufficient for the Avants of the  child.  The same  is the case with some
others, Avho, although  apparently  in  good health, have no milk before the
fifth or sixth day, Avithout our being able to account for the delay.
  Lastly, the strength of some Avomen is so exhausted by a tedious labor.
that it is  indispensable to allow them  two  or three days of perfect rest.
Under all these circumstances, the place of the colostrum must be supplied
by a little sugar and  Avater mixed Avith one-fourth  the  quantity of milk;
and  should the  mother's recovery be postponed longer than three or four
days, the  child  ought  to be given temporarily to  a  Avet-nurse, Avhich were
far preferable to artificial feeding.
  Even Avhen lactation has commenced regularly and properly, accidents
are still liable to happen, all tending to lessen the  quantity and  injure the
quality of the milk.
  A. Alterations in quantity. — The quantity  of  milk  may be altered in two
Avays,  there may be too little of it or none at all, or there may be far more
of it than the child requires.  The former condition  has  received the name
of agalactia, and the latter that of galactorrhoza.
  Agalactia. — Nature seems to  have  left  her Avork unfinished  in some
women, Avho, although capable of becoming mothers, are often unable to nurse
their child on account of their having little or no milk. The agalactia may
be either  complete or partial: complete, when the secretion is  absolutely
wanting;  and partial, Avhen merely insufficient for the nourishment of the
child.  - In both  cases,  it may be either original  or accidental:  original,
when the breasts are the seat of no fluxion Avhatever after delivery, or Avhen
Avhat secretion may take  place is insufficient for  the requirements of the
child;  secondary, Avhen  the milk, though abundant  at  the outset, lessens
considerably in amount or even ceases to be secreted  altogether.
  It is very difficult to determine the causes of primitive agalactia.   Imper-
fect  development of  the mammary gland,  its atrophy,  and  the  various
diseases to Avhich it is  liable, may certainly occasion  it in some instances.
There  are  others, hoAvever, in Avhich, unless  we attribute  it like M. Trous-
seau to deficient vital energy, due  probably to imperfect* development of the
vessel j supplying the gland, it is almost impossible  to explain it.   AVe have
already studied  the causes Avhich may give  rise to accidental  agalactia, in
the chapter on  Lactation.
  It is generally quite easy to ascertain the existence of complete agalactia;
but when  the nurse has  any interest to practise deception, it is necessary to
be very careful, if Ave Avould detect it Avhen only partial.   The first and best
sign is the emaciation of the child, or, at least, its  arrested  development.
On examination, the mother's breasts are found to  be soft and flaccid, even
Avhen  the  child  has  not sucked  for a  long while.   The latter is always
hun<n v, and  even putting it to  the breast does not  quiet  its  cries; it 
1090
HYGIENE OF CHILDREN.
abandons the  nipple  at every instant, and sometimes even  discards it
angrily, as though enraged at finding  nothing in it;  finally, if after allow-
ing it  to suck for a long Avhile, it is presented  Avith a bottle of milk and
sweetened Avater, it takes it Avith avidity.
  When the absence of milk is due  to an organic cause, all  hope of re-
establishing the secretion will have to be given up and the mixed  method
resorted  to, or  else the child committed to a wet-nurse altogether.   But
when it is accidental, and especially when it is the consequence of a violent
moral emotion, of a slight indisposition, or an evanescent febrile  movement,
it will be necessary to rest  satisfied  with  artificial  nursing for a few days;
and  after the  cause is removed, the  gland may be excited by frequently
putting the child  to the breast.
  I have very  little confidence  in  the medicines or articles of food, which
have long enjoyed a reputation for increasing the flow of milk.  Still, Ave
haA^e the authority of Desormeaux in favor of  anise, fennel, and lentils,
Avhich he asserts having knoAvn to increase the lacteal  secretion  in some of
his  patients.
  Galactorrhea, or the too abundant secretion of milk, presents two varieties
Avhich it is very important to distinguish.   In the one, the milk  retains all
its properties;  it is a mere hypersecretion, which ordinarily diminishes of
itself after a time, and is only inconvenient  to the mother and  the child.
The stream is so large and rapid as to give the  latter no time to swallow,
so that it is every moment threatened Avith suffocation ; often, also, the milk
escapes  from both sides Avhilst the  child is  nursing and wets the  mother.
Sometimes, again, the breasts are so  swollen as to be painful, and the mother
is then obliged  to use the breast-pump herself, or have it applied  by another
person.
  In the other  variety, the milk is  clear, serous, and  manifestly  altered; it
also  flows  passively and almost continually from  the nipple.   The latter
variety  is the only serious one.   The poverty of the milk soon  injures  the
child ;  but the  mother, especially, suffers from this sort of mammary diabetes.
Should  it continue, general  debility,  loss of appetite, notAvithstanding  the
almost constant feeling of need  of food, a sensation of heat in the stomach
and fauces, and pains and dragging  sensations in the back  and  chest, soon
make their appearance.  Rather later, symptoms of the nurse's phthisis, as
Morton  called it, shoAV themselves,  and these unfortunates, feeble  and
emaciated, are  quickly brought by hectic fever to an early death.
  Weaning is  the •only means of preventing this fatal termination.   The
milk ceases to be secreted  immediately afterward, and it then  remains to
restore the exhausted strength of the mother by the administration of iron,
proper nourishment, and a residence in the country.
  General deterioration of the mother's health.—The strength of some Avomen
who Avere Avell  at the commencement  of lactation,  fails rapidly  after a feAV
months.   They become more and more emaciated, lose their appetite, and
may suffer all the consequences of galactorrhcea.  In some cases, this altered
state bf health seems to affect injuriously both the quantity and quality of
the milk; yet  I have seen others, in  which  the increasing debility of the
mother  inspired serious  apprehensions, although  the child continued to 
NURSING  OF  CHILDREN.
1091
thrive, as though she supplied it Avith good  nourishment at tht expense of
her own exhaustion ; and this fact they give as a reason  for objecting  to
weaning.   I  am  a very good  nurse, say they, for my  child thrives Avell.
Whatever  may be the condition of the child's  health, when  that of the
mother is endangered by the continuance of nursing, it should be weaned  at
once, under the penalty of falling into consumption.
  B. Altered quality of the milk. — M. Donne was the first to call particular
attention to the changes Avhich the nutritive elements of the milk are liable
to undergo, and to the unfavorable effect Avhich  its poverty or richness,  or
its alteration by deleterious principles, might have upon the health of the
child.   I am indebted to him for the folloAving details.
   Unfavorable effect of a poor milk. — A milk poor in globules or cream, is
watery, and  not  containing a proper amount of nutritive elements,  affords
insufficient nourishment for the development of the child: it is one of the
commonest causes of poor success  in  nursing, and escapes observation the
more easily, as it often coincides  yvith  a notable amount of the fluid, and,
apparently, with the right kind of physical properties.  This coincidence is
far more unfortunate than Avhen the poverty of the milk is accompanied by
diminution in quantity; for, in the latter case, not only is the child  imper-
fectly nourished, but a milk  which is at once  abundant and of  inferior
quality, fatigues the organs by keeping them engorged with a large  amount
of fluid.
   The effect of the extreme richness of the milk is far more surprising ; for  at
first it Avould seem as though this quality could  hardly be otherwise than
advantageous.  Such, however, is far from being  the case, for certain very
delicate children are often inconvenienced by too  substantial a food.  Fre-
quent vomiting, diarrhoea, and  the  affection  called crusta  lactea (impetigo
capitis) often result from  it.
  Nothing short of microscopic examination, or the use of the  lactoscope,
can inform us in respect to the richness or poverty of the milk, and acquaint
us Avith the true cause of  numerous  disorders or  morbid conditions of the
new-born child, Avhich otherwise would remain inexplicable.  The  number,
size, and regularity of the globules will establish the diagnosis in  both cases.
  Poverty of the  milk, unless it  is merely temporary, requires absolutely
either the addition of a certain amount of coav's milk, or a change of nurse.
  Its extreme richness may be remedied either by making the nurse's diet
less substantial, or by occasionally giving the child a  little sweetened Avater
after each repast.  M. Donne has profited by the experiments of M. Peligot,
so far as to deduce from them  some modifications of the plan  of  nursing,
which it seems to me are likely to prove very useful.
  It results from M. Peligot's analyses, that the milk becomes clearer  and
more  Avatery  the  longer it remains in the breasts.   He  has shoAvn  that  if
the product of any one milking be divided  into three parts, that is  to say,
all the milk that is given at once by a cow or  she-ass, the first milk, which
is certainly the longest  secreted, is the most Avatery and  the poorest; Avhat
comes next is richer, and the last is the best of all.  The  same has been
proved  to  be the case with Avomen Avhose milk is  far more watery before
than  after suckling.   From these facts, Avhich are iioav Avell established, 
1092                    HYGIENE  OF  CHILDREN.
result the most important practical consequences.   When, in  fact, a child
appears to be suffering from the  richness of its mother's milk, all that is
requisite is simply to leave a longer interval betAveen its  repasts, and not
allow it  to suck too long, that  it may obtain each time a lighter  milk,
abounding less in nutritive matters ; for on the one hand, the milk is Aveak-
ened by  allowing  it  to remain  longer  in the breast, and on the other, the
child has time to digest better what it has already taken.
  Alteration of the Milk by the elements of Colostrum.—The elements of the
colostrum, Avhich  generally disappear a feAV days after the milk-fever, per-
sist in some Avomen indefinitely, and are discoverable in many others  after
a month, six weeks, and even several months, so that the milk never attains
a state of entire purity.   This  alteration, which can be discovered only by
the use of the microscope, is often a  morbid condition, or at  least results
from a deranged state of secretion.   It is, in fact, produced under the influ-
ence of  general or local diseases  affecting  the  nurse.  Thus, whether  they
are taken Avith fever, or suffer  from engorgement of the  mammary gland,
the characteristic granular corpuscles appear almost immediately.
  The result of this  alteration  on the child is  easily determined, as it pro-
duces all the effects of imperfect nutrition.  " Never," says M. Donne, " have
I met with it, Avithout at the same time finding the children  puny, sickly, and
more or less affected Avith  diarrhoea."  A change of nurse is then absolutely
indicated, unless, indeed, the  alteration is due to an evanescent affection.
  Admixture of Pus  with the Milk. — Engorgements  of the breast, whether
spontaneous or consequent upon fissures and excoriations of the nipple, are
exceedingly common Avith nursing women, and  have a great tendency to
end in suppuration.  These abscesses, the history of Avhich belongs to the
pathology of the female,  will  claim our attention  only in  respect to the
alterations of the milk Avhich they are liable to produce.  In reference to this,
it is very important to distinguish from all others the parenchymatous ab-
scesses seated  in the tissue of the gland itself, and those which, commencing
by  a true lacteal engorgement,  begin in  a milk duct, Avhose Avails, inflamed
and distended into a sort of cyst, secrete  pus.  In  these only can the pus
become diffused in  the milk.   The superficial, or submammary abscesses,
which do not open into the proper ducts, do not affect this fluid by admixture
of pus, and alter its composition only by the reaction which a morbid con-
dition of the kind exerts upon  a  neighboring organ.
  When the glandular abscess is apparent, the presence of pus in the milk
should be suspected, and nursing relinquished; but, as M. Donne remarks,
it often happens that suppuration has taken place in some  deep-seated  parts
of the gland, Avithout being indicated by any external sign.  The slowness
with Avhich  the  suppuration  is  accomplished,  sufficiently explains  this
insidious course.   Therefore, if the breast was affected  at the outset with
simple engorgement, attended with deep-seated lancinating pains, Ave should
be on the watch, and subject the  milk to microscopic examination.   If it is
impossible to make this examination, Avhich  is the only possible way of re-
moving all uncertainty, prudence would dictate the relinquishment of  nurs-
ing, for there  seems to be no doubt that it would  prove  injurious to the
child.   The breasts should be emptied,if necessary, by the useof the pumps
bitherti >  mentioned. 
NURSING  OF  CHILDREN.
1093
                            ARTICLE  V.
                           OF MIXED  NURSING.
   It has been shown in the preceding  pages that a great many women  are
 incapable of affording a full supply of nourishment to their children.  The con-
 stitution, health, and conformation of the breasts of some are all that could
 be desired; still their lactation is defective, either in quality, the milk being
 sufficiently  abundant but too unsubstantial, or, what is more common,  defi-
 cient in quantity, though of excellent quality.   Others, on  the contrary,
 have very good milk, but their feeble and delicate constitution excite fears
 lest a too free  secretion  and  prolonged nursing should injure their future
 health.  Lastly, there are some Avho, in the midst of conditions apparently
 the most favorable, find  their milk  fail, and even disappear very rapidly.
 To supply this deficiency, it becomes necessary to give the child other nour-
 ishment than Avhat it is able to obtain from its mother's breast.  This mix-
 ture constitutes precisely what is termed mixed nursing.  It should be un-
 derstood that I do not include in this appellation that system of nursing in
 Avhich the child  is kept from the mother at night, giving it diluted milk to
 drink, once or  tAvice, for the purpose of enabling her to take what sleep  her
 condition requires.
   The  indications presented  by insufficiency  of the  mother's milk, vary
 according to the causes Avhich  produce it;  they are also subject to the in-
 fluence of a multitude of circumstances, foreign, it is true, to the question in
 its purely medical aspect, but Avhich it is impossible not to take account of
 in practice.
   There are women Avho, having no  great  desire to nurse, and  alarmed at
 the sacrifices which  the  fulfilment  of  this duty  involves, as also  by  the
 fatigues inseparable  from it, consent to nurse their child only  on account
 of the solicitation of  their husbands or  their family, and sometimes even by
 a sort of respect to  humanity, but Avho Avould like nothing  better than a
 good  excuse for avoiding  it altogether.   With a little  tact and experience,
 the physician is soon able to know just Avhat to depend upon, and under
 these circumstances he ought not to hesitate, but, provided the position of
 the family is such as to permit of the employment of a wet-nurse, he should
 encourage the woman to give up the idea of suckling.
   On the other  hand, there are women who possess the maternal  instinct
 even to jealousy, and Avho cannot become reconciled to the idea of alloAving
 their  children to be nursed by another.  They are fully determined to run
 all risks before intrusting them Avith a  hireling.  A sentiment of this kind
 is certainly  too laudable for the physician to pass over it lightly.  Besides,
 the advantages Avhich the  little  one derives from the attentive and affec-
 tionate cares lavished upon it by its mother, compensate for the imperfection
 of her milk.  Nor do I see why in the majority of these cases there should
 be any impropriety in trying the  mixed method,  on the condition, however,
 of Avatching carefully OA-er the child's health, and having recourse to another
 nurse as soon as it shall appear to suffer from it.
  The samr* remark applies to young mothers whose condition in life does
not permit  them  to  take  in  a Avet-nurse.   Children removed from  the pa- 
1094
HYGIENE  OF  CHILDREN.
rental abode incur too many unfavorable risks, and it is so rare to me./t with
women who, Avhen free from all oversight, perform the immense duty which
they  accept, conscientiously, that I make no hesitation in preferring the
oaixed method to the removal of  the child.
   There are still some other circumstances which may render necessary the
latter method of nursing.   Thus, Avhen a woman has  been delivered of tAvins,
it is very rarely that she will not be obliged to supply the deficiency of her
lacteal secretion by artificial nursing.  The same  is  the  case when  the
mother is able to suckle  from one side only ; for, although it is strictly pos-
sible  for a  single breast to suffice, the co-operation of both is commonly
necessary.
   During the first days subsequent to birth, the child  needs so little food
that it will ahvays find a sufficiency in its  mother's breasts;  and, except in
cases  where some circumstance or other prevents nursing, it were useless to
give it anything else.  Besides, this first milk possesses very useful  proper-
ties, Avhich might be interfered Avith  by paps, or  the milk of an  animal.
HoAA'ever, Avhen the mixed method is decided upon, it should be commenced
as soon as possible, for othenvise the child, having  become  accustomed to
the breast, Avould be prevailed upon Avith great difficulty to take any other
food.  In the majority of cases, also, although there  is a sufficiency of milk
during the first week, there would soon be too little should the nursing  be
deferred.  Coav's or goat's milk, given  subject to the rules to be mentioned
hereafter whea treating of artificial nursing, are certainly the kinds of"food
best suited to the child, and the  only ones that Ave  recommend to  be used
for the first three or four months.
   If the child  is in a satisfactory condition, the  paps, panadas, &c, men-
tioned in connection Avith weaning, may be given rather sooner than in the
maternal  nursing proper.  The  child, having been  long accustomed to a
rather more substantial nourishment  than  it derives from  the  mother's
breast exclusively, may commence taking some farinaceous paps about the
fourth or fifth month.  It will be thus  prepared for the weaning; which will
probably have to be effected about the  tenth or eleventh  month.
   The mixed method, thus understood, and continued for ten months or a
year,  is certainly preferable to a purely artificial nursing.  I  confess even,
that when the mothers are obliged to send their children away, if committed
at all to a wet-nurse, the absence  of the parent's oversight is attended with
so many  inconveniences, that I. prefer  the mixed method to putting out to
nurse. Could the mother only give it suck two or three times in the twenty-
four hours, I Avould advise her to keep  her child.
   What has just been said applies also to Avomen whose secretion of milk,
although small  in amount,  is yet  kept up regularly for nearly a year.  But
there  are some who secrete abundantly during the early months, and then
Buddenly lose it altogether;  in others the  milk continues to be formed,  but
their health suffers so greatly from the  fatigues of nursing, as to oblige them
absolutely to give it up.
   In both cases, the choice lies between an early weaning and the continua-
tion of nursing  by a Avet-nurse — the mixed method  being here out of the
question.  I begin  by declaring  that Avhenever the  general health or  the 
NURSING OF  CHILDREN.
1095
antecedents of the woman are such as to cause me to feai lest she should
not be able to continue nursing longer than  two or three months, I Avould
advise her not to undertake a task beyond her poAvers.   She Avould thus be
spared one of the severest disappointments that a Avoman can suffer, namely,
that of giving up her child to another, after nursing it for several months.
But, whether  because our advice is  not  follpAved, or that nursing by the
toother has to be relinquished suddenly on account of some accident, ought
the child to be raised  by the bottle, or should  it be supplied with a nurse?
I am of Desormeaux's opinion, that artificial nursing is  attended  with far
greater chance of success in the case of a child Avhich has sucked for several
months, than with one neAvly born; but  experience has  so often proved to
me the great difficulties and inconveniences of artificial  nursing  in  large
cities, that I much prefer a nurse, even for a child  four  or five months old.
I do all in my poAver to overcome the repugnance of the mother in reference
thereto, and  unless  both herself and the child can go into the country to
reside, I persist  in my opinion.
   Should the child,  however, be strong and vigorous, if it is born  of robust
parents,  if nothing  but  an accident has obliged  the  mother  to suspend
nursing, and if  our views meet  Avith  great  opposition, an  attempt may be
made to bring it up  Avith the bottle, but still, on the condition of observing
attentively its digestive  functions, and having  recourse  to a nurse as soon
as the necessity  shall be  manifest.
   Before  finishing what we  have to say of  the  mixed method, we ought to
insist upon the necessity of supplying the deficiency in the mother's milk by
a species of food approaching the nearest to it in quality.   We repeat, there-
fore, cow's milk, pure or diluted, according to the age of the child, and goat's
milk, seem to us far preferable  during  the first four  months.  Paps and
panadas, Avhen  given  prematurely, may be successful under certain excep-
tional circumstances;  but this success, Avhich is constantly throAvn  up  to us,
cannot make us  forget the disastrous effect which it has on some Aveak con-
stitutions,  and on many  children in large cities.  We repeat, therefore, that
children born in the country of robust parents, and Avho are constantly ex-
posed to the  vivifying influence of the sun  and fresh air, derive from the
good hygienic conditions in Avhich they live, a power  of digestion Avhich
enables them to assimilate with advantage a food Avhich Avould  be indiges-
tible for others.
                           ARTICLE VI.
                         SUCKLING  BY NURSES.
   Some Avomen  cannot, and others will not,  nurse their children.  Noav, the
latter should be subjected as little as  possible to the bad effects of this inca-
pacity or unAvillingness;  and the best substitute for the  mother's milk is,
certainly, that of a nurse.

   §  1. Of Choosing  a  Nurse.
   The physician generally is, and ahvays ought  to be, charged Avith the
selection of a nurse.    Noav, this choice is one of the most delicate and com-
promising acts of medical practice, for its conscientious performance neces- 
1096                 HYGIENE  OF  CHILDREN.
 sitates precautions and  investigations, which, to speak frankly, it is impos-
 sible to make in the majority of cases.  To choose a nurse properly, is  tc
 guarantee the  family a  full supply of  milk of good quality, and to assure
 them as to the excellence of her constitution, and especially that she is not
 nor  ever has been, affected with any disease capable of being transmitted  to
 the nursling.
   Now, it must be acknoAvledged, that if an examination of the milk pro-
 perly performed  is capable of affording  us a  tolerably correct  idea of its
 composition;  if  an  investigation of the  principal organs of the chest  and
 abdomen, and  the exploration of the mouth, teeth,  and cervical, and even
 inguinal glands, are  competent to assure us as to her good health ;  if the
 development of the  muscles of the body and  limbs, and  the  color of the
 skin, can enable us to appreciate the strength and vigor of the constitution,
 it is about  all  that we  can expect to accomplish.  To require a nurse to
 submit to a thorough examination of the genital parts and the use of the
 speculum, which is indispensable to a strict diagnosis, would be to receive
 an almost certain refusal.  Perhaps some shameless Avomen, or unfortunates,
 Avhom hunger allows to object to nothing, Avould not decline; but I  am con-
 vinced that we should fail Avith those good and  chaste country nurses, Avhose
 simple habits are foreign to the debasedness of cities.  Such examination
 could be made obligatory only by public authority, and then  by confining
 it to a  single physician, Avho should be  charged Avith  the examination of
 all.  These poor Avomen  would then have to submit to a  single visit only.
 But  it must not  be  forgotten that in  Paris especially, before a Avoman  is
 received by any one  physician, she  has  often been  presented to ten  differ-
 ent  families.  She would,  therefore, have been obliged to submit to the
 examination ten times.  It is plain that this could not be done, or if it were,
 I would find it difficult to confide in one who had alloAved  it; for though I
 might  feel satisfied  as to  her physical condition, I should certainly have
 strong doubts as to her  moral  qualities.  Besides, would  this examination
 ahvays be so conclusive as to justify an absolute assurance to the families?
 Doubtless, Ave might  be able, in the majority of cases, to certify that there
 does not exist, at the  time, any symptom of syphilis; but is the present any
 security for the past?  The local  symptoms disappear, but  does  not the
 general infection remain, which may socmer or later become manifest ? We
 see, therefore, that Avere the examination always possible, the evidences of a
 recent attack of syphilis might be overlooked, and could give us little or no
 information in respect to  the antecedents.  I coincide, therefore,  with M.
 Donne, in the belief that the examination Avould be  useful, and Avould even
 be disposed to direct the  attention of  the  authorities  to the propriety of
 causing a medical inspection of nurses ; but  in the  present condition of
 things, I believe it impossible that each one should require this thorough
 examination.
  After examining the  chest, and  ascertaining the absence of scrofulous
 cicatrices, the healthy condition of the cervical glands, and, if  possible, of
 the inguinal glands, and  after inspecting the development  of the muscular
system iu order to appreciate the vigor of constitution,  the physician should
next give  his attej tion to the milk, and the organs Avhich secrete it.   I con- 
NURSING  OF  CHILDREN.
1097
fess regarding the color of the hair and soundness of the teeth as of minor
importance;  for blondes make  as good  nurses  as  brunettes, and, in some
countries, the teeth are subject to early decay Avithout the  health of  the
inhabitants  being  any the less  robust.   Neither is it important  that  the
nurse should be of the  same age, stature, and temperament as the mother
Avhose child  is to be submitted to her  charge.  Without paying too much
regard to attractiveness  and beauty of external  configuration, it is proper
that there should be nothing unpleasant about  the woman, and especially
that she should be physically agreeable to the young mother.  The latter is
obliged to live for a year or eighteen months almost constantly in  the pres-
ence of her child's nurse, and it is far from immaterial Avhether she is to be
in continual  relation Avith a repulsive countenance.   Much consideration
should  be had for whatever  information is attainable in respect to  her
intelligence,  character,  and general  disposition.  A  nurse avIio  is  gentle,
good-natured,  and who knows Iioav to amuse a child,  ought, other things
being  equal, to be  preferred.   It Avere useless  to  remark, that  no  woman
should be introduced into a family of whose probity and morality there  can
be the least  doubt: unfortunately, hoAvever, Ave  are  too commonly obliged
to trust to chance in regard to the latter point.1
  The nurse's age is not a matter of indifference.  I think it better  to choose
one betAveen the ages of twenty and thirty years ;  and Avould advise declining
all avIio are over thirty-five.  As a general rule, women who  have already
had  several children, and Avho are consequently familiar with all the offices
which they require, are received more willingly  than primiparas.   It is far
better that an inexperienced mother should have an experienced nurse, Avho
is accustomed to handle and take charge of children.  Besides, by inquiring
of families  where  they have already  nursed, we  may  have more  certain
information as regards their disposition, their honesty, and the amount  and
quality of their milk in  a previous  nursing, Avhich  may serve, to  a certain
extent, as a guarantee for the future.   Finally, they are much less affected
by putting away their own child than  primiparas, and, therefore, are  far  less
likely to lose their milk suddenly.  The  former  have, therefore, undoubted
advantages over the latter, but they are also liable to some objections : thus,
they have acquired habits Avhich they  relinquish Avith difficulty; it is much
harder to subject them to the regimen which you Avish them to follow; lastly,
provided they do not find in their neAV position  the  pecuniary advantages,
the indulgences and attentions of Avhich some parents are lavish, they make
unfavorable comparisons, and become  discontented and exacting.
  1 It were better, as a general rule, not to engage nurses too long in advance.  I think
it prudent to reserve the right of examination at the time when they shall be'needed ;
for there are cases in abundance, in which, notwithstanding the most favorable appear-
ances, the lactation is defective.  For a still  stronger reason  would it be wrong in
parents to retain a pregnant woman without consulting their physician,  because she
had already nursed for one of their acquaintances, who had recommended her highly.
So many circumstances are liable to interfere  with lactation, and  so many accidents
may happen after delivery capable of seriously injuring a health which had been  per-
fectly good up  to that time, that  I  advise  .-ill my patients never  to treat with  their
nurses  otherwise than provisionally, and to promise only conditionally, and always
subject to the  fnal recommendation of their physician.  Disregard to this  limitation
has given rise t) many unpleasant occurrences in families. 
1098
HYGIENE OF  CHILDREN.
  The woman Avho offers herself as a nurse may be still pregnant, or have
been delivered for some time.
  If she is still pregnant, it is important to be sure, in the ;5rst place, that
her labor will be over at least tAvo months before that of the  mother of the
child.  The organs have hardly returned to their normal condition, and the
woman is barely recovered before tAvo months after delivery, and not before
then ought she to be intrusted with a neAV nursling.  Earlier  than this, the
neAV-born child Avould  have  a milk better adapted to its digestive poAvers;
but a Avoman is liable to so many accidents during  the first six Aveeks after
delivery, that it is impossible to ansAver  for the future.
  It is much more difficult to judge of the future qualities of a nurse during
pregnancy,  and Avhatever may be the  result of a first examination, it  is
necessary to be very cautious as to what one says in regard to it.
  We have already noticed the points of useful information to be ascertained
by an examination of the colostrum secreted during  the latter months of
gestation, and we shall not recur to the subject; it is almost the only element
of importance in the question under consideration.  The form  and  size of
the breasts are of but secondary value.
  Voluminous breasts are by no means  a certain indication of a full supply
of milk in the future; for generally the entire mass is in  great part made
up of fat.   This remark does not ahvays apply to the size of the gland itself,
which can often be distinguished from the  thick layers surrounding it.   It
is important, in fact, that it should not be too small.  But, provided it is of
about the normal size, the flow of milk may be  sufficient or even abundant
if the veins of the breast are largely developed.
  Dealers  in coavs, says M. Trousseau,  know very Avell  that their  milking
qualities cannot be judged of by the size of the  udder.   Thus,  a cow whose
udder has  a cubic capacity of four quarts may give ten quarts of milk,
being six quarts  more  than  the apparent  size,  which proves that milk is
secreted during the act  of sucking or of milking.  The same is the case  in
the human species; the size of the breast is  not an absolute indication of
good nursing qualities.
  M. Trousseau thinks that very important information may be derived from
the phenomena observed in the breasts  of certain women at each menstrual
period.   When, says he, there is  a strong  determination to  the breasts  at
each period, Avhen the latter groAV  hard  and painful, and the globules of the
gland become more distinct and  form projections, the Avoman is likely to be
a good nurse.  ... I have  never had  an  opportunity of  testing the value
of this conclusion.
  When the Avoman has been delivered  and nursed for some time, the phy-
sician ought to direct his attention especially to  the  amount  and quality
of the milk   I shall not revert  to the  means for determining  the richness
or poverty of the milk, its purity, or its alteration by heterogeneous elements.
I Avould, hoAvever, remark, that to have ascertained, by placing  a feAV drops
of milk in  a spoon, that it is opaque, homogeneous, of medium  consistency,
and Avithout any peculiar taste or odor, does not  obviate the  necessity of
having recourse to  the microscope whenever possible.   By it  alone can be
estimated the number, regularity, and size of the  globules, and, consequently, 
NURSING  OF CHILDREN.
1099
the amount of cream or buttery part which they constitute.  Unfortunately,
but feAV physicians have this instrument at their disposal or know hoAv to
use it; and still less are they accustomed to chemical analysis.   In ordinary
cases, and in the absence of a better process, the richness of the milk may be
estimated by measuring the thickness of the layer of cream ; for this purpose,
M. Donne's little graduated test-tubes may be used, or, still better, the lacto-
scope of the same author, Avhose application requires but a few minutes.
   It is important to bear in mind the variations in the milk pointed out by
M. Peligot according to the  time it has remained in the breasts (see page
1091).   If  a woman presents herself  Avith breasts much  distended, it is
necessary that she should allow her child  to  suck for some time, before Ave
shall be  able to form  a correct idea of the density of the milk;  for the first
milk is much thinner and  more watery than that Avhich is secreted  a  short
time before its extraction.
   Lastly, the best means of judging of the quantity of  milk, is to examine
the physical condition of the nurse's child; to be certain, as far as possible,
that it takes no other food; to Avitness it suck several times, and determine
Avhether  its appetite seems satisfied, although the breasts still retain a con-
siderable degree of firmness.  Again, like M.  Natalis Guillot, Ave may cause
the child to be weighed before and after putting to the breast; the quantity of
milk SAvallowed being indicated by the difference in Aveight.   From 21 to 5
or 6 ounces should be Avithdrawn at each suckling;  but less than 2\ ounces
is insufficient for the purposes of nutrition.
   The complete absence of glandular engorgement should lead us to suppose
that the  milk is uncontaminated  Avith a single globule of pus; but if the
condition of the breast is such as  to leave any doubt in the mind, nothing
but microscopic examination is capable of settling the question.  This in-
strument is  still more necessary for ascertaining the presence of the elements
of colostrum at a period Avhen they ought to have disappeared altogether.
   Lastly, the age of the milk should be taken  into serious consideration:
As Ave are obliged to alloAV the nurse at least tAvo months for the purpose of
recovering from the  fatigues of labor, the accoucheur cannot supply the
child Avith a very young milk, such, for instance, as its  mother might fur-
nish it;  but it is at least better not to give  it  milk from a  nurse avIio has
been delivered longer than from eight to ten months.  At this time, it is no
longer adapted  to the requirements of the child, and as most Avomen are
barely able to  nurse longer than from eighteen to twenty  months, there
would be some risk  of finding the secretion cease altogether,  before the
natural  period  of  Aveaning.  A  milk  of  from tAvo to  six months should
therefore be preferred.
   Women who have nursed for a year or fifteen  months, and desire to take
charge of another child, say that a young infant restores the milk,  but the
responsibility of the assertion  must be left Avith the good women  themselves.
  Most of the  precepts Avhich Ave  have laid down for natural nursing are
entirely  applicable to Avet-nursing; there  are, hoAvever, some peculiarities
which it  is proper to indicate. 
1100
HYGIENE OF  CHILDREN.
  § 2.  Of the Regulation  of Wet-nursing.
  At what time ought the nurse to give the breast to a nt v-born child f — A
nurse Avho has been delivered for three or four months, is, at the  outset,  in-
capable of providing the young infant with as suitable a nourishment as it
would have derived from the mother's breast.  The colostrum secreted  by
the mammae of a recently delivered  female, is not  merely a food, but pos-
sesses laxative properties eminently adapted to the expulsion of  the meco-
nium.   Though slightly charged with nutritive matters at first,  this colos-
trum is perfectly suited  to the digestive poAvers of the neAV-born  child;  for
to load  its stomach with anything more substantial, Avould expose it to im-
perfect elaboration and  all its unfortunate consequences.  Struck  Avith these
inconveniences, some practitioners advise the mother to begin suckling  for
the first few days, and not to give the child to the nurse until it is better
able to digest her milk.   Besides, say they, it is not only for the interest of
the  child, but of the mother  also,  for the secretion of milk is  a natural
emunctory, Avell adapted by the sort  of derivation it occasions to  lessen the
tendency to the various  inflammations to which lying-in women are so fre-
quently exposed.
  I cannot accept this vieAV.   If we  regard only the interests of the child,
there can be no doubt that the lactescent serosity furnished  by the  breasts
at the outset, is the kind of  nourishment best  adapted to its condition, and
that in  this respect, the  milk of a nurse of three  or four  months would be
less suitable; but Ave shall see  hoAv easily the too great density of the latter
kind of milk may be remedied by a sort  of mixed nursing, and daily  ob-
servation proves, that Avith  such precaution the health of the  child is in
no Avise endangered. Noav, a nursing once begun, and suddenly interrupted
after four or  five days, is  far from being devoid  of  danger and incon-
venience to the mother.  The  fact  is, that Avomen suffer the most from
nursing at the outset.  Then  it is  that fissures and cracks of the nipple,
lacteal engorgements, and inflammation and  abscesses  of the breast, make
their appearance.   That a female Avho is  determined to nurse should brave
all these dangers  may  be easily understood, for she is  sufficiently compen-
sated by the fulfilment  of a grateful duty; but that one Avho cannot nurse
should expose herself to them  unnecessarily, is incomprehensible, unless we
suppose her Avilling to add to the painful sacrifice  which the giving up of
her child to a wet-nurse imposes upon her.   Besides, Ave  must not believe,
as some physicians do, that nursing protects women from puerperal diseases.
We have but too often occasion to know from experience in our hospitals,
that puerperal fever, for  example, attacks Avith  equal  violence  those who
nurse and those who do not.
   In civil practice, Avhere the minutest attentions  are bestoAved upon  the
child, I can  discover but feAV  advantages fon it, and many inconveniences
for the mother, in beginning to nurse, Avhen she has no expectation  of con-
tinuing to do so.   The case  is different  in our large lying-in  hospitals.
HoAvever carefully conducted, it has  never yet been possible to provide a
supply  of nurses 3qual  to the demands of all  the children. In the clinic
of the  Faculty, f r example,  there are but five or six  nurses  for tAventy
children, and the number of  ordinary or Avard nurses being too small to 
NURSING  OF  CHILDREN.                 1101
give the  little unfortunates the most necessary attentions, a great number
perish, Ave  are bound  to  acknoAvledge, of cold and hunger.  Under these
circumstances, the physician is perfectly right in requiring the  mother to
suckle her  child  until it can be provided Avith a nurse.
  For the first  tAventy-four hours after  birth, the child will take nothing
but  a little sweetened Avater as a substitute for the colostrum ;  and if it
should seem difficult to expel  the meconium, a feAV spoonfuls of  compound
syrup of chicory may be administered.   By  this time, the boAvels will be
sufficiently emptied, and it may be put to the breast.  But for the first five
or six days, or rather longer if the child  is feeble, it will not depend exclu-
sively upon the nurse's milk, but the latter is to be alternated Avith SAveetened
water during the first three or four days; after the fifth or sixth, it will be
alloAved to suck  for a short time, and the  nursing be immediately folloAved
by the administration  of a feAV  dessert-spoonfuls of sugar and Avater; lastly,
about the tenth  day, it Avill be  confined to the breast altogether.
  The neAV-born child is rarely able to take enough milk to empty the
nurse's breasts ;  therefore, it is well to keep her own child near her for some
days, in order to avoid extreme distention of the mamma?.   She ought then
to be advised to give the first milk to the nursling.  If separated from her
child, she  should endeavor to decrease the flow of milk by a very moderate
diet  and  diluent drinks; and if, notAvithstanding these  precautions, the
breasts become painful, they must be emptied by a breast-pump.
   The precautions Avhich it is necessary for the  mother to observe, are not
required in the case of a robust nurse Avho is accustomed to fatigue, and she
is expected to give the child suck  during the night.  Upon the  Avhole, the
precepts in regard to the regulation of the repasts, are as applicable here as
to nursing by the mother.
   Some nurses-are in the habit of taking the child to bed with them.  This
ought to be positively prohibited, as terrible accidents might result from it.
Several  times it has been the  lot of nurses to find only a dead  body upon
Avaking,  from having suffocated the child Avhilst asleep.  The best means of
being certain that the child shall be laid in its cradle after nursing, is to
give the nurse so narroAv a bed as  to make it almost impossible for her to
sleep with the child beside her

   § 3: Regimen  of  Nurses.
   The diet of  nurses should  be  moderate but  substantial.   The latter
quality ought not, hoAvever, to be so far insisted  upon as to give them a
food Avhich is too succulent and too rich in azotized matters.   They should
certainly partake of a certain  amount of meat, but it Avould be improper to
confine them exclusively to it.  Being accustomed from childhood to indulge
freely in  vegetables,  they Avould not long support a  merely animal diet
Avithout disadvantage.
   Nurses  brought up in the country often suffer from confinement to the
house in cities, and their condition is still further aggravated by the indo-
lence Avhich takes the place of their previous active habits.   Therefore, after
the  first few  days, they  ought, if  possible, to be employed in  some light
household duties, and, even Avhen the child is unable to accompany them,
they should be made to take exercise out of doors. 
1102                  hygiene  of  children.
  The nurse may at any time lose  her milk, be  attacked  by an acute dis-
ease, or be affected by some occurrence Avhich lessens or alters the secretion.
It is a painful thing to most families to have to change their nurse, and it is
important to  console them Avith  the assurance, that the change is  not  so
serious a matter as is generally represented.   Provided the child receives a
milk of good quality and enough of it,, it will suffer  nothing in this respect.
Therefore, all that we have to do, is to choose a milk equal to, if not  better,
than what it has been deprived of.  Under these circumstances, the change
is a matter of such  indifference, that when the nurse's disposition is too dis-
agreeable, or if she  does not take  proper care of the child, I do not hesitate,
whatever the qualities of her milk may be, to advise a change.
  The only precaution to be  observed  is, that when once  decided upon,
she should not be informed of the project until another one  is engaged  to
replace her.
  The only difficulty is to get  the child to take the breast of a neAV nurse.
If it has attained the age of from six to eight months, it often manifests a
great repugnance thereto.  It  should then  be left  for some time without
nursing, and  advantage be taken of the  night  or a dark place, to put it  to
the breast for the first time.

                         ARTICLE  VII.
                       NURSING by an animal.
  Nursing by a female animal constitutes the transition, so to speak, between
wet-nursing and artificial  nursing.  Though much in vogue  in some coun-
tries, it is rarely had recourse to in  Paris or most of  the departments.  We
hardly ever recommend it, except when a child  Avho  has been weaned for a
long time becomes suddenly ill  and  requires a diet composed  exclusively of
milk, and in certain special circumstances making it necessary to adminis-
ter  to  the child a milk Avhich  has  been rendered medicinal.  By causing
animals to SAvallow various remedies,  such  as  mercury, iodine, and iron,
their milk becomes  imbued with most of the properties of these substances.
It would be unjustifiable to subject a healthy nurse to a treatment of this
kind for the benefit  of the child, as it might readily prove  injurious to her.
  The animals made use of are goats, sheep, she-asses, and  coavs ; but most
frequently the she-goat.   The shape and size of the  teats, which  are easily
seized  by the child, the abundance  and quality of its milk, the  docility of
the animal, the ease Avith Avhich it is trained to give suck to  the child, and
the attachment Avhich it is capable of forming  for it, are sufficient reasons
for the preference.   That  species  should be  preferred Avhich  is destitute of
horns and Avhich have long, thick, and white hair, because  they possess the
hircine odor in a slighter degree.  A young goat Avhich has nursed several
times, and given birth recently  to her kid, ought to be preferred.
  This mode of nursing, says  Desormeaux, requires  at the outset much
care and attention as respects the presentation of the mamma to the child.
The petulance and impatience of the animal expose it to frequent accidents,
but after a time the goat comes of its OAvn  accord  to give  it suck.   The
infant should be laid in a  Ioav cradle placed upon the floor.
  When it is desired to communicate medicinal properties to  the milk,  they 
NURSING OF  CHILDREN.
1103
are made to take internally or to absorb by the skin the active principles
of these medicines.   Thus, mercurial ointment is  rubbed into the skin of
goats in order to communicate antisyphilitic properties to the milk.

                         ARTICLE  VIII.
                          ARTIFICIAL NURSING.
  I have but little to say of artificial nursing ; for it is admitted by all to
be the worst of the various methods  proposed for  nourishing  a child.   In
large cities, Avhere it is a difficult  matter to procure good milk, and Avhere
the bad  health of the coavs renders  useless all the precautions taken Avith
this object, most of the unfortunate children subjected  to this regimen die
Avithin  the year.  In the country, however, the  chances are  far more in
favor of artificial nursing;  for there  it is possible to be  almost  certain as to
the health of the  animal, the  food it takes, and the good  qualities of its
milk.   Besides, the excellent atmospheric conditions in which  the child is
placed,  compensate, to a  certain extent, for the imperfection of the mode
of alimentation.   Although a Avoman's milk  is ahvays preferable to any
other, the artificial  nursing,  Avhich  I proscribe unconditionally for large
cities, may be tolerated in  the country, with  the  understanding,  hoAvever,
that it shall be pursued Avith intelligence.
  Coav's milk is generally employed,  but its administration  demands some
precautions.   Being too rich for a new-born child, it requires to be diluted
Avith pure Avater, barley Avater, a decoction of crumbs of bread, of rice slightly
SAveetened, or gruel.   Pure Avater should, I think, be preferred in most cases,
and the proportions of the mixture must necessarily vary Avith the age and
digestive poAvers of the child.   During  the first Aveek, three parts of water
should be added to one part of coav's  milk,  and during the early months the
latter should be diluted one-half; after which, unless the digestion is feeble,
but one-fourth of Avater may be added until the sixth month, Avhen the milk
may be given pure.
  Desormeaux advises, when the children are feeble, that the milk be diluted
Avith chicken-Avater, or a fluid containing animal matter. I have seen some,
says he, Avhose stomachs were better suited  by  weak decoctions of meat than
by milk, and I am convinced by a multitude of practical observations that
the matters ingested irritate less in consequence of their  being azotized, than
because they are digested Avith difficulty. I think this regimen proper after
the sixth month, but Avould not advise it in the earlier months, Avhen, if used
at all, it should be with great caution.
  It is Avell to SAveeten slightly the children's  drink.  Although sugar  has
not the heating qualities Avhich the  Avomen attribute to it, it must be used
moderately, for it is not  ahvays digested easily.   I have seen, says Desor-
meaux,  feeble children  throAV up unchanged the SAveetened Avater and solu-
tions of gum and starch which had been given  them as drink.
  The drinks ought to be rather more than lukeAvarm.  When  pure milk is
used,  it  should be brought by the Avater-bath to the temperature it Avould
have had if just draAvn from the coav ; if, on the contrary, it is to be diluted.
only the fluid to be mixed Avith it should be heated.  In no case ought the
milk to  be boiled; for ebullition deprives it of a part of its aroma, and of
the air Avhich renders it more digestible. 
1104
HYGIENE OF CHILDREN.
  The mixture of milk with one of the above-mentioned substances soon fer-
ments  and spoils, especially in summer, or in Avarm rooms  in Avinter.  It
ought, therefore, to be prepared only Avhen about to be. administered.
  We  have before stated  that a child, whose  alimentary canal has  been
habituated by mixed  nursing to more substantial  nourishment than the
mother's milk, is able to take paps and solid food rather sooner than it other-
Avise Avould.  The same is  true after artificial  nursing.  There is  no occa-
sion to revert  to the precautions laid down in the article on Weaning.
  The instruments used for giving children drink are numerous.  The spoon
and drinking-cups, by whose assistance  the milk is poured into the mouth,
are subject to  some inconveniences; so that, unless they are unable to suck
at all, I prefer the nursing-bottle  as most nearly affording the conditions of
natural nursing.   It can be readily  procured everywhere, and Avere it on
that account alone, it deserves to be mentioned.  It is either an ordinary
four-ounce medicine vial or one  of those  small flattened bottles  used by
yvine merchants for exhibiting their specimens; into the neck is introduced
a sponge cut for the purpose, and  Avhich projects about  an inch and a half
beyond it; the Avhole is covered with a piece of muslin, and  fastened  by a
thread.   The  thread  ought also  to be drawn with a moderate  degree of
tightness around the sponge at its exit from the bottle, so as to compress it,
and prevent the  milk from floAving  too rapidly.  Care should be taken to
keep the sponge, muslin, and thread, ahvays in fresh clean water, and before
using, pass a little milk through  it and squeeze, so as to drive out  the cold
Avater,  and replace it by warm milk.
  With all these precautions,  this bottle has still more imperfections, which
many instrument-makers have sought to avoid.  The nursing-bottle manu-
factured by M. Charriere, I think merits special recommendation.
  In terminating this chapter, I cannot recommend too highly to physicians
a little work  by Dr. Donne,  which,  under the modest title of Advice to
Mothers, will furnish them  Avith an abundance of useful hints in relation to
the education  of children.
                                                              /
                        CHAPTER  III.

   GENERAL CONSIDERATIONS ON  CERTAIN  POINTS  RELATING TO
                        INFANTILE  HYGIENE.
  1.  Of Clothing.—The clothes of the neAV-born child should be so loose as
not to obstruct its motions.   The SAvaddling-clothes, which are still in  gen-
eral use, and Avhich were formerly draAvn much  too tight, may be retained,
but only on the condition  of leaving sufficient freedom of motion to the
limbs of the  child.   I confess that, for the first Aveeks, they seem to me to
have some advantages over Avhat is called the Englisii style, by protecting
the children better  from the cold, especially when they are Avet with urine,
and also by affording greater facilities to those  Avho have to take  them up
and carry them  about.   I therefore approve  of SAvaddling, but would  have
the clothes so loose as to alloAV the extremities, the loAver ones especially,
sufficient freedom of motion. 
INFANTILE  HYGIENE.
1105
  After  the  umbilical  cord has fallen off, a folded compress, as large as a
silver dollar, should be applied upon the navel, and kept in place by a mod-
erately drawn circular bandage.  It serves to prevent the rubbing, and con-
sequent irritation of the umbilical cicatrix, and perhaps, also, the formation
of a hernia.
  Pins should be used as little as possible in dressing the child.   They may
become loose, and, by sticking it, give rise to serious accidents, such as con-
vulsions and death.
  It is  important, also, that the little cap string or  ribbon, Avhich  passes
under the jaw, should  be sufficiently loose, for the cap  is  liable to be dis-
placed,  and the neck might be subjected to constriction.   To avoid this, the
string should be attached to one end of a band, the other  end of Avhich is
fastened in front of the chest.
  After  the  second or third month,  the  SAvaddling-clothes should  be  re-
placed by long dresses; from this time the style of garment  is subject to the
fancy of the parents, and, provided the child is  protected from the cold
and sufficiently at its ease, the physician need concern  himself no further
about it.
  2. Of Washing, Bathing, and Cleanliness. — Perfect cleanliness  is indis-
pensable to the health of children, and nurses cannot be watched too closely
for  the purpose of preventing their  alloAving them to remain in their urine
or fecal  matters; they should be changed as  soon as they become soiled.
They ought to be washed with warm Avater, and not merely Aviped, as is done
by some nurses.  It is difficult to do otherwise Avhen out walking; but the
omission  should be  supplied immediately  on reaching home.  In some
countries, cold water is used in these Avashings; I think, hoAvever, that it is
rather hazardous within the first year, and  I do not recommend it before the
child is eighteen months or two years of age.
  I am in the habit of directing the children to be bathed every other day ;
but Avhen they seem to be rather more fatigued  and enervated on the day
of the bath,  I advise it to be performed but tAvice a Aveek, and  am content
Avith a  simple immersion, or Avashing  all over, every morning.  The tem-
perature of the water should be from 77° to 86° F.  The bathing ought to
be short in proportion to the fatigue of the child, but, as a  general rule, it
ought not to  be longer than five minutes in the first month, and rarely ten
minutes  in the subsequent ones.   When  the children are restless at night,
and  sleep little or badly, it is a good  plan to  bathe them  in  the evening
before going  to bed.   When the restlessness and  insomnia are very great, I
have used with advantage a bath prepared  with a decoction of lettuce-leaves.
  In Avinter,  or Avhen -the Aveather is cold and damp, it is important not to
alloAV the child to go  out for several hours  after bathing.
  Some  persons are  afraid to Avash the child's head, yet it  should be done,
in order to remove the scurf Avhich forms there? and to prevent the forma-
tion of the crusts which some persons are glad  to  see appear.  AVhen they
are  already formed, they ought not to be respected, but after rubbing the
head gently  with a warm cloth, the}' may  be removed by a soft brush.   If
this is not sufficient, the head may be greased, and the next morning thev
will be found to come oft' readily.
      70 
1106
HYGIENE OF  CHILDREN.
  3. Taking the air, walking. — The child  should be placed, immediately
after its birth, in a large, airy chamber, kept for the first Aveek at a rather
elevated temperature.   If the child is Aveak or born prematurely, it is im-
portant, in Avinter, to surround it with bottles of warm Avater: one at its feet,
and one at each side.   The head of the cradle  should be turned toAvards the
AvindoAvs, in order to protect the child's eyes from the too bright light.  The
omission of this precaution  has seemed to me to favor the development of
purulent ophthalmia.
  In Avinter, especially, the children should not  be taken out before the fif-
teenth day.  During the intense  heats of summer, this rule need not  be
adhered  to so strictly, provided they are strong and Avell.   But after the
first going out, they should be promenaded  every day for several hours, and
at three  months, they ought to remain for the greater part of the  day ex-
posed to the air; in Avinter, autumn, and spring, they Avill be kept out for at
least three or four hours.  The air and sun are almost as necessary as  good
nourishment, and it is perfectly useless to consult barometer and thermom-
eter to know whether it is proper  for a child to  go out.  Even in the Avorst
days, a favorable hour can ahvays be found and made available; only Avhen
it is cold and freezing, the walk will be shortened.  There is  no occasion to
fear disturbing their sleep whilst promenading,  for they never  sleep more
soundly than then.
  Of latter time, some philanthropic physicians, at the head of Avhom I am
pleased to  name  my colleague  and friend, M. Loir, have insisted strongly
that the recording of births should be done at home, and that there should
be no obligation to carry the poor children at every  season to the mayoralty
Avithin the first three days.  This laAv has fallen into neglect in most of the
provinces; but in Paris it is still  observed  quite rigorously, unless that the
accoucheur certifies that the child  is in poor health, and that it is impossible
to transport it thither.  I am happy to unite my feeble voice with those of
my colleagues, to solicit from the  authorities a modification of the existing
laws.   The same motives of humanity  induce  me to express the desire that
Catholic families should cause their children to be baptized at home, unless
the ceremony be put off to a somewhat remote period from birth.  Undoubted
advantages would result from it as respects both mother and child.
  4.  Of Sleep. — For the first days subsequent to birth, children do nothing
but suck and sleep.   Whilst asleep, they  should be laid upon the side —
sometimes upon one and  sometimes upon  the other, in order to avoid bad
habits.   At first, they  almost ahvays fall asleep Avhilst suckling, so that it
is nearly impossible to lay them aAvake in the  cradle; but rather later, care
should be taken not to allow them to go to sleep in  the arms or on the lap.
Having once acquired this habit,  it becomes a necessity ;  and on awakening
at night, they will not go to sleeep again except in their nurse's arms.  They
ought to be put in the cradl§ whilst awake, and alloAved-to go to sleep there;
for when once alloAved to acquire bad habits in  this respect, it is very difficult
to break them.  It requires great firmness to hear them cry for a long time;
but with courage and perseverance, and by a temporary removal of the nurses,
of wnose weakness they are aAvare, a complete reform is finally obtained.  The
Bame remarks apply to the habit Avhich some nurses have of rocking children. 
INFANTILE  HYGIENE.
1107
  Most children at the breast sleep during the day  until they are twenty
months or tAvo years old.   This sleep, which is almost constant at the outset,
becomes shorter and less frequent as they advance in age;  but it is very rare
for them not to take three or four hours of sleep daily during this early period
of life.  This repose is, therefore, a necessity, but there is no occasion to avoid
the least sound for fear of wakening them, as they very readily become accus-
tomed to sleeping in the midst of motion and noise; some children sleep but
lightly, because they have always been accustomed to solitude  and silence.
Though it is Avell not to be too scrupulous in this matter, they ought not to be
awakened too suddenly for  fear of alarming them.
  5.  Exercise. — The  only  exercise of new-born children consists  in slight
motions of their arms and legs, which, as Ave have said, ought not to be
confined too closely.  Rather  later, they may be moA'ed about  in the arms ;
toAvard the fifth or sixth month, they may be exercised in standing on a carpet
or coverlet, and left to themselves in order to try their  strength ; they begin
first to drag  themselves, then to creep on all  fours,  and  soon get up by
taking hold of furniture;  after Avhich they make a feAV steps.   As a general
rule, I do not think it advisable to encourage children to Avalk  too  soon
by supporting them  Avith  belts of listing, wagons, &c.;  we ought ahvays
tc await the first promptings of nature. 
INDEX.
A.
Ablomen, siin of,  altered by pregnancy,
            154.
          enlargement of, as sign of preg-
            nancy, 240.
          palpation of, 247.
          smallness of cavity of, induction
            of premature labor for, 1006.
Abdominal pains during pregnancy, 520.
           muscles, effect of contraction of,
                     during labor, 612.
                   effect of paralysis of,
                     during labor, 613.
Abortion  560.
          spontaneous, 561.
               causes of, 561.
                   due to the father, 562.
                             mother,562.
                   due  to diseases of the
                     womb  and ' its  ap-
                     pendages, 563.
                   due  to diseases of the
                     ovum, 564.
                   due  to  disease   and
                     death of foetus, 565.
          accidental, causes of,  566
                symptoms of, 567.
                diagnosis, 571.
                delivery of  after-birth,
                  575.
                prognosis, 578.
                treatment, 579.
                retention  of placenta in
                  cases of, 577.
          causes on account of which it is
            artificially produced, 567.
          production of, 1022.
                reasons for, 1023
                mode of operating, 1024.
                by  detachment of mem-
                  branes, 1024.
                by puncture of the ovum,
                  1025.
Abscesses in the lips of the cervix uteri,
  704.
Acute  diseases, induction of  premature
  labor for,  1007.
After-birth,  natural delivery of the, 381.
            artificial delivery of the, 868.
After-birth, delivery of, in cases of abor-
              tion, 575.
            accidents that may complicate
              its delivery, 884.
After-pains, 429.
Agalactia,  1089.
Agglutination of the external uterine ori-
  fice, 696.
Albuminuria during pregnancy, 490.
             frequency of  oedema  from,
               496.
             time of commencement, 496.
             nervous disorders from, 496,
               499.
             progress of, 497.
             prognosis of, 497.
             a cause of abortion, 498.
                      various obscure dis-
                        orders, 498.
             treatment of, 498.
             as a cause of eclampsia, 792.
Albuminous urine, mode of testing, 494.
Allantoid, the, 186.
          vesicle, 187.
Amaurosis  during pregnancy, 508.
Amnion, the, 184, 190.
         waters of the, 184, 191.
         dropsy of the, 541.
                      prognosis, 543.
                       treatment, 544.
Amniotic fluid, 184.
              fcetor of the, 400.
Amputation of limbs of the foetus, 557,
              the  thigh, effect  of, upon
                labor, 613.
Anaesthetics  use of, in obstetrical practice,
               915.
             effect of.  an the uterine con-
                          traction, 917.
                        abdominal mu-
                          cles, 919.
                        resistance of the
                          perineum, 919.
                        mother's health,
                          920.
                        life and health of
                          the foetus, 923.
             use of, m eclampsia, M4, 817.
             indications  for the  use of,
               923.
                            1108 
INDEX.
11(W
Anaesthetics, use of,  in  obstetrical  opera-
                     tions, 925.
                  during pregnancy, 925.
                  for convulsions  during
                     pregnancy, 925.
                  whilst nursing,  926.
            mode of administering, 926.
            in pelvic version, 948.
Anchylosis of the foetal articulations, 862.
Aneurism during labor, 825.
Anhistous membrane, 170.
Anorexia during pregnancy, 463.
Anteversion of  the  uterus  during preg-
  nancy, 539.
Aorta, compression of, for uterine  hemor-
  rhage, 892.
Apoplexy and asphyxia of  new-born chil-
            dren, 409.
          of the placenta, 554, 765.
          placental, 7G5.
          puerperal, 790.
Areola  the, 115.
        changes in,  from pregnancy, 155.
        changes of, as a sign of pregnancy,
          241.
Artery, omphalo-mesenteric,  189.
Articulation, sacro-coccygeal, 42.
Ascites during pregnancy, 502.
                           prognosis,  503.
                           treatment. 504.
        of foetus, 858.
Asthma during  labor, 825.
Attentions to the woman during labor, 388.
                 child during labor, 399.
                 woman immediately after
                   delivery, 405.
                 child  immediately after
                   delivery, 406.
                 lying-in woman, 439.
 Auscultation, as applied to pregnancy, 252.
              in vertex presentations, 316.
                 face presentations, 336.
                 breech presentations, 349.


                    B.

 Bag of Avaters, the,  294.
               double, 29 t.
 Ballottement, 245.
 Battledoor-placenta, 210.
 Bellows murmur  as a  sign of pregnancy,
   253.
 Bile, secretion of, in the foetus, 237.
 Bladder, displacements  of, during preg-
            nancy,  153.
          rupture of, during labor, 393.
                           symptoms, 393.
          paralysis of, after labor, 439.
          distention of, during labor, 393.
          tumors of, 726.
          procidentia of, 726.
          cancer of, 726.
          lateral displacement of, 730.
          distention of, as a cause of con-
             vulsions, 795.
Blastodermic membrane, formation of, 182.
Blood, changes in, from pregnancy, 157.
       alterations  of, during pregnancy,
               479.
             as a cause of convulsions,794
                         secondary hem-
                          orrhage, 900.
Blood-letting  and  debilitating  regimen,
         effect of, on the development of
         the child, 911.
Blot's perforator,  1041.
Bodies of Rosenmiiller, 82.
Botal, foramen of, 212, 231.
Branchial fissures, 213, 229.
Breasts, the, 115.
         anomalies of, 115.
         changes in,during pregnancy, 155.
Breech presentation, 347.
Broad ligaments, 82.
                 cysts of, 83.
c.
Caesarean operation, 1030.
                    history of, 1030.
                    on the living female,
                      1031.
                    post-mortem, 1039.
                    mortality of, 1031.
                    indications for, 1032
                    compared  with em
                      bryotomy, 1032.
                    propriety of, as influ
                      enced by the dura
        P             tion  of  the labor
                      1035.
                    propriety of, as influ
                      enced by the rup
                      ture  of  the  mem
                      branes,  1035.
                    preparatory    mea-
                      sures, 1036.
                    mode of performance,
                      1036.
                    dressing     of    the
                      wound,  1037.
                    vaginal, 1038.
Calculi, urinary, 727.
Callipers, Baudelocque's, 654.
Canal of Nuck, 84.
Cancer of the neck of the uterus, 711.
              rectum, 726.
              bladder, 726.
Caput succedaneum, 334, 852.
Carunculae myrtiformes, 63.
Catheter, mode of introducing, 61.
Caul, the, 296.
Cauliflower tumors of the cervix uteri, 710,
Cephalalgia during pregnancy,  507.
            from uterine hemorrhage, 771
Cephalic version, 929.
Cephalotripsy, 1045.
               repeated, without traction,
                 1053.
               pelvic version after, 1053. 
1110                               INDEX.
Cephalotripsy, after delivery of the trunk,
                 105:;.
               objections to, 1054.
               statistics of, 1054.
Cephalotribe forceps, 1045.
                     Cazeaux's modifica-
                       tion, 1046.
                     Chailly's do., 1047.
                     Depaul's do., 1047.
                     Blot's do., 1047.
                     Locarelli's do., 1048.
                     Hiiter's,  Scanzoni's,
                       and  Braun's  do.,
                       1048.
                     effect of, on the di-
                       ameters   of   the
                       head, 1048.
                     crushing power  of,
                       1048.
                     limits of applicabil-
                       ity, 1048.
                     mode of using, 1050.
                     difficulties in the use
                       of, 1050.
Child, healthy, management of, 406.
      diseased or feeble, management, of,
         409.
      attentions   to,   immediately  after
         birth, 406.
      debility of, 409.
      apparent death of, 409.
                         treatment, 416.
      lesions of respiration of, 412.
                circulation of, 414.
                nervous centres of, 414.
Child, effect  of bleeding  and deBilitating
  regimen on its  development,  911.
Children,  hygiene of,  from  birth  until
             weaning, 1062.
           clothing of, 1104.
           washing,  bathing, and cleanli-
             ness of, 1105.
           out-door exercise of, 1106.
           sleep of, 1106.
           exercise of, 1107.
Chlorosis during pregnancy, 455.
Chloasma, 513.
Chloroform, use of, in eclampsia, 814,  817.
Chorion, composition and formation of,  193.
         villi of,  202.
         dropsy of the villi of,  547.
Circulation,  changes in, from  pregnancy,
               157.
             of foetus, 231.
             changes in, after birth, 233.
             lesions of, during pregnancy,
               479.
Clitoris, the, 60.
Coagulum in uterus, as  cause of secondary
  hemorrhage, 899.
Coccyx, the, 36.
Colostrum, 435, 1062.
           characters of, 1062.
           time of continuance of, 1063.
           contamination of milk by, 1092.
Colpeurynter, 1010.
Conception, 119.
Congenital hernia, 207.
Constipation after delivery, 440.
            during pregnancy, 477.
Convulsions, puerperal, 788.
Cord, umbilical, prolapsus of, 828.
      great length of, 834.
      shortness of, 834.
      constriction of neck of child by, 83-1
      encircling of body of child by,  835.
      short, diagnosis of, 835.
            treatment of, 838.
Corpora lutea, 96.
              cause of color of, 98.
              as a sign of pregnancy, 99.
Coxal bone, 37.
Cranioclasm. 1054.
Cranioclast, Simpson's, 1054.
                     description of,  1054,
                     mode of using,  1054.
                     advantages of,  1055.
Craniotome, 1042.
Craniotomy, 1041.
            mode of perforating the cra-
               nium, 1043.
            advantages of, 1044.
            in  mento-posterior positions
              of the  face, 848.
Crotchet,  the, 1044.
Cystocele, 729,
D.
Deafness during pregnancy, 508.
Decapitation of the foetus, 1059.
Decidua, 167.
         old theory of the, 167.
         reflexa, 168.
         uterine,  168.
         inter-utero placental, 167,
         serotina, 169.
         present theory of the, 171.
         structure of the, 172.
         description of the three portions
            of, 175.
         at the end of  gestation, 177.
Deformities of the pelvis, 616.
Delivery, forcible, post-mortem, 1039.
Dentition, history of, 1081.
Diameters of the head at term, 219.
Diarrhoea during pregnancy, 477.
Diet of lying-in women, 441.
Digestion, disturbances of from pregnancy,
   157.
Dilatation of the os uteri, 292.
Diseases of the ovum, 541.
         of the foetus, 854.
         that may occur during pregnancy,
           443.
         that may complicate labor, 824.
Disengagement,  irregularities  in vertex
   presentations,  324.
Dropsy of the cellular  tissue during preg
             nancy, 500.
           causes of, 500.
           progress and symptoms of, 501
           terminations of,  501. 
INDEX.
1111
Dropsy of the cellular tissue, treatment of,
         502.
       of the amnion,  541.
       of the villi of the chorion, 547.
       of the foetus, 557.
Duct of Gartner, 87.
Ductus arteriosus, 232.
       venosus, 232
Dysmenorrhoea, membranous, 110.
Dystocia, 604.
         occasioned by the  foetal  appen-
            dages, 828.
         due to the foetus, 839.
         from  multiple and independent
            foetuses, 863.
                   adherent foetuses, 866.

                   E.

Eclampsia, 788.
           during pregnancy, 505.
           frequency of, 790.
           time of occurrence, 791.
           causes, predisposing, 792.
                   determining, 793.
           symptoms,  796.
           precursory  phenomena,  796.
           phenomena of the attack, 797.
           stages of the attack, 798.
           effect  of, upon  the alimentary
                     canal,  798.
                   respiration. 799.
                   larynx, 799.
                   pharynx, 799.
                   heart, 799.
                   secretion of urine, 799.
                   pulse, 799.
                   sensorial and intellec-
                     tual functions, 799.
                   contractility   of  the
                     uterus, 800.
           phenomena of the cessation of
             the attack, 800.
           duration of the attack, 800.
           number of the paroxysms, 801.
           interval of the paroxysms, 801.
           comatose state of, 801.
           termination of, 802.
           effect  on the memory and intel-
                         lectual faculties,
                         802.
                       vision and hearing,
                        802,
           mode  of producing death, 802.
           diagnosis of, 804.
                   from hysteria, 804.
                        epilepsy, 804.
                        tetanus, 805.
                        apoplexy, 805.
                        concussion of the
                          brain, 805.
                        intoxication, 805.
           prognosis,  805.
                      in nervous subjects,
                        806.
                      in cases of alteration
                        of the blood, 806.
Eclampsia, prognosis, incases of irritation
                        of organs, 806.
                     in different stages of
                       labor,  807.
                     after delivery, 807.
                     as regards the child,
                       807.
           pathological anatomy of, 808.
           nature of, 810.
           connection of, with albuminu-
             ria, 810.
           treatment, preventive, 812.
                       venesection, 812.
                        diuretics, 813.
                        tartar emetic, 813.
                        induction of  pre-
                         mature  labor,
                            813.
                       chloroform, 814.
                     curative,  814.
                       blood-letting, 814.
                       emetics, 816,
                       purgatives, 816.
                       catheterism, 817.
                       revulsives. 817.
                       Junod'scups, 817.
                       aspersions, 817.
                       antispasmodics,
                                    818,
                       opiates, 819.
                       premature labor,
                         820.
                       mode of protecting
                         the tongue, 819.
                       during  gestation,
        «                 820.
                       during labor, 821.
                       after delivery, 824.
Electricity, use of, for induction of prema-
  ture labor, 1008.
Embryonic spot, the, 183.
Embryotomy, 1040.
             forceps, Baudelocque's, 1045.
                     Simpson's, 1054.
Emphysema, pulmonary and subcutaneous,
              v during labor, 827.
             of the foetus, 859.
Enchondroma of  the pelvis, 676.
Epichorion of Chaussier, 168.
Epilepsy during pregnancy, 455.
Ergot, natural history of, 907.
       therapeutical action of,  908.
Evolution, spontaneous, 368.
Exhaustion during labor, 826.
Exostosis of the pelvis, 675.
External genital parts, excessive resistance
                        of,  677.
                      obstruction of,  du
                      ring labor from ci
                      catrices, 681.
F.
Face presentations, 335.
                   frequency of, 335
                   causes of, 335. 
L112
INDEX.
Face presentations, diagnosis, 336.
                   mechanism, 338.
                      in mento-posterior
                        positions, 343.
                   inclined or irregular,
                     345, 844.
                   mento-posterior  posi-
                     tions, treatment, 846.
Facial nerve, paralysis of, from use of for-
  ceps, 994.
Fallopian tubes, 85.
                structure of, 85.
                anomalies of, 86
                obliteration  of, as a cause
                  of  extra  uterine preg-
                  nancy, 598.
                tumors of the, 725.
False kidneys, 212.
     labor, 39.
     waters, 546.
Fecundation, where effected, 120.
             causes of, 123.
             period of occurrence, 123.
Fevers, eruptive, during pregnancy, 446.
        of the foetus, 556.
Fcetal appendages, 187.
      monstrosities, 862.
Foetus, the, 210.
       dimensions and weight  of, at dif-
         ferent  periods of  intra-uterine
         life, 211.
       position and attitude of, 222.
       functions of, 225.
       nutrition of, 229.
       respiration of, 229
       circulation of, 231.
       changes in the circulation of, after
         birth, 233.
       innervation of, 236.
       secretions of, 236.
       active movements of, as a sign of
         pregnancy, 251.
       inflammation of the organs of, 556.
       fevers of, 556.
       icterus of, 556.
       syphilis of, 556.
       dropsies  of, 556.
       spontaneous fractures of, 556.
       amputation of the limbs of, 556.
       death of, 558.
       effect of  eclampsia upon, 807.
       unusual size of, 839.
       diseases of, 556, 854.
       hydrocephalus of, 854.
       hydrothorax of, 858.
       retention of urine of, 858.
       emphysema of, 859.
       tumors,  various, of, 860.
       anchylosis  of articulations of, 862.
       spontaneous fractures of, 557.
       death of, in preceding pregnancies,
         an indication  for  induction  of
         premature labor, 1007.
       section of the neck and body of, 1058
                   cases requiring, 1058.
                   operation, 1059.
Foetus, decapitation of, instruments for
                                    1060
                    Baudelocque's, 1060.
                    Ramsbotham's, 1060.
                    Van der Ecken's, 1060.
                    Tarnier's,  1060.
                    Pajot's, 1060.
                    Jacquemier's, 1060.
       delivery of, by amputation of arm
         and perforation of the abdomen,
         1061.
       delivery of, by section of the bodv
         of, 1061.
Foetuses, multiple and independent,dystocia
                        from, 863.
                      adherent,  dystocia
                        from, 866.
Fontanelles and sutures, 218.
            ossa Wormiana in, 839
Foramen of Botal,  212, 231.
Forceps, the, 959.
         history of, 959.
         Chamberlen's,  960.
         Levret's, 960.
         Smellie's, 960.
         Tarsitani's, 960.
         leniceps, 963.
         Lyonese, 962.
         Baumer's,  963.
         Leake's, 963.
         Thenance's, 962.
         Simpson's, 964.
         various modes  of articulating,
           962.
         apparatus  for steady traction of,
             Chassagny's, 963.
             Joulin's, 963.
         use of, preliminary precautions,
           964.
         general rules of application, 966.
         application on pelvic extremity,
           965.
         method of applying, Hatin's, 966.
                     Baudelocque's, 967.
                     Velpeau's, 967.
                      Mad.  Lachapelle's,
                        967.
                     German      accou-
                        cheurs, 968.
         mode of locking, 969.
                 making traction,  970.
         special rules of application, 971.
         application in  vertex  presenta-
           tions, with the head at the in-
           ferior strait,  971.
         application in occipito-anterior
                    positions, 971.
                 occipito-posterior  posi-
                    tions, 972, 994.
                 left  anterior  occipito-
                    iliac position, 973.
                 right posterior occipito-
                    iliac position, 973.
                          rotation of th«
                            head in, 974 
INDEX.
1113
 Forceps, application in right anterior oc-
                    cipito-iliac   position,
                    975.
                  left  posterior  occipito-
                    iliac position,  975.
                  left transverse occipito-
                    iliac position,  975.
                  vertex     presentations,
                    with the head merely
                    engaged at the supe-
                    rior strait, 977.
                  vertex positions, with the
                    head  movable above
                    the  superior  strait,
                    978.
                  ace positions, 980.
                         above  the supe-
                           rior strait, 983.
                  mento-posterior    posi-
                    tions, 846, 981.
                  when the head remains
                    after the  body is ex-
                    pelled, 983.
         general considerations on the use
           of, 985.
         use of, in inclined vertex or face
                     positions, 985.
                   contracted pelves,  986.
         comparison with version  in con-
           tracted pelves, 988.
         when  applicable in case of acci-
           dent during labor, 991.
         use of, for resistance of perineal
                      muscles, 991.
                    a short cord, 992.
         at what  period of labor applica-
           ble, 992.
         statistics and general view of the
           operation, 993.
         effect of pressure of, on the child's
                       head, 994.
                     in  producing facial
                       paralysis, 994.
         embryotomy,Baudelocque's, 1045.
                     Simpson's, 1054.
         saw, Van Huevel's, 1055.
Forcible delivery, post-mortem, 1039.
Fossa navicularis, 63.
Fourchette, the, 58.
Fraenum linguae, section of, 1073.
Fractures,  spontaneous, of the fcetus, 557.
Fracture of the sternum during labor, 828.
G
Gartner, duct of, 87.
Galactorrhoea, 1090.
Generation, external  organs of, 57.
             internal organs of, 68.
Germinal vesicle, 92.
         spot, 92.
               disappearance of, 180.
Giddiness during pregnancy, 505.
Glairy discharges, 293.
Gland, vulvo-vaginal, 6J
Glands of the ■» alva, 64.
Glycosuria, physiological. 438.
Graafian vesicles, 89.


                   H.

Head of foetus at term,  217.
              diameters of, 219.
              circumference of, 220.
        child, unusual  size of, during la-
           bor, 839.
Heart,  hypertrophy of, from pregnancy,
         160.
        foetal, sound of,  as  a sign of preg-
         nancy,  253.
        chronic diseases of, during labor,
         825.
Hematemesis during labor, 824.
Hemicrania during pregnancy, 507.
Hemiplegia  during pregnancy, 509.
Hemorrhage during pregnancy,  486.
             puerperal,  747
             unavoidable, 755.
             uterine, from shortness of the
                           cord, 762.
                         sudden contrac-
                           tion  of  the
                           uterus, 762.
                    general symptoms of
                      763.
                    local  symptoms  of,
                      763.
                    external, 763.
                    internal, 764.
                    diagnosis, 765.
                    from abnormal inser-
                      tion of the placen-
                      ta,  signs of, 766,
                      767.
                    from rupture  of the
                     umbilical cord, 768.
                    external ani inter-
                     nal ; prognosis,770,
                    blindness,  deafness,
                      and    cephalalgia
                      from, 771.
                    effect  of,  upon  the
                      fcetus,  772.
                    from abnormal inser-
                      tion of the placen-
                      ta, prognosis, 773,
                    treatment, 775.
                        general, 776.
                        special, 776.
                    moderate, occurring
                     in  the  last  three
                     months, 776.
                    profuse, in the hast
                     three months, 777.
                    internal,  782.
                    moderate, during  la-
                     bor, 7b3.
                    profuse,  duriug la-
                     bor, 783. 
1114                               INDEX.
Hemorrhage, uterine, from abnormal inser-
                      tion of the placen-
                      ta, treatment, 785.
                    synoptical  table of
                      treatment,  787.
                    attendant  upon  de-
                           livery of  the
                           placenta, 884.
                         causes, 884.
                         symptoms, 885.
                         diagnosis, 887.
                         prognosis, 888.
                         treatment,  pre-
                           ventive, 888.
                         treatment,   cu-
                           rative, 889.
                         tampon for, 891.
                         compression of
                           the  aorta for,
                           802.
                         ergot for, 894.
                         opium for, 894.
                         transfusion for,
                           895.
                    secondary,  898.
                    from  the  umbilical
                      cord. 901.
Hemorrhoids during pregnancy,  487.
Hemoptysis  during labor, 824.
Hepatic portal vein,  189.
Hernia, congenital, 207.
        of the womb, 719.
        intestinal  or omental, 728.
        vulvar or perineal, 728.
        vesical or  cystocele, 729.
        during labor, 825.
Hour-glass contraction of the womb, 871.
Hydatiform  mole, 547.
Hydraemia during  pregnancy, 479.
Hydrocephalus, 854.
               diagnosis of, 855.
               treatment of, 857.
Hydrorrhoea, 545.
Hydrothorax of foetus,  858.
Hygiene of children from birth until wean-
  ing,  1062.
Hymen, 62.
        persistence  of the, 681.
Hysterotomy, vaginal, for  spasm  of  the
  cervix uteri, 700.
I.
icterus during pregnancy, 449.
       as a cause of abortion, 449.
       of the fcetus, 556.
Ilium, 39.
Induration,  with  hypertrophy of the neck
  of the  uterus, 711.
Inertia, secondary,  of the Avomb, 898.
       of the uterus, 868.
Infantile  hygiene, 1062.
Inguinal  pains during pregnancy, 520.
Innominatum, 37.
Insanity during pregnancy, 510.
Insanity, puerperal, 512.
Intestinal irritation as a cause of eclamp-
  sia, 795.
Intra-uterine dilator,  1016.
Inversion of the uterus, 902
Iodine, effect of the  administration of, on
  the development of the child, 914.
Ischium, 39.
Itching of the skin during pregnancy, 512
J.
Jaundice as a cause of abortion, 449.
         during pregnancy, 449.
         of the foetus, 556.
Junod's apparatus, 8.17.
                  use of,in eclampsia,817.
K.
Kidneys, false,  212.
Kyesteine, 161.
Labia majora, 58.
      minora, 59.
      adhesions of the, 681.
      externa, oedema of, 686.
Labor, 275.
       causes of, at term, 276.
                 efficient, 276.
                 determining, 280.
       physiological phenomena of, 284.
       precursory signs of, 284
       first stage of, 286.
       second stage of, 287.
       pain or contraction, 288.
            cause of, 290.
       state of the pulse during, 291.
       duration of, 297.
       prognosis of, 298.
       effect of, on the mother and child,
         300.
       mechanical phenomena of, 304.
       in general. Review of the mechan-
         ism of, 371.
       table of the six stages of, in all the
         presentations, 373.
       twin, 375.
       premature, 377.
       retarded, 379.
       attentions to the woman during, 388.
       retrocession of, 390.
       false, 390.
       regimen of Avomen during, 398.
       signs of the life or  death of  the
      *  child during, 399.
       preternatural and painful, 604.
       extreme slowness of,  605.
       tedious,  607.
       pains, slowness or feebleness of, 607.
             relaxation  or  susp^.,sion of.
               607. 
INDEX.
1115
Labor pains, irregularity of, 611.
      too rapid, 613.
                treatment of, 616.
      effect of, upon the mother,  615.
                        child, 615.
      with pelvis contracted to 3| inches
                   in its smallest diame-
                   ter, 669.
                   measuring 3f inches at
                   the most and 2 J inches
                   at the least in its small-
                   est diameter, 671.
       with the dimensions  of the pelvis
         under 2J inches, 673.
       hemoptysis during. 824.
       hematemesis during, 824.
       aneurism during, 825.
       diseases of the heart during, 825.
       asthma during, 825.
       hernia during, 825.
       syncope during,  826.
       exhaustion during, 826.
       emphysema during, 827.
       hemorrhage during, 783.
       fracture of the sternum during, 828.
       irregular  or complicated presenta-
         tions and positions during, 841.
       anomalies in the mechanism of, 841.
       unusual size of the head during, 839.
                  of the shoulders during,
                     839.
       premature, induction of, 1000.
Lactation,  1062.
           duration of,  1064.
           glycosuria during, 438.
Lead-poisoning as a cause of abortion, 453.
Leucorrhcea during pregnancy, 518.
Ligament, pubic, 40.
          sacro-sciatic, 41.
          sacro-iliac, 41.
          sacro-coccygeal, 43.
          sacro-vertebral, 44.
          ilio-lumbar, 44.
Lipothvmia during pregnancy, 505.
Liver, fatty condition of, during pregnancy,
         157.
      enlarged, of foetus, with dropsy of
         the amnion, -544.
Lochia, 431.
        characters of, 431.
        duration of, 431.
        absence of, 431.
        effect of lactation upon, 433.
        profuse or purulent,  435.
        substituted by hematemesis, 433.
        long  continued, 433.
        suppression of,  435.
Lying-in, phenomena of the, 421.
M.
Malformations of the vulva and vagina, 681.
Mammary gland, 116.
Mammae, changes  in, as a  sign of  preg-
  n<uny, 241
Measles during pregnancy, 448.
        congenital, 448.
Meconium, 237.
           discharge of, during labor, 400
Membrana media,  190.
Membrane, utero-epichorial, 203.
Membranes, rupture of, 295.
                       time   of  occur-
                         rence, 296.
                       in  natural labor,
                         396.
            abnormal adhesions of, 879.
            retention  of, as a  cause  of
              secondary hemorrhage, 899.
            detachment of, for producing
              abortion, 1024.
            puncture   of,  for  producing
              abortion, 1025.
Membranous dysmenorrhoea, 110.
Menstruation, 103.
              time of beginning, 104
              precocious, 106.
              duration of, 107.
              quantity of, 107.
              vaginal, 108.
              physical characters of, 109.
              cessation of,  113.
              cause of, 110.
              suppression of, as a sign of
               pregnancy, 238.
              during pregnancy, 238.
Milk fever, 435.
           time of commencement, 437.
           cause of, 437.
     suppression  or  prevention  of  the
       secretion, 437.
     amount, and quality, tests of,  1063.
     properties of, before the  milk fever,
                     1063.
                   after the milk fever,
                     1063.
     microscopic characters of, 1063.
     individual differences in, 1064.
     induced secretion of,  1064.
     variation in the quantity of, 1065.
     effect of  the health  of the  nurse
              upon, 1065.
           of moral emotions upon, 1066.
           of menstruation upon, 1067.
           of pregnancy upon, 1068.
           of sexual  intercourse  upon,
              1068.
            of  alimentary  and medicinal
              substances upon, 1068
     absence or small amount of, 1089.
     profuse secretion of, 1090.
     altered quality of, 1091,
     poor, effects  of, 1091.
     over-rich, effects of, 1091.
     quality of, dependent upon the time
       of its secretion, 1091.
     altered by colostrum, 1092.
                          effects of, 1092
     altered by pus, 1092.
                    effects of, 1092.
Mole, hydatiform,  547. 
1116
INDEX.
Mole, fleshy, 578.
Mons veneris, 58.
Monstrosity by inclusion,  274.
Monstrosities, foetal, 862.
Motions of the child productive of pain, 523.
                  when first observable,
                    251.
                  characters of,  251.
                  simulated, 251.
                  mode of detecting, 251.
                  mode of exciting, 251.
Myrtiform caruncles, 63.
N.
Neck of gravid uterus, 130.
                      softening of, 130.
                      volume of, 131.
                      form of, 133.
                      situation  and  di-
                        rection of, 135.
                      shortening of, 132.
                      posterior obliquity
                        of, 135.
Nervous disorders, induction of premature
  labor for, 1006.
Neuralgia during pregnancy, 507.
Nipple, structure of the,  116.
       supplementary, 115.
       changes in, from pregnancy, 155.
       too short, 1070.
                 mode  of  remedying,
                   1070, 1083.
       over-sensitive, remedy for,  1071.
       shields, 1070.
       affections of  the, 1084.
                    preventive measures,
                      1086.
                    treatment, 1087.
       artificial, 1088.
Nuck, canal of, 84.
Nurses, selection of,  1095.
        examination of, 1096.
        temperament of, 1097.
        age of, 1097.
        pregnancy of, 1098.
        examination of breasts of,  1098.
        examination of milk of, 1098.
        regimen of,  1101.
Nursing,  maternal, 1069.
         precautions to be observed, 1070.
         rules of,  1071.
         when to be commenced,  1072.
         obstacles to, 1070.
         children, food for, 1079.
                          when to be first
                            given, 1078.
         mother, regimen of, 1082.
         impediments to, 1083.
               from affections of the nip-
                 ple, 1084.
               from  interfering circum-
                 stances, 1089.
               from deterioration  of  the
                 mother's milk, 1090.
 Nursing,  mixed,  1093.
          by an animal, 1102.
          artificial, 1103.
          by wet-nurses, 1095.
                      regulation of, 1100
 Nymphae, 59.

                   0.

 Obliteration of the neck of the uterus,  697.
 Obliquities, uterine, during pregnancy,  541.
 Obliquity of the uterine orifice, 702.
          uterine, as a cause of dystocia,
            713.
          anterior, as a cause of dystocia,
            713.
 Obturator membrane, 44.
          foramen, 37.
 Odontalgia during pregnancy, 507.
 Oedema of the labia  externa, 686.
        of the entire  soft parts of  the
          pelvis,  686.
 Omphalo-mesenteric  vein, 189.
                    artery, 189.
 Organs of connection, 194.
 Ossa Wormiana in the fontanelles, 839.
 Osteophytes of  the cranial bones, 166.
 Osteosteatoma of the pelvis,  676.
Osteosarcoma of the pelvis, 676.
Os uteri, dilatation of, 292.
         difficulty  of  reaching  during
           labor,  293.
Ovaries, the, 86.
        ligaments of, 86.
        situation of,  86.
        size of, 87.
        vesicles of, 88.
        nerves of, 88.
        structure of, 88.
Ovary, tumors of the, 723.
Ovarian vesicles,  89, 90.
                 number of, 89.
                 structure of, 90.
                 modifications undergone
                  by, 93.
Ovula Nabothi,  77.
Ovulation and menstruation,  93.
Ovule, the, 90.
       size of, 91.
       changes of, after fecundation,  179.
                  in the tube,  180.
                  from  arrival  in  the
                    womb until after the
                    development of  the
                    allantoid, 182.
 Ovum, diseases of the, 541


                   P.
 Padjeras, 111.
 Palpation of the abdomen, 247.
 Paralysis during pregnancy, 507.
          facial, during pregnancy,  509.
                 from the use of the  foi
                   ceps, 994.
 Paraplegia  during pregnancy, 509. 
INDEX.
1117
Pelvis, 33.
       articulations of, 39.
       in general, 44.
       external surface, 44.
       internal surface, 35.
       greater, 44.
       lesser, 45.
       inclined planes of 47.
       superior strait of, 47.
                         inclination of
                           plane of, 47.
                         diameters of, 48.
       inferior strait of, 49.
                        inclination    of
                          plane of, 50.
       diameters of inferior strait, 51.
       excavation, or cavity of, 51.
       diameters of cavity of, 52.
       general axis of,  52.
       base of, 53.
       differences of,   according  to sex,
         age,  and race, 53, 54.
       uses of, 54.
       covered by soft  parts, 54,
       deformities of the, 616.
       deformed  by excess of  amplitude,
                               617.
                            contraction,
                               618.
       simple contracted, 619.
       contracted by curvature and  mal-
         formation of the bones, 620.
       oblique contraction of, 623.
       deformed, variations in the  depth
                   of, 625.
                 by absolute narrowness,
                   626.
                 by rachitis, 626.
                 by osteomalacia, 629.
       oblique-oval, 630.
       malformation of, dependent upon
               previous deformity of an-
               other part of the skeleton,
               634.
             dependent  upon  congenital
                    luxation   of   the
                    femur, 535.
                  upon   non-congenital
                         luxation of the
                           femur, 640.
                         lesions  of  the
                           inferior   ex-
                           tremities,640.
      deformities of, influence of, upon
        pregnancy and parturition,  641.
      having at least 3| inches in  its con-
                       tracted part, 644.
                    21 inches in  its con-
                       tracted part, 646.
             less  than 21 inches  in its
               contracted part, 646.
      deformities of, diagnosis, 649.
                    sensible signs of,653.
                    indications pre-
                      sented by, 668.
      exostosis of, 675.
 Pelvis, enchondroma of, 676.
        osteosteatoma of, 676.
        osteosarcoma of, 676.
        bony  tumors  of, caused  by frac-
          tures, 676.
        inclined positions of the, 844
 Pelyic presentation, 347.
                    frequency, 348.
                    causes, 349.
                    mechanism, 351.
                    prognosis, 357.
                          as regards  the
                            mother, 357.
                          as regards  the
                            child, 359.
       articulations, relaxations of, during
                         pregnancy, 514.
                       after delivery, 515.
                       prognosis, 515.
                       treatment, 516.
                    inflammation of, 516.
      deformities, causes and mode of pro-
         duction, 625.
Pelvimeters, 654.
             Baudelocque's,  654.
             Coutouly's, 656.
             Mad. Boivin's, 656.
             Stein's, 656.
             Wellenbergh's,  657.
             Van Huevel's, 657.
             the finger as a,  663.
Perforator,  Blot's. 1041.
            Smellie's, 1041.
            Kilian's, 1043.
Perineum, 67.
          extent of. 56.
          resistance of, during labor, 678
          laceration of, 680.
Phthisis during pregnancy,  453.
Pica,  or malacia, during pregnancy, 464.
Pigmentary deposits, 167.
            spots, during pregnancy, 513.
Pityriasis during pregnancy, 513.
Placenta,  the, 194.
          structure, 196.
          arteries of, 198.
          veins of, 199.
          point of insertion, 206.
          battledoor, 210.
          natural delivery of the, 381.
          lesions of the villi of,  549.
                         treatment, 552.
          fibrous obliteration of the villi
            of, 550.
          induration of, 550.
          encephaloid of, 550.
          cancerous, 550.
          tuberculous,  550.
          fatty, 550.
          fibrinous, 550.
          effusions of blood in, 552.
          apoplexy of,  554.
          delivery of, in cases of abortion
            575.
          retention of, in cases of abortion
            577. 
1118
INDEX.
Placenta, absorption of, in cases of abor-
           tion, 578.
         large, coincident with dropsy of
           the amnion, 544.
         insertion  of, on the  lower seg-
           ment of the uterus, 754.
         praevia, 755.
         perforation  of, by the  child's
           head, 774.
         expulsion of, in advance of the
           child,  774.
         artificial delivery  of tlie,  868.
         difficult delivery of, 868.
         excessive volume of, 869.
         encystment of, 872.
         encasement of, 872.
         abnormal adhesions of, 875.
                         causes, 875.
                         diagnosis, 876.
                         treatment, 877.
         retention of, 879.
                      treatment, 883.
         putrid absorption  of, 880.
         late expulsion  of,  881.
         complete absorption of, 882.
         accidents  that  may  complicate
           its delivery,  884.
         hemorrhage attendant upon its
            delivery, 884.
 Placental murmur, 258.
         apoplexy, 554, 765.
 Plethora during pregnancy,  479.
 Pneumonia during  pregnancy, 448.
 Polar globules, appearance  of, 180.
 Polypi, uterine, as  a cause of secondary
   hemorrhage, 900.
 Positions and attitude of the foetus, 222.
 Pregnancy, 118.
            varieties of, 118
            diagnosis of, 237.
            rational signs of, 237.
            sensible signs of, 242.
            signs, of,  at various periods,
              266'.
            pathology of, 443.
            diseases  which  may  occur
             during, 443.
            epidemic diseases during, 443.
            influenza during, 443.
            cholera during, 444.
            endemic diseases during, 445.
            intermittent fever during, 445.
            variola during, 446.
            eruptive fevers during, 446.
            scarlatina during, 447.
            measles during, 448.
            sporadic diseases during, 448.
            typhoid fever during,  448.
            pneumonia, during, 448.
            inflammatory diseases during,
              449.
            icterus during, 449.
            syphilis  during, 451.
            lead-poisoning during, 453.
            phthisis during, 453.
            hysteria during. 455.
Pregnancy, epilepsy during, 455.
           chlorosis during, 455.
           surgical diseases during, 455.
           tumors  in  the  abdomen and
              pelvis during, 456.
           hypertrophy  of the  thyroid
              gland during, 457.
           ulceration of the neck of the
              uterus during, 457.
           diseases of, 461.
           lesions  of  digestion  during,
              463.
           pica, or malacia, during, 464.
           pyrosis during, 464.
           vomiting during, 465.
           constipation during, 477.
           diarrhoea during. 477.
           lesions of respiration during,
                        478.
                      circulation  during,
                        479.
           plethora during, 479.
           bydraemia during, 479.
           hemorrhage during, 486.
           varicose veins during, 487
           hemorrhoids during, 487.
           lesions  of  the secretions and
              excretions during, 488.
           ptyalism during, 488.
           excretion of urine during, 489.
           albuminuria during, 490.
           uraemia during, 490.
           dropsy of  the cellular tissue
              during, 500.
           ascites  during, 502.
           lesions of innervation during
              505.
           eclampsia during, 505.
           vertigo during,  505.
           giddiness during, 505.
           lipothymia during, 505.
          . syncope during, 505.
           neuralgia during, 507.
           odontalgia during, 507.
           paralysis during, 507.
           intellectual  disorders during,
              510.
           insanity during, 510.
           diseases of  the skin during,
              512.
           lesions  of the pelvic articula-
              tions during, 514.
           diseases of  the vulva and va-
              gina during,  517.
           pruritus of  the  vulva during,
              517.
           leucorrhcea during, 518.
           vegetations   on  the  external
             /parts during, 519.
           abdominal,  lumbar,  and  in-
              guinal pains during, 520.
           rheumatism of the uterus dur-
              ing,  524.
            displacements  of  the uterus
              during,  528.
            extra-uterine, 585. 
INDEX.
1119
Pregnancy, abdominal, 5PC
           internal ovarian, 586.
           peritoneal, 587.
           tubo-abdominal, 588.
           tubal,  5S9.
           interstitial tubo-uterine, 589.
           utero-tubal, 589.
           extra-uterine, pathological
              changes in, 591.
           extra-uterine,  pathological
              changes in the  product of
              conception, 591.
           extra-uterine, pathological
              changes in the tissues of the
              mother, 593.
           extra-uterine,  symptoms  and
                   diagnosis, 594.
                 progress  and  termina-
                   tion, 596.
                 rupture of the  cyst,  696.
                 prolonged  retention of
                   the cyst  in, 597.
                 causes of, 598.
                 treatment of, 601.
 Premature labor, 377.
                  treatment  of, 379.
                  induction of, 1000.
                      history of, 1000.
                      cases  requiring,
                        1002.
                      contva-indications,
                        1004.
                      contra-indi cations
                        on account of ab-
                        dominal tumors,
                        1006.
                      contra-indications
                        on   account  of
                        smallness  of ab-
                        dominal cavity,
                        1006.
                      contra-indications
                        on   account  of
                        nervous disorders,
                        1006.
                      contra-indications
                         on   account of
                        intercurrent acute
                         diseases, 1007.
                      contra-indications
                         on account of the
                         death of the foetus
                         in preceding preg-
                         nancies. 1007.
                      operations for, 1007.
                      by external  stimu-
                         lation  of the body
                         of the uterus,
                         1008.
                      by stimulation of the
                         os tincae, 1009.
                       by uterine douches,
                         1010.
                       by douches of car-
                         bonic  acid  gas,
                            1011.
Premature labor, induction of, by dilata-
                      tion of the neck of
                      the  womb by  pre-
                      pared sponge, 1011.
                     by irritants placed
                       between the walls
                       of the uterus and
                       ovum, 1015.
                     by  detachment  of
                       the  membranes,
                       1015.
                     by  the spheno-sy-
                       phon, 1014.   \
                     by the colpeurynter,
                       1010.
                     by the intra-uterine
                       dila.tor. 1016.
                     by electricity, 1008.
                     by Hiiter's process,
                       1009.
                     by Braun's do.,1010.
                      by  Meissner's  do.,
                       1020.
                      by Villeneuve's do.,
                       1021.
                      by Schosller's
                        method, 1009.
                      by Kiwisch's do.,
                        1010.
                      by Scanzoni's do.,
                        1010.
                      by  Kluge's  do.,
                        1011.
                      by  Lehman's do.,
                        1015.
                      bv  Cohen's  do.,
                       '1015.
                      by  Krause's  do.,
                        1016.
                      by  Busch's  dilator.
                        1013.
                      by  Krause's do.,
                        1014.
                      by  Schnackenber-
                        ger's do., 1014.
                      by  Barnes'  do.,
                        1014.
                      by  Tarnier's do.,
                        1016.
                      by  puncture of the
                        membranes, 1019.
                      appreciation of va-
                        rious  methods of
                        accomplishing,
                        1021.
  Premature delivery, 1000.
  Presentations and positions, 304.
                      classification of, 305.
               complicated, 849.
               and positions irregular oi
                  complicated, 841.
  Procidentia  of the bladder, 726.
  Prolapsus uteri, 720.
                  during pregnancy, 528.
            of the cord, 828.
                       causes, 829. 
1120
INDEX.
Prolapsus of the cord, signs of, 829.
                     prognosis, 831.
                     treatment, 832.
Pruritus of the vulva during pregnancy,
  517.
Ptyalism during pregnancy, 488.
Pubis, 39.
       articulation of, 40
       arch of, 49.
       section of, as a substitute for sym-
         physeotomy, 1030.
Puerperal condition, the, 421.
          hemorrhage,  747.
                       causes of, 748.
                              predispos-
                               ing, 748.
                              determin-
                               ing, 753.
                              special,
                                754.
           convulsions,  788.
                       partial, 788.
          apoplexy, 790.
Pulse, during labor, 291.
      after delivery, 422.
      vaginal, 693.
Pus, contamination of the milk by, 1092.
Pyrosis during pregnancy, 464.


                   Q.

Quickening, time of, 251.


                   R.

Rectum, tumors of the, 725.
Regimen of women during labor,  398.
Relaxation of the pelvic articulations, 514.
Respiration of the child, lesions of, 412.
             lesions of, during pregnancy,
              478.
Retarded labor, 379.
Retention of  urine after labor, 439.
                   foetal, 859.
Reticulated or vitriform body, 187.
Retroversion  of the  uterus  during  preg-
                             nancy. 532.
                        diagnosis, 534
                        treatment,  536.
 Rheumatism of the uterus, 524.
         influence of, on the  progress  of
           gestation, 526.
         influence of, on labor, 526.
         influence  of, on  the  puerperal
           functions. 527.
         prognosis, 527.
         treatment,  528.
 Rigidity of the neck of the uterus, 698.
 Rosenmiiller, bodies of, 82.
 Rupture of the uterus, 732, 906.
                  causes, 733.
                       predisposing, 733.
                       determining, 734.
                       traumatic, 734.
Rupture of the uterus, causes, internal, 735
               symptoms, 737.
               prognosis and termination.
                 739.
               hemorrhage from, 739.
               inflammation from, 740.
               escape  and strangulation
                 of intestine from, 740.
               recovery from, 741.
               pathological anatomy, 741
               treatment of, 743.
                     during labor, 743.
                     during latter months
                       of gestation, 745.
               early,during gestation,745.
Rupture of  the vagina, 745.

                   s.

Sacro-iliac articulations, 41.
Sacrum,  34.
Saw forceps, Van Huevel's, 1055.
             advantages of, 1055.
             description of, 1055.
             mode of operating with, 1056.
             statistics of, 1057.
             objections to,  1057.
Scarlatina during pregnancy, 447.
Sebaceous coat of foetus,  215.
Section of the neck and body of the foetus,
   1058.
Secondary hemorrhage, 898.
           inertia, 898.
Shoulders of child, unusual size of, during
   labor, 839.
Sigaultian operation, 1025.
Signs of < pregnancy at various  periods,
   table of, 266.
Smellie's scissors, 1041.
Souffle of the cord,  257.
Spasmodic contraction of the neck of the
   uterus, 699.
Spasmodic  contraction of  the  neck  and
   internal orifice of the uterus, 700.
Spermatic fluid, 119.
Spermatine, 119.
Spermatorrhoea, 119.
Spheno-syphon, 1014.
Spontaneous ovulation, 101.
             version, 366.
             evolution, 368.
Sternum, fracture of, during labor, 828.
Sublingual  tumors in infants, 1074.
Surgical diseases during pregnancy, 455.
         operations during pregnancy, 455,
Sutures  and fontanelles, 218.
Symphysis, sacro-vertebral, 43.
Symphyseotomy,  1025.
                  history of, 1025.
                  effect of, 1026.
                  indications for,  1027.
                  mode of operating,  1029.
                  subcutaneous, 1030.
                  Stoltz's operation, 1030.
 Syncope during pregnancy7, 505.
I  "             labor, 826. 
INDEX.
1121
Syphilis during pregnancy, 451.
        transmission of, by the father,452.
                            mother, 452.
        of the foetus, 556.
T.
Tampon, the, 584, 778, 785, 891, 927.
         use of, for hemorrhage following
           delivery of the placenta, 891.
Tedious labor, 607.
Therapeutics, 907.
Thrombus of the vulva and vagina, 686.
                          causes,  687.
                          symptoms, 688.
                          diagnosis, 691.
                          prognosis, 691.
                          treatment, 691.
           of the lips of the cervix uteri,
             704, 705.
Thyroid gland,  hypertrophy  of,  during
  pregnancy, 457.
Tongue-tie, 1073.
Touch, the, 242.
        vaginal, 243.
        anal, 245.
Transfusion, for uterine hemorrhage, 895.
Trunk presentations, 361,  849.
                     frequency of, 362.
                     causes, 362.
                     recurrence,  363.
                     diagnosis, 363.
                     auscultation in, 364.
                     mechanism of, 366.
                     spontaneous version
                       in, 366.
                     spontaneous  evolu-
                       tion in, 368.
                     prognosis, 371.
Tumors in tne abdomen and.pelvis during
          pregnancy, 456.
         fibrous, of the uterus  during preg-
          nancy, 456.
         bony, of the  pelvis, 674.
                          caused by frac-
                             tures, 676.
         of the vulva  and vagina,  686.
         sanguineous or thrombus, 686.
         various, of external genital parts,
          695.
         fungous or cauliflower, of the cer-
          vix uteri, 710.
         encysted, of the uterus or vagina,
          710.
         sanguineous, of  the  lips  of  the
          neck of the uterus,  705.
         fibrous,  of the cervix uteri, 706.
         polypous of the cervix uteri, 706.
         of the body of the uterus, 721.
         fibrous, of the body of the uterus,
          721.
         of the ovary, 723
               Fallopian tube, 725.
               rectum,  726.
               bladder, 726.
Tumors, hernial, 728.
       in the  cellular tissue of the pel-
          vis, 731.
       various, of the foetus, 860.
       abdominal, induction of premature
          labor for,  1006.            »
       sublingual, in infants, 1074.
Turning, 929.
Twin pregnancy, 269.
                 discovered  by ausculta-
                  tion, 255.
                 causes, 270.
                 diagnosis, 270.
      labor, 375.
            table of positions in, 375.
            diagnosis of positions in, 377.
Typhoid fever during pregnancy, 448.
u.
Umbilicus, affections of, by pregnancy, 154.
           changes of, as a sign of preg-
             nancy, 241.
Umbilical arteries, 186, 232.
          vein, 186.
          vesicle, 188.
          cord, 190, 207.
               souflie of the, 257.
               management  of,  during
                  labor, 401.
               rupture of, or of one of its
                  vessels, 758.
               weakness of, 870.
               shortness of, as  a cause of
                           rupture, 761.
                           flooding, 762.
                hemorrhage from,  901.
          vessels, abnormal distribution of,
             as a  cause of  hemorrhage, 760.
 Urachus, 188.
 Uraemia during pregnancy, 498.
         nervous disorders caused by, 499.
 Urethra, the, 61.
         increased curvature and swelling
            of, from pregnancy,  153.
 Urinaemia,  499.
 Ui'ine, changes of, from pregnancy, 160.
        alteration of, as a sign of pregnan-
          cy, 242.
        retention of, in lying-in women, 439.
        excretion of, during pregnancy,489.
        albuminous, mode of testing, 494.
        retention of, from prolapse of the
                            uterus during
                            pregnancy,
                            531.
                          retroversion
                            during preg-
                            nancy, 534.
        secretion of, in the foetus, 237.
        retention of, foetal, 859.
 Urinary calculi,  727.
! Uterine souffle, 258.
         pains during pregnancy, 522
         hemorrhage, external, 763. 
1122
INDEX.
Uterine hemorrhage, internal. 764.
                             seat of, 764.
                             diagnosis
                              of, 769.
Uterus, the, 71.
       situation of, 72.
       size of, 72.
       altered direction of, 72.
       weight of,  73
       external surface of, 73.
       body of, 73.
       neck of.  74
       internal surface of, 76.
       cavity of the body of,  76.
                    neck of,  77.
       structure of, 78.
       tissue proper of,  78.
       external membrane of, 78.
       internal membrane of, 79.
       structure of internal  or mucous
                      membrane of, 80.
                    the  glands  of the
                      neck of, 81.
       vessels of,  81.
       nerves of,  81.
       development of, 82.
       broad ligaments of, 82.
       round ligaments of, 84.
       vesico-uterine  ligaments of,  84.
       utero-sacral ligaments of, 84.
       changes in, from pregnancy, 125
                          volume, 125.
                          shape, 125.
                          situation, 126.
                          direction, 127.
                          density,  130.
                          weight, 130.
       lateral obliquity  of, 127.
                          causes, 128.
       relations of, at. term,  128.
       thickness of parietes at term, 129.
       changes in the neck of, from  preg-
                        nancy,  130.
                      texture  of,  from
                        pregnancy, 136.
                      serous coat,  from
                        pregnancy, 136.
                      middle coat, from
                        pregnancy, 137.
                      mucous coat, from
                        pregnancy, 137.
       development of the muscular struc-
          ture of,  from pregnancy, 137.
       vascular  apparatus   of,  during
          pregnancy, 145.
       lymphatics of, during pregnancy,
          147.
       nerves of,  during pregnancy, 147.
       changes in the properties of, dur-
          ing pregnancy, 148.
       sensibility of,  during pregnancy.
          148.
       irritability of, during pregnancy,
          148.
        contractility cf, during pregnancy,
          149.
i, retractility of, during pregnancy,
    151.
  changes  in  the  adjacent  parts
    during pregnancy, 152.
  atrophy of, after delivery, 423.
  internal surface of, after delivery,
    424.
  fibrous  tumors of,  during  preg-
    nancy, 456.
  ulceration of the  neck  of, during
    pregnancy, 457.
  rheumatism of, 524.
  displacements  of, during  preg-
    nancy, 528.
  prolapsus of,  during pregnancy,
    528.
  retroversion of, during pregnancy,
    532.
  anteversion of, during pregnancy,
    532.
  lateral obliquities of, during preg-
    nancy, 541.
  obstacles at. the neck of, 696.
  obliteration of the neck, 697.
  rigidity of the neck, 698.
  spasmodic contraction of the neck,
                     699.
                   of the internal
                     orifice,  700.
  incision of the neck for spasm, 700.
  obliquity of the orifice,  702.
  swelling and elongation of the an-
    terior lip, 703.
  thrombus of the lips of the cervix,
    704.
  abscess  in the lips of the cervix,
    704.
  sanguineous tumors  or thrombus
    of the lips of the cervix, 705.
  fibrous tumors of the cervix, 706.
  polypus of the cervix, 709.
  fungous or cauliflower  tumors of
    the cervix, 710.
  encysted tumors of, 710.
  agglutination  of the external ori-
    fice of, 696.
  induration with  hypertrophy  of
    the cervix of, 711.
  cancer of the  neck of, 711.
  obstacles  to  delivery  dependent
    upon  the body of, 713.
  obliquity of, as a cause of  dysto-
    cia, 713.
  posterior obliquity of, as a cause
                  of dystocia, 713.
                symptoms, 717.
                causes, 717.
                prognosis, 717.
  lateral obliquity of, as a cause of
                dystocia, 718.
             treatment, 718.
  hernia of, 719.
  prolapsus of, 720.
  tumors of the  body of, 721.
  rupture of,  732, 906.
  sudden  contraction of, as a cause
    of hemorrhage, 702. 
INDEX.
1123
Uterus, excitement of, as a cause of con-
          vulsions, 794.
        inertia of, 868.
        irregular  or  spasmodic contrac-
          tion of, 870.
        spasmodic contractions of the ex-
                  ternal orifice, 871.
              of the  internal orifice, 871.
        irregular contraction of the body
          of, 872.
        hour-glass contraction of, 871.
        spasmodic contraction of the en-
          tire organ, 874.
        congestion of, as a cause of secon-
          dary hemorrhage, 899.
        inversion of,  902.
Utero-epichorial mucous membrane, 203.
Vagina, the, 68.
        structure of, 70.
        bulb of,  70.
        changes in, during pregnancy, lo2.
        congestion of, as a  sign of preg-
           nancy, 152.
        diseases of, during pregnancy,517.
        malformations of, 681.
        inversion of, 685.
        tumors of, 686.
        encysted tumors of,  710.
        rupture of, 745.
Vaginal pulse, 153, 693.
        Caesarean operation, 1038.
Vaginitis, granular, 518.
Varicose veins during pregnancy,  487.
Variola, congenital, 447.
Vectis, or lever, the, 995.
       history of, 995.
       mode of introduction, 995.
       experiments with, on the dead body,
          996.
       use of, in vertex presentations, 997.
       use of, in  face presentations, 999.
       use of, in mento-posterior positions,
          846.
       use of, upon the head after the body
          has been delivered, 999.
Vegetations on  the external organs, 519.
Vein, omphalo-mesenteric, 189.
      hepatic portal, 189.
Version,  spontaneous, 366.
Version,  929
        cephalic, 929.
        by external manipulation, 930.
               before labor,  931.
               during labor and  before
               rupture of the membrane.
                 931.
               contraindications, 932.
               positions   of  the child  in
                 which it ought to be per-
                 formed, 932.
               preliminary measures, 932.
               mode  of performance, 932.
Version by external manipulation, during
                 labor and after rupture
                 of the membranes, 934.
               in  breech  present! tions,
                 935.
        pelvic, 936.
           precautions to be observed, 937.
           necessary conditions, 938.
           general rules of the operation.
             939.  ■
           introduction of the hand. 939.
           evolution of the foetus, 942.
           use of fillet in, 942.
           extraction  of the fcetus, 943.
           management of the cord,  943.
                        of the arms, 944.
                      •  of the head, 945.
           difficulties  of, 945.
                    from smallness of the
                     vulva, 945.
                   from resistance of the
                     uterine orifice, 946.
                   from insertion of the
                     placenta on the neck
                      of the uterus, 947.
                   from forcible contrac-
                      tion of the  body of
                     the womb, 947.
                   from  mobility of the
                     body of the  uterus,
                     949.
                   from  shortness of the
                     cord, 949.
                   from  large  should-ir?,
                      949.
                   from  crossing of the
                     arms   behind   the
                     neck, 949.
                   from arrest of the head,
                     950.
           appreciation of, 952.
                  in vertex presentations,
                    953.
                  in  face  presentation,
                    954.
                  in pelvic presentatior's,
                    955.
                  with descent of the an *»,
                    957.
Vertex presentation, 314.
             causes of,  314.
             diagnosis, 315.
             mechanism of labor  in,  S1
             inclined  or irregular, 331
             prognosis, 331.
       inclined positions of, 841.
Vertigo, during pregnancy, 505.
Vesicle, allantoid, 187.
        umbilical, 188.
Vestibule, the,  61.
Vitelline membrane, 91.
         nucleus, formation of the, 181
Vitellus, the, 91.
        condensation of the, 180.
        segmentation  of the, lp1.
Vitriform body, the, 187. 
1124
INDEX.
Vomiting during pregnancy, 464.
         simple, 465.
         irrepressible, 467.
         during pregnancy, causes, 465.
                     progress  and dura-
                       tion, 468.
                     etiology and  patho-
                       logical anatomyof,
                         468.
                     diagnosis, 468.
                     prognosis, 469.
                     medical  treatment,
                       470.
                     surgical  treatment,
                       474.
 Vulva, the, 58.
       glands of, 64.
       and  vagina,  diseases of,   during
         pregnancy, 517.
       pruritus of,  517.
       smallness  and  rigidity  of, from
         cicatrices, 681.
       malformations of, 681.
Vulva, tumors of, 686.
       thrombus of, 686.
Vulvo-vaginal gland, 65.


                  w.

Weaning, period of, 1080.
          mode of accomplishing, 1081
Wet-nursing, 1095.
             regulation of, 1100.
Wharton's gelatine, 209.
Wolffian  bodies, 212.
Womb, hernia of the, 719.
       prolapsus  of, 720.
       cancer of the neck of, 711.
       inertia of, 868.
       irregular or spasmodic contraction
         of, 870.
       hour-glass contraction of, 871.
       inversion  of, 902.
       rupture of, 906.
END OF INDEX. 
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put in  the hands of every  student or practitioner in the country.  In our estimation it  is  the best
ivxik of the kind ever written."—N. Y. Medical Journal.

On  the Action  of   Medicines   in  the  System.

   By F. W. Headland, M. D., Fellow of the Royal College of Physicians, &c.,
     <(v.   From the Fourth London Revised and  Enlarged Edition.    One
     volume octavo.   Price     ........  $3.00
  Dr.  Headland's work  gives the onlv scientific and satisfactory view of the action of medi-
cine ;  and this is not in  the war of idle speculation, but by demonstration and experiments,
and inferences almost as indisputable as demonstrations.   It is truly a great scientific work
in a small compass, and deserves to be the hand-book of every lover of the Profession.  It
has received the most unqualified approbation of the Medical Press, both in this country and
in Europe, and is pronounced by them to be  the most original and practically useful work
that has been  published  for many years. 
 Cazeaux's  Great Work on  Obstetrics.


       THE  MOST COMPLETE TEXT-BOOK NOW PUBLISHED.

 GREATLY  ENLARGED  AND   IMPROVED.

                CONTAINING lib  ILLUSTRATIONS.

   A Thooretical and Practical  Treatise  on Midwifery, including the  Disease

     of  Pregnancy and Parturition,  by  P. Cazeaux, Member of the Imperial

     Academy of Medicine; Adjunct Professor in  the  Faculty of Medicine of

     Paris,  etc., etc.  Revised  and Annotated by  S. Tarnier, Adjunct  Pro-

     fessor in the Faculty of Medicine of Paris ; Former Clinical Chief of the.

     Lying-in-Hospital, etc., etc.  Fifth American from the Seventh French Edv

     tion.   Translated by Wm. II. Bullock,  M. D.   In  one volume  Royal Oc

     tavo, of over  1100 pages, with numerous  Lithographic and other Illustra-

     tions on Wood.

       Price, bound in Cloth,  bevelled boards,             .     .     .     $6.50
                        Leather,         .          .....7.50

  M. Cazeaux's  Great Work on Obstetrics has become classical in  its character, and
almost an  Encyclopaedia in its fulness.  Written expressly for  the use of students of
medicine, and those of midwifery especially, its teachings  are plain and explicit, present-
ing  a condensed summary of  the leading principles established  by the masters of the
obstetric art, and such clear, practical directions  for the  management of the pregnant,
parturient, and  puerperal  states, as have been  sanctioned by the  most authoritative
practitioners, and confirmed by the  author's  own experience. Collecting his materials
from the writings of  the entire  body of antecedent  writers, carefully testing their correct-
ness and value by his own daily  experience, and rejecting all  such as were falsified by
the numerous cases brought under his own immediate observation, he has formed out of
them a body of doctrine, and a system of practical rules, which  he illustrates  and enforces
in the clearest and most simple manner possible.

                             OPINIONS OF TIIE  PRESS.

  " It is unquestionably a work of the highest excellence, rich in information, and perhaps fuller in details
than any  text-book with which we are acquainted.  The author has not merely treated of every ques-
tion which relates to tho  business of parturition, but he  has done so with  judgment  and ability."
British and Foreign Medico-Chiruryical Iteview.
  "The translation of Dr. Bullock is remarkably well done.   We can recommend this  work to those
especially interested in the subjects treated, and can especially recommend tho American edition."
Medical Times and Gazette.
  "The edition  before us is one of unquestionable excellence.  Every portion of it has undergone a
thorough revision, and no little modification ; while copious and important additions have been made to
neaMy every part  of it.  It is well and beautifully illustrated by numerous wood and lithographic
engravings, and, in typographical execution, will bear a favorable comparison with other works  cf the
Baine class."—American Medical Journal.
  " In the multitudinous collection of works devoted to tho  propagation of human beings, and to tht
JttailH of parturition, none, in our estimation, bears any comparison to the work of Cazeaux, in >i>
entire perfectness; and if we were called upon to rely alone on one work on accouehinents, our  choic»
woulJ fall upon the book before us without any kind of hesitation."—West. Jour, of Med. a-.d Surgery
  " We do not  hesitate to say, that  it is now the most complete and best treatise on tho subject  in th»
English language."—Buffalo Medical Journal.
  "We know of no work on this all-important branch of our profession that we can recommond to tht
Btudent or practitioner as a safe guide before this."—Chicago Medical Journal.
  "Among the many valuable treatises on the science and  art of obstetrics, the work of Cazeaux stana;
pre-eminent."— St. Louis Med. and Surg. Journat.
  " M. Cazeaux's book is the most complete we have ever seen upon the subject.  It is well translates
*nd roflwta great credit upon D-. Bullock's intelligence and industry."— N. A. Medi.cc-Chirurg. Renin* 
It is eminently a book which will teach the  Student.—Practitioner.
It forms one of the most convenient, practical, and concise  books yet
     published on  the subject. —London Lancet.


         MEADOWS'  MANUAL  OF  OBSTETRICS.

            THE SECOND REVISED  AND  ENLARGED EDITION.

                      WITH NUMEROUS  ILLUSTRATIONS.

   INCLUDING  THE  SIGNS  AND SYMPTOMS  OF  PREGNANCY,
     Obstetric Operations, Diseases of the Puerperal  State,  &c,  &c.   By
     Alfred  Meadows,  M. D., Physician to  the Hospital for Women, to
     the General Lying-in Hospital,  &c, &c.   First American  from  the
     Second London Edition.   With numerous Illustrations.  Price   $3.00

  In this new edition,.. .not merely is the practical treatment of Labor, and also of the Dis-
eases and Accidents of Pregnancy, well and clearly taught, but the  anatomical machinery
of parturition is more effectively explained than in any other treatise that we remember;
besides this, the book is honorably distinguished among manuals of Midwifery by the  ful-
ness with which it goes into the subject of tlie structure and development of the ovum.  On
all questions of treatment, whether by medicines, by hygienic regimen, or by mechanical or
operative appliances, this treatise is as satisfactory as a work of manual size could be; students
and practitioners can hardly do better than adopt it as their vade-mecum.— The Practitioner.
  Upwards of ninety new engravings have been inserted in this edition, and, with a view to
facilitate reference, the author has furnished it with a very full and complete table of contents
and index.  We can cordially recommend this manual as accurate and practical, and as con-
taining in a small compass a large amount of the kind of information suitable alike to the
student and practitioner.—London Lancet.
  It is concise, well arranged, and remarkably complete, as a guide to the student during his
lecture term; and as a ready reference to the Physician, no work of similar character equals
it in value.—Buffalo Medical Journal.
  The systematic arrangement of subjects,  and the concise, practical style in which it is
written, make the work especially valuable as a student's manual, while a very full table
of contents and index renders it easily accessible as a work of reference.—Chicago Medical
Examiner.
  There can be no doubt that this manual will be generally accepted as a brief, convenient,
and compendious  guide to the  study and practice of the Obstetric Art—Richmond and
Louisville Medical Journal.
  We cannot but feel that every teacher of obstetrics has good cause to congratulate himself
on being able to put in the hands of  the student a  book which contains so much valuable
and reliable information in so condensed a form.—Philadelphia Medical Times.
  It is concisely and clearly written, and the information is on the whole on a level with the
most recent knowledge of the day.--British and Foreign 3Iedical Review.
  A work which embodies a larger amount of practical information than any other book on
the subject.— Pacific Medical and Surgical Journal.
  It is with great gratification that we are enabled to class  Dr. Meadows' Manual as a rare
exception, and to pronounce it an accurate, practical, and creditable work, and  to unhesi-
tatingly recommend it to both student and practitioner.—American Journal of Obstetrics.
  It is a book of decided merit: every page teems with sound, practical common sense, advice
and suggestions.—Kansas City Medical Journal. 
   SOELBERG  WELLS  ON  THE   EYE.


       THE AUTHOR'S  THIRD REVISED AND  ENLARGED

            EDITION, PRINTED IN  LONDON  UNDER  HIS

                  IMMEDIATE  SUPERINTENDENCE.

        AND PUBLISHED  IN  THIS  COUNTRY BY SPECIAL

                     ARRANGEMENT WITH HIM.


A TREATISE  ON THE DISEASES  OF THE  EYE, illustrated
     by  Ophthalmoscopic Plates  done  in Chromo-Lithography,  and  nu-
     merous Engravings on wood.  By J. Soelberg Wells, Professor of
     Ophthalmology in King's College,  London ;  Ophthalmic Surgeon to
     King's College Hospital, and Assistant  Surgeon to  the Royal London
     Ophthalmic Hospital,  &c,  &c.
  The Author's long experience in  the  treatment of Diseases  of the Eye, together with the
unusual facilities possessed by him, as Professor of Ophthalmology, and as Surgeon to King's
College, and the Royal London Ophthalmic Hospital, has enabled him  to make a most com-
plete and comprehensive work. It embodies all the most recent views in Ophthalmology, as
well as the newest operations upon  the  eye, fully illustrated.   The Ophthalmoscope and
ITS Use in the internal diseases of the eye receives, also, the fullest consideration, and is
illustrated by beautifully* colored plates.
  The rapid sale of the first and second editions, and its translation into the French and
German languages, has given the work a world-wide reputation as the best on the  subject
in tlie English language.
     Royal Octavo, Price, bound in cloth    .     .    .     .     .   #5.00
               "       "       "     leather.....6.00
  "Of all works in the English language on the subject, it is  the best adapted to the wants
of the general practitioner.  It is thoroughly up to  date, well illustrated, readable, and
handy." — Edinburgh Medical Journal.
  " We welcome the speedy appearance of a new edition of this comprehensive volume, and
congratulate the profession upon the opportunity it affords them of obtaining an encyclopedic
knowledge of eye disease in a single volume." —London Lancet.
  " Of the work we may assuredly  say that for English students and practitioners it is cer-
tainly the standard book on the subject.  It is very complete, and the descriptions are clearly
and interestingly written." — British Medical Journal.
  " The book contains an admirable, and, on the whole, succinct account of diseases of the
eye.  The additions have been most judiciously made.   In every respect it is most reliable
authority." — Medical Times and Gazette.
  " It must now fill  the place formerly occupied by the classic works of Lawrence and
Mackenzie." — American Journal of Medical Sciences.


                       BY  SAME  AUTHOR.

ON  LONG,  SHORT, AND WEAK  SIGHT, and  their Treatment
     by the  Scientific  Use of Spectacles.    Third Edition,  Revised,  with
     Additions and Numerous Illustrations.   Octavo.   Price  .     .  $3.00 
          A  COMPLETE  TEXT-BOOK


    ON  DISEASES AND INJURIES  OF  THE  EYE.



 LINDSAY  &  BLAKISTON  HAVE  NOW READY,


 The  Diseases  and Injuries  of the Eye,  their

   Medical and Surgical  Treatment, wm mustratwns.
   By George Lawson,  F.R.C.S., Surgeon to the Royal London  Ophthalmic
   Hospital, and Assistant Surgeon to the Middlesex Hospital.  In one volume,
   royal 12mo.                                              Price, 82.50

   This Manual comprises a brief account of all the Medical and Surgical
 Affections of the Eye, with the Treatment essential  for their  relief, each
 subject being discussed in a separate section under its own  peculiar head-
 ing.  The very favorable notices appended below attest its  great value to
 the student.
   " We have been fully supplied in the last two or three years with systematic treatises
 on diseases of the eye.  But there seems  still to be room for a clear, brief, and concise
 yet practically full manual on modern  ophthalmic medicine and  surgery, such as
 might serve for  a text-book for students and a companion for the busy  practitioner.
 This Mr. Lawson has supplied, and supplied admirably well.  Of his qualifications
 for the task of producing  such a work  it would be superfluous to  speak.   He iu a
 ' Past Master' on the  subject, and while any work of his is sure of a favorable reception,
 he has  taught the profession to judge him by a high standard of excellency, and so
 judged  the book we now notice will certainly not disappoint its readers.   Necessarily
 brief and concise as  to details, it is admirably clear  and  eminently practical.  The
 reader feels that he is in the hands of a teacher who has a right to speak  with author-
 ity, and who, if he may be  said to be positive, is so from the fulness of knowledge
 and experience, and who, while well acquainted with the writings and labors of other
 authorities on the matters he treats of,  has himself practically worked  out what he
 teaches."—London Medical Times and Gazette, Aug. 14, 1869.
  "We  congratulate  Mr. Lawson  on the production of such an excellent  work on
 ophthalmic diseases as this.  Without depreciating the large and valuable treatises on
 this subject that have recently appeared, we have long  felt that a manual was wanted
 which would serve as a text-book for students, and also should form a trustworthy guide
 for practitioners in dealing with diseases of the eye.   Well has Mr. Lawson supplied
 this want.  He has described the various affections of the eye, briefly but yet clearly,
 and from the large experience he has acquired as surgeon to  the Royal London Oph-
 thalmic Hospital, Moorfields, he has made his work thoroughly practical.  The profession
 will find this manual just the sort of work  they want on eye diseases,  vhile to tho
 Btudent it will be invaluable as a text-book."—British Medical Journal, July 24, 18'iP
  " This handy and  beautifully  printed volume is as good in the quality of its
contents as it is attractive to the eye.  Mr. Lawson has long been known as an oph-
thalmic surgeon, he has enjoyed a long experience, and he has  the  faculty of telling
 his story clearly.  He has  here given  us a manual of moderate size, in which the
practitioner will find  short and clear descriptions and directions for the treatment of
every kind  of eye  disease.  The work is sure to become very popular, and to enjoy a
large circulation."—Practitioner, Aug., 1869. 
Hewitt's  Diagnosis,   Pathology,  and  Treatment  of

                  the  Diseases  of  Women.

               THE THIRD EDITION NOW READY.

Revised, Enlarged, Rearranged,  and Mostly Rewritten; with
                     Many  New  Illustrations.

                     Price in Cloth $5.00.  In Leather $6.00.

          OPINIONS OF THE  PRESS ON THE THIKD EDITION.

  The changes and additions which have been made, as well as the general rearrange-
ment of the whole  subject matter,  render this new edition an essentially new work.—
Chicago Med. Examiner.
  It forms a volume of 740 pages, numerously illustrated, and though called a new edition,
it is really a new work.  The style is attractive and practical, the mechanical execution
of the work creditable, and as a reliable guide in the treatment of diseases peculiar to
women it has no superior. — Canada Lancet.
  It now forms a complete and systematic treatise, admirable in arrangement, beautiful
in appearance, and rich in the wisdom that comes from ample experience, mature thought
and active industry. —Leavenworth Herald.
  He has really rewritten the former edition, embodying  his extensive clinical experi-
ence, making this edition a most complete  and thorough work on all that pertains to the
pathology and treatment of diseases peculiar to women.—Cincinnati Medical News.
  For those who desire full instruction and careful illustration in this department nothing
can equal the work before  us; the philosophy of mechanics, and the modes of applica-
tion are fully presented. —Buffalo Medical and Surgical Journal.
  It is unquestionably one of the most valuable guides to a correct diagnosis to be found
in the English language. —Richmond and Louisville Journal.
  The latest, best, and most authoritative exponent of a well-defined bias that powerfully
afiects a zealous  class of gynecologists . .  . We hail Dr. Graily Hewitt's work as the
lineal successor to Simpson's.—Brit. Med.  Jour.
  The style is clear and very readable, and it gives evidence throughout of honest hard
work ; not that of the office book-worm, but of the careful clinical observer. — Canada
Med. and Surg. Jour.


                      RECENTLY  PUBLISHED,

Dillnherger's   Handy-Book   of  the   Treatment  of

    Women and  Children's Diseases,  according to  the Vienna
    Medical School.
Part I.  The Diseases of Women.        Part. II.  The Diseases of Children.
     Translated from the Second German Edition, by P. Nicol, M. D.   One
     volume i2mo.   Price   ........  #1.75
  We noticed favorably the orisrinal of this hand-book some months ago, and suggested that
an English translation of it, with notes showing the main points wherein the practice of our
medical schools differs  from that at Vienna, might be well received.  Mr. Kicol has now
carried out this idea, and we imagine that many practitioners will be glad to possess this little
manual, which gives a large mass of practical hints respecting the treatment of diseases
which probably make up the  larger half of every-day practice.  The translation is well
and correctly performed, and the necessary explanations of reference  to German medicinal
preparations are given with proper fulness.— The Practitioner. 
 New  Book on  Diseases of Women.

         SECOND  EDITION,  REVISED  AND ENLARGED.


 Atthill's Clinical  Lectures on  Diseases Pecul-

    iar  tO Women.   By Lombe  Atthill, M.D,  Fellow  and

     Examiner in Midwiferg, King  and Queeris College of Physicians:
     Obstetric Physician to the Adelaide Hospital, and formerly Assistant
     Physician  to  the Rotundo Lying-in Hospital.   Demy Octavo, with
     Illustrations.  Now Ready.                              Price, $2.25
  " This excellent little book has three great merits. It treats of very common diseases
 which are generally very badly  taught in our Schools.   Secondly, it treats of them in
 a thoroughly  clinical and  practical way;  and finally,  without being too short, is a
 compact book, calculated to be very useful to the practitioner. Dr. Atthill's practice,
 if not original, is  thoroughly independent,  and he illustrates it with a copious quota-
 tion of good cases.  We commend the whole book to the careful attention of advanced
 students and general practitioners." —Lancet,March 23, 1872.
  " The lectures before us have  the merit of calling attention to this important subject
 with the voice of personal experience. Those on  Menorrhagia, endo-Metritis, and
 endo-Cervicitis, we would specially point out as worthy  of note; and, without endors-
 ing the author's therapeutic treatment of those affections, we cannot but admire the
 clearness of style and practical character of their literary treatment." — Glasgow
 Medical Journal, May, 1872.
  «' These lectures form an admirable text-book for students.  Dr. Atthill, as Examiner
 in the Queen's University and College of Physicians of Ireland, discovered the utter
 ignorance of the majority of students on the important subject of Diseases Peculiar to
 Women.  The publication of this little volume supplies a want that has  long been felt
 by students preparing for examination.  In these lectures is  to be found  a clear and
 concise summary  of the clinical  practice of the diseases peculiar to women.  The work
 is the result of large and accurate  clinical observation, recorded in an admirably terse and
 perspicuous style, and is remarkable for the best qualities of a practical guide to the
 student and practitioner." — British Medical Journal, May 11, 1872.
  " A most excellent though brief hand-book on the Diseases Peculiar to Women ;  one
 that cannot fail to be of great use to students, and that, will guide them to  a right
 understanding of the cases brought before them  in their  hospital practice.  Nor is
 this all; to the busy practitioner this  book will be of use in many an emergency, not
 only assisting him in the recognition of the various forms of  disease most frequently
 met with, but also forming a safe and reliable guide to their treatment on sound and
 scientific principles.  We think  Dr. Atthill has done good  service  in publishing his
 lectures, and we strongly recommend  them to the careful and attentive  perusal of  all
 who wish to study the diseases of women." — Dublin Journal of Medical Science, Novem-
 ber, 1871.


 Acton  on the Functions  and Disorders of the

                   Reproductive  Organs.

  In Childhood, Youth,  Adult Age, and  Advanced Life, considered in their
     Physiological,  Social, and  Moral  Relations.   By  William  Acton,
     M. R. C S., etc.   Third American,  from the  Fifth London Edition.
     Carefully revised by the  author, with additions.  Just  ready.  Octavo.
     Price...........$3.00
  To such of our readers as are not familiar with Acton's book, we may say that his plan em-
braces the consideration of topics of great interest: such as are peculiar to childhood, embracing
its vices ; those peculiar to precocity and included in masturbation ; similar inquiries pertaining
to youth and adult age,  and so on through the stages  of life with its inquiries.  Indeed,  we
may say that all those delicate matters pertaining to the male sexual conditions are treated in
this volume with singular care and intelligence — Lancet and Observer, October, 1871. 
Byford  on  the  Uterus,   second  edition.

   On  the Chronic Inflammation and Displacement of the  Unimpregnutea
     Uterus.   A  New,  Enlarged,  and  Thoroughly Revised Edition,  with
     Numerous Illustrations.   Now Ready.   One volume.   Octavo.   $3.00

Prom Fordyce Barker, M.D.,  Professor of Obstetrics and Diseases of Women and Children
    in Bellevue Hospital Medical College.
  Some weeks ago  I received  a copy of your work  on the Uterus.  I have delayed
acknowledging the favor until  I could give the book a careful perusal.  I have jusl
finished a thorough reading of  it.  I feel personally indebted to you, not merely for the
cepj —which, of course, I should have bought — but for writing the book; and I  think
you have laid  the Profession in this country under a load of obligation by giving them
such a clear, concise, and practical treatise on a  class of affections *hat even now is
very little understood by the greater majority.
From R. A. F. Penrose, M.D.,  Professor of Obstetrics in the University of Pennsylvania.
  Accept my  thanks for the copy of your  new work which you so kindly sent me.  ]
have, as yet, not had time to give it the careful study it merits; hut  from  the super-
ficial inspection I have made, I find much that is most valuable.

Erom S. G.  Hubbard, M.D., Professor of Obstetrics in Yale College, New Haven.
  I was gratified by the receipt of your new work on the Uterus, and I thank you sin-
cerely for it.  I have spent all  my leisure in its examination,  and  have derived both
pleasure and profit from its perusal.  It is  commendable for its clearness and definite-
ness as well as for the great practical common sense which pervades it.  I am sure that
it will prove a very useful treatise,  not only to junior practitioners,  but to those also
among us who, from not having devoted themselves to the treatment of uterine disease,
as a specialty, have neither time nor opportunity to make original investigations in thia
department, and are not, therefore, perfectly at home in its practice.

From James P. White, Professor of Obstetrics and Diseases of Women and Children  in the
     University of Buffalo-
  I have  had  time, as yet, to  run  over but few of the chapters of your work on the
Uterus;  I am most  happy, however, in being able  to say that, so far as I have read, it
does credit to American authorship.  It is concise and brief, and eminently practical.
The work was  certainly a desideratum, and will be especially useful to practitioners
who can illy afford to purchase all or most  of the works referred to in your preface.  I
shall examine it with much interest, and, no doubt, often consult it  with profit.

From G.  S. Bedford, M.D., Professor of Obstetrics  and Diseases of Women and Children
     in the University of Neiv York.
   On my return to the city I found on my table ;' Byford on the  Uterus."  The next day
I commenced  perusing it, and have read it from  cover to cover.  I need not say that,
in my judgment, the book enhances your deserved  reputation.  You have, if my opin-
ion be worth anything, given the Profession an excellent work,  and  one that is sensible
and practical.   Go on, my dear Doctor, and  give us more of your experience.   It is
what the  Profession most needs — the experience  of good and ripe minds.

              RECENTLY PUBLISHED,  THE SECOND EDITION OF

Byford's  Practice  of  Medicine  and  Surgery.

   Applied to  the Diseases and Accidents Incident to  Women.  By W. H.
     Byford, A.M., M.D., Professor of  Obstetrics and Diseases of Women
     and  Children in  the  Chicago  Medical College,  &c, &c.   The  Second
     Edition, Revised  and  Enlarged, with  Additional Illustrations.    One
     volume.  Octavo..........$5.00
   The rapid sale of the first edition of this book,  which was exhausted in a little more
than a year, has enabled the author to carefully revise the whole work, add many im-
provements, and to make a large addition of new  matter, without, however, materially
increasing the size of the volume.
   This work treats well-nigh all the diseases incident to women, diseases and accidents
of the vulva and perineum, stone in the bladder, inflammation of the vagina, menstrua-
tion and its disorders, the uterus and its ailments, ovarian tumors, diseases of the mam-
mas, puerperal convulsions, phlegmasia alba dolens, puerperal  fever,  &c.  Its scope is
thus of the most extended character, yet the observations are concise but convey much
practical information. — London Lancet. 
MEIGS AND  PEPPER ON  CHILDREN.
  "The most thorough and Practical Work on the subject now before the
                                Profession."

    THE PIFTH  REVISED  AND IMPEOVED EDITION NOW EEADT.

A PRACTICAL TREATISE on the DISEASES of CHILDREN.
     By J.  Forsyth Meigs,  M. D., one of the Physicians to the Pennsylvania
     Hospital, Consulting Physician to the  Children's Hospital, &c,  and
     William Pepper, M. D., Physician to the Philadelphia Hospital, Fellow
     of the College of Physicians, &c, &c.  The Fifth Revised and Impro\ed
     Edition.   In one volume of over 900 royal octavo pages.

  The fourth edition of this work was almost entirely rearranged.  Several of the articles, as
those on Eclampsia, Chorea, and Parasitic Skin Diseases, were much enlarged ; others, on the
Diseases of the Stomach and Intestines, and that on Eczematous Affections, entirely rewritten.
In addition, articles were added upon the following important subjects:
         Diseases of the Heart.                         Facial Paralysis.
         Cyanosis.                                   Rheumatism.
         Diseases of the Caecum and Appendix.           Diphtheria.
         Intussusception.                              Mumps.
         Chronic Hydrocephalus.                       Rickets.
         Tetanus Nascentium.                         Tuberculosis.
         Atrophic Infantile Paralysis.                   Infantile Syphilis.
         Progressive Paralysis, with apparent Hy-        Typhoid Fever.
           pertrophy of the Muscles.                    Sclerema.
  The rapid sale of this edition has again made it necessary for the authors to thoroughly
revise the work, and make such additions  that it will continue to represent fully, in its most
advanced state, the  present condition of  medicine as applied to Children's Diseases, and
retain that eminently practical character which the authors' long experience in this  specialty
has given to it.

  Price, handsomely bound in cloth,      .....   $6.00
     "        "         "       leather,       ....       7.00

               The London Lancet,  sjtealiing of it, says:
  It is not necessary to say much, in the way of criticism, of a work so well known as " Meigs
on Diseases of Children," especially when it has reached a fourth edition.  It contains more
than 900 good  American pages, and is more encyclopsedial than clinical. But it is clinical,
and withal most effectually brought up to the light, pathological and therapeutical, of the
present day.  Like so many other good American medical books, it marvellously combines a
resumf of all the best European literature and. practice, with evidence  throughout of good
personal judgment, knowledge, and experience.  The book also abounds in exposition of
American experience and observation in all that relates to the diseases of children.  We are
glad to add this work to our library.  There are few diseases of children which it does not
treat of fully and wisely in the light of the latest physiological, pathological, and therapeu-
tical science.


                       RECENTLY PUBLISHED.

TANNER'S  PRACTICAL   TREATISE  ON  THE  DISEASES
     OF INFANCY  AND  CHILDHOOD.   Third  American  Edition, Re-
     vised and Enlarged.   Price.......$3-5°

HILLIER'S  CLINICAL  TREATISE  ON  THE DISEASES  OF
     CHILDREN.  Price........$3-°o 
"The leading feature of this book is its essentially practical characier.'>>—
                                                     London Lancet.

Tanner's  Practice  of  Medicine.

   FIFTH  AMERICAN,  FROM THE SIXTH LONDON  EDITION
         EN LA It GED A ND THOB O UGIIL Y HE VISED.

                       JUST  HEADY.

   THE PRACTICE OF MEDICINE, by Thomas  IIawkes  Tanner,
     M.D., Fellow of the Rogal College of Phgsicians, Author of  Tanner1*
     practical Treatise on the Diseases of  Children, &c,  &c.   Fifth Ame-
     rican Edition,  with a verg large Collection of Formulae.   One Volume,
     Rogal Octavo,  containing over 1100 pages.
Price, handsomely bound in Cloth,     .     .     $6 00
          "          "       Leather,  .     .      1 00

              OOHTE1TTS.
Part 1.	General Diseases.	Part 10.	Diseases of the Abdominal Walls.
« 2.	Fevers.	" 11.	Diseases of the Urinary Organs.
" 3.	Venereal Diseases.	» 12.	Diseases of the Uterine Organs.
" 4.	Diseases of the Nervous System.	" 13.	Diseases of the Skin.
« 5.	Diseases of the Organs of Respi-	" 14.	Diseases of Cutaneous Append-
	ration and Circulation.		ages.
" 6.	Diseases of the Thoracic Walls.	" 15.	Diseases of the Bloodvessels.
« 7.	Diseases of the Alimentary Canal.	« 16.	Diseases of the Absorbent System.
" 8.	Diseases of the Liver.		Appendix of Formulas
« 9.	Diseases of the Pancreas and		General Index.
  "The rapidity with which edition after edition of this work has appeared and dis-
appeared is, on the whole, a true test of its merits.  The fifth edition was, we believe,
a very large one, yet the book was for some time out of print before the present one
could be prepared.  Dr. Tanner has chosen his title well; his work is essentially one
on the practice of medicine in its widest sense, and it is in what relates to pure prac-
tice, as contradistinguished from the theory of medicine, that the  book is strongest;
for it has been the author's  aim to collect everything he could think of which would
aid the practitioner in the discharge of his duties.  But it is not to men  engaged  in
the active discharge of the duties.of  their profession alone to whom the book is wel-
come.   With the student, preparing himself to enter upon these duties, the  book has
long been a favorite, chiefly, we believe, from the lucidity of its style and the character
of its substance.  Other books there are, more eloquent and  more recondite, but none
excel Dr. Tanner's work in these important features.  All that is necessary to know
is here, disposed in such a manner as to admit of the readiest reference, and of being
most easily retained in the memory.  Our  limits will not admit of an extended review,
which would be out of place with regard to a book practically established as a standard.
It carries its own recommendation, and is its own best passport to general use.   It has
been the result of very great labor — labor well spent; and it appears in a form which
is creditable to its publishers as it is pleasing  to those who have to use the book. --
                      British and Foreign Medico-Chirurgical Review, April, 1870.
  "Dr. Tanner's works are all essentially and thoroughly practical,—he never for on«
moment allows this utilitarian end to escape his mental view.   He aims at teaching how
to recognize and how to cure disease, and in  this he is thoroughly successful.   It in
indeed a wonderful mine of knowledge." — Medical Times and Gazette, July, 1869. 
   SANDERSON  AND  FOSTER'S  PHYSIOLOGICAL

              HAND-BOOK.    Elegantly Illustrated.

A HAND-BOOK FOR THE PHYSIOLOGICAL LABORATORY

     Being Practical Exercises for Students in Physiology and Histology, by

     E. Klein, M. D., Assistant  Professor in the Pathological Laboratory

     of  the  Brown Institution,  London;  J. Burdon-Sanderson, M.D.,

     F.R.S., Professor  of Practical  Physiology in University College,  Lon-

     don ;  Michael Foster, M.D.,  F.R.S., Fellow of and Prselector of Phy-

     siology in Trinity College, Cambridge; and T. Lauder Brunton, M.D.,

     D.Sc, Lecturer on Materia Medica in the Medical College of St. Bar-

     tholomew's Hospital.   Edited by J. Burdon-Sanderson.

  This book is intended for beginners in physiological work.  It is a book of methods, not a
compendium of the science of physiology, and consequently claims a place rather  in the
laboratory than in the study.  But although designed for workers, it will be found not the
less useful to those who desire to inform themselves by reading as to the extent to which the
science is based on experiment, and as to the nature of the experiments which chiefly deserve
to be regarded as fundamental.
  The illustrations to the book, which consist of One  Hundred and Twenty-Three Oc-
tavo pages, and include over Three Hundred and Fifty Figures, each having  appro-
priate letter-press explanations attached with references to the Text, when necessary, are
bound in a separate volume for more convenient reference.

     Price of the two volumes      .......   $8.00

  " The publication of this work marks an era in the history of Physiology in this country
and throughout the world, for there  is indeed no other such work in any language.  It
teaches the study of nature as nearly as possible under natural conditions.
  " The four authors have each selected a definite division.  Dr. Klein is solely responsible
for the Histological portion. This is characterized by a fulness of practical knowledge which is
very rare, and can only be attained by many years of study and inquiry.   Dr. Sanderson
for that  relating to Heat, Circulation, and  Respiration.  This is most excellent; he deals
with a difficult subject,  and has done so  in a masterly way.  Dr. Foster's  subject  is
the Muscles and Nerves, a  subject not less interesting, but having, in many respects, a less
practical bearing.  Dr. Brunton's is Digestion and Secretion, which is exceedingly good
and thoroughly practical. It is, upon the whole, a book of very great value. Its aim is essen-
tially practical. As a laboratory guide it has no equal."—London Medical  Times and Gazette.

  " The profession must  feel deeply indebted to  Dr. Sanderson and his  coadjutors for the
ability with which this whole work is prepared, for the clearness of the descriptions, their
excellent arrangement, and judicious selection. The book is perfectly unique, and will prove
of equal value to both student and teacher." — London Lancet.

  " No more useful aids to medical instruction have been supplied us in modern times than
these volumes furnish.  Thev are the first fruits of the new education, the object  of which is
to teach men to observe, think, and deduce, as well as to remember.  We are told that the
book is intended  for beginners in physiological work, but we believe there are no teachers of
physiology and histology in this country  who would  not teach with new enthusiasm by
making it their guide.  We believe, moreover, that there'is no other book, in any language,
so useful to teacher or student in the departments which it covers.  For,  in addition  to the
fact that there is  no single work in the German which covers so extended a field, there is,
even in those extant, a want of preciseness in the directions given which makes them un-
satisfactory to beginners."—Philadelphia Medical Times.

  " We feel  that we cannot recommend this work too highly.  To those who are engaged in
physiological work as students or teachers,  it will be almost indispensable ; and to those who
ai e not, a perusal of it will bv no means be unprofitable.  The execution of the plates leaves
nothing to be desired.  They are mostly original; their arrangement in a separate volume has
great and obvious advantages." — Dublin Journal of Medical Sciences.

  " The authors of these volumes are masters of the subjects upon which they wrote. They
have devoted themselves to the laborious investigation of each physiological detail involving
manipulations, vivisections, chemical analysis, researches by the aid of the microscope, &c,
&<• and they have presented us with a collection of the most erudite and  valuable practical
treatises upon their respective subjects which can be found  in the English language. It is
filled with practical detail and minute instruction."— Charleston Medical Journal and Review. 
TROUSSEAU'S   CLINICAL    MEDICINE.

                              COMPLETE.

                In  Two Large  Royal Octavo Volumes,

     EMBKACTNG ALL THE  LECTURES CONTAINED IN THE FIVE
                VOLUME EDITION  AS ISSUED BY  THE
                          SYDENHAM SOCIETY.

     Price, handsomely bound in cloth  ......  $10.00
                                 leather.....12.00


Lectures   on   Clinical   Medicine.
     Delivered at the Hotel Dieu, Paris, by A. Trousseau, Professor of Clin-
     ical Medicine to the  Faculty of Medicine, Paris, &c, &c.   Translated
     from the Third Revised and Enlarged Edition  by P. Victor Bazire,
     M. D., London and Paris; and John Rose Cormack, M. D., Edinburgh,
     F. R. S., &c.  With a full Index, Table of Contents, &c.

  Trousseau's Lectures have attained a reputation both in England and in this country far
greater than any work of a similar character heretofore written, and, notwithstanding but few
medical men could afford to purchase the expensive  edition issued  by the Sydenham Soci-
ety, it has had an extensive sale. In order, however, to bring the work within the reach of all
the profession, the publishers now issue this edition, containing all the lectures as contained
in the five volume edition, at one-half the price.  The London Lancet, in speaking of the
work,says:
  " It treats of diseases of daily occurrence and of the most vital interest to the practitioner.
And we should  think any medical library absurdly incomplete now which did not have
alongside of Watson, Graves, and Tanner, the ' Clinical Medicine' of Trousseau."

  Some opinion of the great value of the work can be formed from the titles of the Lectures
as given below.  A very full Table of Contents is furnished in each volume.

                       CONTENTS OF VOLUME ONE.
  Lecture 1.   Small-pox.  2. Variolous Inoculation.  3.  Cow-pox.  4. Chicken-pox.  5.
Scarlatina.  6.  Measles, and in particular its unfavorable Symptoms and Complications.  7.
Rubeola.  8. Erythema Nodosum.   9. Erythema Papulatum.  10. Erysipelas, and in par-
ticular Erysipelas of the Face.  11. Mumps.  12. Urticaria.   13. Zona, or Herpes Zoster.
14. Sudoral Exanthemata.  15. Dothinenteria, or Typhoid Fever.  16. Typhus.   17. Mem-
branous Sore Throat, and  in particular Herpes of  the Pharynx.   18. Gangrenous Sore
Throat.  19. Inflammatory  Sore Throat. 20. Diphtheria.  21. Thrush. 22. Specific Ele-
ment in Disease.  23. Contagion.  24. Ozsena.  25. Stridulous Laryngitis, or False Croup.
26. OZdema of the Larynx.  27. Aphonia: Cauterization of the Larynx.  28. Dilatation of
the Bronchi, and Bronchorrhcea.  29. Haemoptysis. 30. Pulmonary Phthisis.  31. Gangrene
of the Lung. 32. Pleurisy: Paracentesis of the Chest.  33. Traumatic Effusion of Blood into
the Pleura: Paracentesis of the Chest.  34. Hydatids of the Lung.  35. Pulmonary Abscesses
and Peripneumonic Vomicae.  36. Treatment of Pneumonia.  37. Paracentesis of the Peri-
cardium.  38. Organic Affections of the Heart.  39. On Venesection in Cerebral Hemor-
rhage and Apoplexy.  40. On Apoplectiform Cerebral Congestion, and its Relations to Epi-
lepsy and Eclampsia.  41. On Epilepsy.  42. On Epileptiform  Neuralgia.  43. Infantile
Convulsions.  44. Eclampsia of Pregnant and Parturient Women.  45. On Tetany.  46. On
Chorea.  47. Senile Trembling and Paralysis Agitans.  48.  Cerebral Fever.  49. Cross-
paralysis, or Alternate Hemiplegia.  50. Facial Paralysis, or Bell's Paralysis.  51. Ou
Glosso-laryngeal Paralysis. 
                          CONTENTS OF VOLUME TWO.
  Lecture 52. Alcoholism.   53. On  Neuralgia.   54.  Hydrophobia.   55.  Asthma.   56
 Hooping-Cough.  57. Angina Pectoris.  58. Exophthalmic Goitre, or Graves' Disease.  59.
 Progressive Locomotor  Ataxy.  60. Progressive  Muscular Atrophy.  61. On Aphasia.  62.
 Spermatorrhoea.  63. Nocturnal Incontinence of Urine.  64. Glucosuria:  Saccharine  Dia-
 betes.  65. Polydipsia.  66. Cerebral Rheumatism.   67. Vertigo a Stomacho Loaso.  6S.  Dys-
 pepsia.  69. Chronic Gastritis.  70. Simple Chronic Ulcer of the Stomach.  71.  Diarrhoea
 - Chronic Diarrhoea.  72. Infantile Cholera — Diarrhoea of Children.  73. Lactation, First
 Dentition, and the Weaning of Infants.  74. Dysentery.  75.  Constipation.   76. Fissure of
 the Anus.   77.  Intestinal Occlusions.  78. Hepatic Colic: Biliary Calculus.  79. Hydatid
 Cysts of the Liver.   80. Malignant Jaundice.  81. Syphilis in Infants.  82. Gout.  83. Nodu-
 lar Rheumatism, erroneously called Rheumatic Gout.   84. Acute Articular Rheumatism
 and Ulcerating Endocarditis.  85. Marsh  Fevers: Intermittent Fevers.  86.  Rickets.  87.
 True and False Chlorosis.   88. Cirrhosis.   89. Addison's Disease.  90.  Leucocythaemia.
 91. Adenia.   92. Amenorrhcea and Menorrhagic Fever.   93. Pelvic Hematocele.  94. Puer-
 peral  Purulent Infection. 95.  Phlegmasia Alba  Dolens.  96. Perinephric  Abscess.  97.
 Perihysteric Abscess.  98. New Species of Anasarca the Sequel of Retention  of Urine.
 99. Movable Kidney.  100. Loosening  of the Pelvic Symphyses.   101. Percussion.  Index.

  " The  Clinical Lectures of Prof. Trousseau, in attractiveness of manner  and richness of
 thoroughly practical matter, worthily takes its place beside the classical lectures of Watson
 and Graves.   Very rarely it occurs that a book on medicine is met with so pleasant to read,
 and so abundant in sound practical instruction. In reading Trousseau's  book we feel as
 though the learned, eloquent, accomplished teacher; the observant, suggestive, and accom-
 plished physician, were speaking, viva  voce.  The remarkably graphic narrative of the cases
 present true and impressive pictures of disease, and retain for the book that interest which is
 generally limited to the living voice of the clinical teacher.  The reader sees Trousseau's
 patients with him, listens  to his remarks on their diseases, and applies to them individually
 the precepts inculcated and the pathological opinions set  forth." — British Jfedical Journal.

  " The work is full of the results of the richest natural  observation, and is the production
 of one who was enlightened enough to combine with new methods of investigation the vigor-
 ous and independent ideas of the old physicians  whom he so eloquently magnifies. It is an
 extremely rich and valuable addition to the library of physicians and practitioners generally."
 — London Lancet.

  " This book furnishes an example of the best kind of clinical teaching.  It deserves to be
 popularized.   We scarcely know of any work better fitted for presentation to a young man
 when entering upon the practical work of his life.  The delineation of the recorded cases is
 graphic, and their narration devoid of that prolixity which, desirable as it is for purposes of
 extended analysis,  is highly undesirable when the object is to point to a practical lesson."—
 London Medical Times and Gazette.

  " The publication of Trousseau's Lectures furnishes  medical men with one of the best
 practical treatises on disease as seen at the bedside.  The conversational style adopted by
 the author lends animation to the work, and the translator deserves credit for having so well
preserved the easy and ready  style of the original." — British and Foreign Medico-Chirur-
gical Review.
  " The great reputation of Prof. Trousseau as a practitioner and teacher of Medicine in all
its b-anches, renders the present appearance of his Clinical Lectures particularly welcome."
— Medical Press and Circidar.
  " A cVver translation of Prof. Trousseau's admirable and exhaustive work, the best book
of reference upon the Practice of Medicine." —Indian Medical Gazette.

 The Sgrftiiham Society's Edition of Trousseau can still be furnished
    in sets,  or in separate vol times, as folloivs:

       Volumes I., IL, and III., $5.00 each.   Volumes IV. and V., $4.00 each. 
NEW  BOOKS,  JUST  READY.
PROF. AGNEW ON THE LACERATIONS OF THE FEMALE
    PERINEUM, AND VESICO-VAGINAL FISTULA, their History and
    Treatment,  with  numerous illustrations engraved  on  wood.   By  D.
    Hayes Agnew, M.D., Professor of Surgery in the University of Penn-
    sylvania,  &c,  &c.  In one volume octavo.   Price      .     .   #2.00

PARKES' MANUAL OF PRACTICAL HYGIENE, the fourth
    revised and  enlarged  edition,  for  Medical Officers  of the  Army,
    Civil Medical  Officers, Boards of Health, &c, &c.   By  Edward  A.
    Parkes, M.D., Professor of Military  Hygiene in the Army Medical
    School,  &c,  &c.   With  many Illustrations.   One  volume  octavo.
    Price   ...........   $6.00
  " This work, previously unrivalled as a text-book for medical officers of the army, is now
equally unrivalled as a text-book for civil medical officers.  The first book treats in succes-
sive chapters of water, air, ventilation, examination of air, food, quality, choice, and cooking
of food, beverages, and  condiments;  soil, habitations, removal of excreta, warming of houses,
exercise, clothing, climate, meteorology, individual  hygienic management, disposal of  the
dead, the prevention of some common diseases,  disinfection, and statistics.  The second
book is devoted to the service of the soldier, but is hardly less instructive to the civil officer
of health.  It is, in short,  a comprehensive and trustworthy text-book of hygiene for  the
scientific or general reader." — London Lancet, July, 1873.

SIR HENRY THOMPSON  ON THE  PREVENTITIVE TREAT-
    MENT OF CALCULOUS DISEASE, and the Use  of Solvent  Reme-
    dies.  By Sir Henry Thompson, F.R.C.S., &c.  i6mo.   Price  $1.00

COLES' MANUAL  OF DENTAL MECHANICS, with an account
    of the Material and Appliances used in Mechanical  Dentistry.   By  A.
    Oakley Coles, D.D.S.   With 140 Illustrations.   Price  .    .  $2.50
  This work has  been prepared mainly as a Text-Book, for  the student, but its practical
character must certainly make it useful to every practitioner of Dentistry.

CLARKE'S  TREATISE  ON  DISEASES  OF THE  TONGUE.
    By  W.  Farlie Clarke,  M.D., Assistant Surgeon  to Charing  Cross
    Hospital, &c.  With Lithographic and  Woodcut Illustrations.  Octavo.
    Price...........$5.00
  It contains The Anatomy and Physiology of the Tongue, Importance of its Minute Exam-
ination, Its Congenital Defects,  Atrophy,"Hypertrophy, Parasitic Diseases, Inflammation,
Syphilis and its effects,  Various Tumors to which it is subject, Accidents, Injuries, &c., &c.

BUCKNILL AND  TUKE'S MANUAL OF PSYCHOLOGICAL
    MEDICINE, containing  the History, Nosology, Description, Statistics,
    Diagnosis, Pathology,  and Treatment of Insanity, with an Appendix  :>f
    Cases.  By J. C. Bucknill, M.D., F.R.S., and Daniel H. Tuke, M.;D.
    The Third Edition, Revised and Enlarged.  One volume octavo.

COOPER'S  DICTIONARY OF PRACTICAL SURGERY,  and
    Encyclopedia of Surgical  Science.  A New Enlarged and Revised Lon-
    don Edition, in 2 vols, of over  1000 pages each.  Price      .   #15.00 
           Recent  Publications

                                   BY


                LINDSAY  &  BLAKISTON.



                    AITKEN  (william), M. D.,

                  Professor of Pathology in the Army Medical School, &c.

THE SCIENCE AND  PRACTICE  OF  MEDICINE.  THIRD
     American,  from  the Sixth  London  Edition.  Thoroughly  Revised,
     Remodelled, many portions Rewritten, with Additions almost equal to
     a Third Volume,  and numerous  additional Illustrations,  without  any
     increase in  bulk  or price.   Containing  a  Colored Map  showing the
     Geographical Distribution of Disease over the Globe, a Lithographic
     Plate, and nearly  200 Illustrations on Wood.
     Two volumes, royal octavo, bound in cloth, price,  .      .     #12.00
      "       "         "          "     leather,       .      .      14.00

  For eighteen months Dr. Aitken has been engaged in again carefully revising this Great
Work, and adding  to it many valuable additions and improvements, amounting in the ag-
gregate almost to a volume of new matter, included in which will be found the adoption and
incorporation  in the text of the " New Nomenclature of the Royal College of Physicians of
London;" to which are added the Definitions and the Foreign Equivalents for their English
names; the New Classification of Disease as adopted by the Royal College of Physicians, &c.

  The American editor, Meredith Clymer, M. D., has also  added to it many
valuable  articles,  with special  reference  to the wants of the American Prac-
titioner.
  The work is now, by almost universal consent, both in  England and the United States,
acknowledged to be in advance of all other works on The Science and Practi-ce of Medicine.
It is a most thorough and complete  Text-book for students of medicine, following such a
systematic arrangement as will give them a consistent view of the main  facts, doctrines, and
practice of medicine, in accordance with accurate physiological and pathological principles
and the present state of science.  For the practitioner it will be found equally acceptable as
a work of reference.
              ALLINGHAM  (william),  F. R. C. S.,

                     Surgeon to St. Mark's Hospital for Fistula, &c,

FISTULA,  HEMORRHOIDS,  PAINFUL   ULCER,  STRICT-
     URE, PROLAPSUS, and other Diseases of the Rectum, their Diagnosis
     and  Treatment.  Second  Edition,  Revised  and  Enlarged  by  the
     Author.  Price.........$2.00

  This book has been well received by the Profession; the first edition sold rap-
idly ;  the present one  has been revised by the author, and some additions made,
chiefly as to the mode of treatment.
  The Medical  Press and Circular, speaking of it, says: "No book on this special subject
tan at all approach Mr. Allingham's in precision, clearness, and practical good sense."
  The London  Lancet: " As a practical guide to the treatment of affections of the lower
bowel, this book is worthy of all commendation."
  The Edinburgh Monthly: " "We cordially recommend it as well deserving the careful study
of Physicians and Surgeons."
                                    1 
                    ATTHILL (lombe), M. D.,

       Fellow and Examiner in Midwifery, King and Queen's College of Physicians, Dublin.

CLINICAL  LECTURES  ON  DISEASES PECULIAR  TO WO-
     MEN.  Second Edition, Revised and Enlarged, with Six Lithographic
     Plates and other Illustrations on Wood. Price    .      .     .   $2.25

  The value and  popularity of this book is proved  by the rapid sale of the first edition,
which was exhausted in less than a year from the  time of its publication.  It appears to
possess three great merits : First, It treats of the diseases very common to females.   Second,
It treats of them in a thoroughly clinical and practical manner.  Third, It is concise, orig-
inal, and illustrated by numerous cases from the author's own  experience. His style is clear
and the volume is the result of the author's large and accurate clinical observation recorded
in a remarkable, perspicuous, and terse manner, and is conspicuous for the best qualities of
a practical guide to the student and practitioner. — British Medical Journal.
                    ALTHAUS  (julius),  M. D.,

                  Physician to the Infirmary for Epilepsy and Paralysis.


             THIRD ENLARGED EDITION, 146 ILLUSTRATIONS.


A TREATISE ON MEDICAL ELECTRICITY, Theoretical  and
     Practical, and its Use in the Treatment of Paralysis, Neuralgia, and other
     Diseases.  Third Edition, Enlarged and  Revised, with  One Hundred
     and Forty-six Illustrations.   In one volume octavo.   Price    .   $6.00
                 ADAMS  (william),  F. R. C. S.,
               Surgeon to the Royal Orthopedic and Great Northern  Hospitals.

CLUB-FOOT:  ITS  CAUSES,  PATHOLOGY,  AND  TREAT-
     MENT.   Being the Jacksonian  Prize  Essay of the Royal College of
     Surgeons.   A New Revised and Enlarged Edition, with 106 Illustrations
     engraved on Wood,  and  Six Lithographic Plates.  A large Octavo
     Volume.   Price   .........   $6.00
                     ADAMS  (robert),  M. D.,
               Regius  Professor of Surgery in the University of Dublin, &.c, &c.

RHEUMATIC  GOUT, or  CHRONIC  RHEUMATIC ARTHRI-
     TIS OF ALL THE JOINTS.   The Second Edition.   Illustrated by
     numerous Woodcuts, and a  quarto  Atlas  of Plates.   2  Volumes.
     Price...........#8.50
              BASH AM  (w.  r.),  M. D., F. R. C. P.,

                   Senior Physician to the Westminster Hospital, &c.

AIDS  TO THE  DIAGNOSIS OF DISEASES  OF THE  KID-
     NEYS.   With Ten large Plates.   Sixty Illustrations.   Price  .   $2.00

  Dr. Basham has been accustomed to make accurate notes and drawings of every case of
renal disease coming under his notice.  This volume contains a selection of the most important
of these cases, with microscopical illustrations and letter-press descriptions, showing an
amount of clinical experience that must prove of great value to those of the profession who
have not had similar opportunities.
                                    2 
                  BLACK  (D. CAMPBELL),  M. D.,

     L. R, C. S. Edinburgh,  Member of the General Council of the University.of Glasgow, &c, &c.

THE FUNCTIONAL DISEASES OF THE  RENAL, URINARY,
     and Reproductive Organs, with a General View of Urinary Pathology.
     Price  .     .     .      .     .      .     .     .     .     .      .  $2.50
                                CONTENTS.
Chap. 1.  On the Conditions  that affect the
         Secretion of the Urine, with special
         reference to Suppression.
  "   2. Retention of  Urine; its Varieties,
         Causes, and Treatment.
  "   3. Irritable Bladder, Strangury.
Chap. 4.  On the Pathology and Treatment of
         Nocturnal Enuresis, and Spermatic
         Incontinence.
  "   5. Sterility in the Male.
  "   6. Male Impotence.
  "   7. Anomalous Urethral Discharges.
  The style of the author is clear, easy, and agreeable, . .  . his work is a valuable contri-
bution to medical science, and being penned in that disposition of unprejudiced philosophical
inquiry which should always guide a true physician, admirably embodies the spirit of its
opening quotation from Professor Huxley. — Philada. Med. Times.



                         BEASLEY  (henry).

THE  BOOK  OF  PRESCRIPTIONS.   Containing  over  3000
     Prescriptions, collected from the Practice of the most Eminent Physi-
     cians and Surgeons — English,  French, and  American; comprising also
     a Compendious History of the  Materia Medica, Lists of the Doses of all
     Officinal and Established Preparations, and  an Index of Diseases and
     their Remedies.   Fourth Edition, Revised and Enlarged.  Price, $2.50

  This new edition of Dr. Beasley's Prescription Book, although presented in a much more
compact form and at a greatly reduced price,  has been  thoroughly revised, and an account
of all the new medicines lately introduced, with  the formulas of the  new Pharmacopoeias
added.  Carefully selecting from the mass of materials at his disposal, the author has aimed
to compile a  volume  sufficiently comprehensive,  in which both physician and druggist,
preseriber and compounder, may find under the head of each remedy the manner in which
that  remedy may be most effectively administered, or combined with other medicines in the
treatment of disease.  The alphabetical arrangement of the book renders this easy. A short
description of each medicine is also given, and a list of the doses in which its several pre-
parations may be prescribed.



                        BY  SAME AUTHOR.

THE POCKET  FORMULARY:  A Synopsis  of the  British  and
     Foreign Pharmacopoeias.   Ninth Revised Edition.  Price   .  $2.50

THE DRUGGIST'S GENERAL RECEIPT  BOOK and VETERI-
     NARY FORMULARY.  Seventh Edition.   Price.     .     .  $3.50



                     BEALE  (Lionels.), M.  D.

DISEASE  GERMS:  AND  ON THE TREATMENT  OF DIS-
     EASES CAUSED BY THEM.
           Part  I. — SUPPOSED NATURE OF  DISEASE GERMS.
           Part IL —REAL NATURE OF DISEASE GERMS.
           Part III. — THE DESTRUCTION  OF DISEASE GERMS.

     Second  Edition, much enlarged, with Twenty-eight  full-page  Plates,
     containing 117  Illustrations, many of them colored.   Demy  Octavo.
     Price...........$5-°°

  This new edition, besides including the contents revised and enlarged of the two former
volumes published by Dr. Beale on Disease Germs, has an entirely new part added on " The
Destruction of Disease Germs." 
                 BEALE  (lionel s.j, M. D., F. R. S.

BIOPLASM.   A Contribution to the Physiology of Life, or an Intro-
     duction to the Study  of Physiology and Medicine,  for Students.   With
     Numerous Illustrations.   Price    ....-•   $3-°°
  This volume is intended as a Text-Book for Students of Physiology, explaining the
nature of some of the most important changes which are characteristic of and peculiar to
living beings.
                        BY SAME AUTHOR.

PROTOPLASM,  OR  MATTER AND LIFE.  Third Edition, very
     much Enlarged.  Nearly 350 pages.  16 Colored Plates.  One volume.
     Price   .                      .......#5-°°
Part I.  DISSENTIENT.   Part II. DEMONSTRATIVE.   Part III. SUGGESTIVE.
  This work contains : 1. Critical remarks on the life-theories advocated by Odling, Bence
Jones, Grove, Owen, Huxley, Bennett, Bastian, Tyndall, Bain, Herbert Spencer, Darwin, and
others.   2. A full account of the author's own conclusions on the nature of life, and a state-
ment of  the facts and observations upon which they are based.  3.  Many arguments against
the scientific materialism of the day, and concludes with 4. A criticism on the theory of
life advocated by Strauss in " The Old Faith and the New."


                      BIDDLE  (john b.),  M. D.,

     Professor of Materia Medica and Therapeutics in the Jefferson Medical College, Philadelphia, &c.

 MATERIA  MEDICA, FOR THE USE  OF  STUDENTS.   With
     Illustrations.   Fifth Edition, Revised and Enlarged.   Price     $4.00
  This new and thoroughly revised edition of Professor Biddle's work has incorporated in
 it all the improvements as adopted by the New United States Pharmacopoeia just issued. It
 is designed to present the leading facts and principles usually comprised under this head as
 set forth by the standard authorities, and to fill a vacuum which seems  to exist in the want
 of an elementary work on the subject.  The larger works usually recommended as text-books
 in our Medical schools are too voluminous for convenient use.  This will be found to contain,
 in a condensed form, all that is most valuable, and will supply students with a reliable guide
 to the course of lectures on Materia Medica as delivered at the various Medical schools in
 the United States.


                           BLOXAM  (c l.),

                      Professor of Chemistry in King's College, London.

 CHEMISTRY, INORGANIC   AND   ORGANIC.    With  Experi-
     ments and a Comparison of Equivalent and Molecular  Formulae.   With
      276 Engravings on Wood.   Second Edition, carefully revised. Octavo.
     Price       ..........    $4.50
   The author has endeavored in this new edition  of his work to supply a book sufficiently
 comprehensive for those studying the science as a branch of general education.  He has also
 devoted special attention to Metallurgy and some other branches of applied Chemistry, in
 order to adapt it to the wants of practical men.  His pages are crowded with facts and experi-
 ments, well chosen, and many of them quite new even to scientific men.
               CHAVASSE  (p. henry),  F. R.C.S.,

                    Author of Advice to a Wife, Advice to a Mother, &c.

APHORISMS  ON  THE MENTAL  CULTURE AND  TRAIN-
     ING  OF A CHILD,  and on various other subjects relating to Health
     and Happiness.   Addressed  to Parents.   Price .     .     .     ^I-5°
  Dr. Chavasse's works have been very favorably received and had a large circulation, the
value of his advice to WIVES and MOTHERS having thus been very generally recognized.
This book is a sequel or companion to them, and it will be found both valuable and important
to all who have the care of families, and who want to bring up their children to become useful
men and women.  It is full of fresh thoughts and graceful illustrations.
                                      4 
                   CLARK  (f. le gros),  F. R.  S.,
                        Senior Surgeon to St. Thomas's Hospital.
OUTLINES OF SURGERY AND SURGICAL  PATHOLOGY,
     including the Diagnosis and Treatment  of Obscure and Urgent Cases,
     and the Surgical Anatomy of some Important Structures and Regions.
     Assisted by W. W. Wagstaffe, F. R. C. S., Resident Assistant-Surgeon
     of, and Joint Lecturer on Anatomy at,  St. Thomas's Hospital.  Second
     Edition, Revised and Enlarged.   Price      ....  $3.00
  This edition brings the work up to the highest level of our present knowledge, incorporat-
ing all that is sound and recent in Physiology so far as  it relates to subjects requiring its
aid.  It is not alone an admirable exposition of the principles of Surgerv, but a trusty guide
to the emergencies of Practice.  We cannot too highly estimate the ability to condense and
the results of a ripened experience furnished to us here in a readable and practical form. —
Med. Times and Gazette.

                           COOLEY  (a. j.).
CYCLOPEDIA OF  PRACTICAL RECEIPTS.  Containing Pro-
     cesses  and  Collateral  Information in the  Arts,  Manufactures, Profes-
     sions,  and  Trades,  including  Medicine,  Pharmacy,  and  Domestic
     Economy;  designed as a General Book of Reference  for the Manufac-
     turer, Tradesman, Amateur, and Heads of Families.   The Fifth  Edi-
     tion, Revised and partly Rewritten by Richard V. Tuson, F.C.S.,  &c.
     Over  1000  royal-octavo pages, double columns.  With  Illustrations.
     Price...........$10.00
  Every part of this edition has been subjected to a thorough and complete revision by the
editor, assisted by other scientific gentlemen.  In the chemical  portion of the book, every
subject of practical importance has been retained, corrected, and  added to; to the name of
every substance of established composition a formula has been attached; while to the Phar-
maceutist its value has been greatly increased by the additions which have been made from
the British, Indian, and United States Pharmacopoeias.
                       CAZEAUX (p.).  M.  D.,
                  Adjunct Professor of the Faculty of Medicine, Paris, etc,
A THEORETICAL AND PRACTICAL TREATISE ON MIDWIFERY,
     including the Diseases of Pregnancy and Parturition.   Translated from
     the Seventh French  Edition,  Revised, Greatly Enlarged, and Improved,
     by S.  Tarnier, Clinical Chief of the Lying-in Hospital, Paris, etc.,
     with numerous  Lithographic and other Illustrations.   Price,  in  Cloth,
     $6.50;  in Leather,  $7.50.
  M. Cazeaux's Great Work on Obstetrics has become classical in its character, and almost
an Encyclopaedia in its  fulness. Written expressly for the  use of students of medicine, its
teachings are plain and  explicit, presenting a condensed summary of the leading principles
established by the masters of the obstetric art, and  such clear, practical directions for the
management of the pregnant, parturient, and puerperal states, as have been sanctioned by
the most authoritative practitioners, and confirmed by the author's own experience.
                     DOBELL  (horace),  M. D.,
                           Senior Physician to the Hospital.
WINTER COUGH (CATARRH, BRONCHITIS, EMPHYSEMA,
     ASTHMA). Lectures Delivered at the Royal Hospital for Diseases of the
     Chest.   New and  Enlarged Edition, with  Colored Plates.  Octavo.
     Price..........$3.50
  This work has  been  thoroughly revised.  Two  new Lectures have been  added — viz.,
Lecture IV., "On the Natural Course of Neglected Winter Cough, and on the Interdepen-
dence of Winter Cough with other Diseases; " Lecture IX., " On Change of Climate in Winter
Cough."  Also additional matter on Post-nasal Catarrh, Ear-Cough, Artificial Respiration as
a means of Treatment, Laryngoscopy, New Methods and Instruments in Treating of Emphy-
sema, a good Index, and Colored Plates, with appended Diagnostic Physical signs. 
                      DALBY  (w. b.), F.R.C.S.,

                        Aural Surgeon to St. George's Hospital.

LECTURES ON  THE  DISEASES  AND INJURIES OF THE
     EAR.    Delivered   at   St.   George's  Hospital.   With   Illustrations.
     Price.......■   .     .      .      .  $1.50
  This admirable little volume by Mr. Dalby, the accomplished aural surgeon to St. George's
Hospital, consists of eleven lectures delivered  by him  at that institution.  With a modest
aim, this work, the latest issued by the English press on Aural Surgery, is happy in concep-
tion and pleasantly written; further, it shows  that its  author is thoroughly au fait in his
specialty.   The subject of which the volume treats  is handled in a terse style, and this, if
we mistake not, will make it acceptable to the  student and practitioner who have a just
horror of unnecessary details.  In conclusion, we hope that we have succeeded in interesting
our readers in the volume.  We  cordially recommend it as a trustworthy guide in the treat-
ment of the affections of the ear.  The book is moderate in price, beautifully illustrated by
wood-cuts, and got up in the best style. — Glasgow Medical Journal.
                       ELLIS (EDWARD),  M. D.

                  Physician to the Victoria Hospital for Sick Children, &c.

 A PRACTICAL  MANUAL  OF  THE  DISEASES  OF  CHIL-
     DREN, with  a Formulary.  Second Edition, Revised and Improved.
     One volume.      .........   $2.75
   The author, in issuing this new edition of his book, says : "I have very carefully revised
 each chapter, adding several new sections, and making considerable additions where the
 subjects seemed to require fuller treatment, without, however,  sacrificing  conciseness or
 unduly increasing the bulk of the volume."



                 FOTHERGILL  (j.  milner), M. D.

 THE  HEART  AND ITS DISEASES,  AND THEIR TREAT-
     MENT.   With Illustrations.   Octavo.   Price     .      .         #5.00
 . This ^ork Sives to the reader a concise view of Cardiac Diseases, uniting the most recent
 information as to the cause of heart-disease, with German Pathology and the latest advances
 in Therapeutics.  It is designed to fill the gap between our standard works and the  present
 position of our knowledge in diseases of the heart.

                       BY  SAME AUTHOR.

 DIGITALIS.   Its Mode  of Action and  its  Use,  illustrating  the
     Effect  of Remedial Agents over Diseased  Conditions of  the Heart
     Price...........H1.25



                 GANT  (FREDERICK J.), F. R. C. S.,

                        Surgeon to the Royal Free Hospital, &c.

THE IRRITABLE  BLADDER.   Its Causes and  Curative Treat-
     ment ;  including a Practical View of Urinary Pathology, Deposits,  and
     Calculi.   Third Edition, Revised and Enlarged.   With  New Illustra-
     tions.   Price.........$2#5o

  The fact that a third edition of this book has been required seems to be sufficient proof
of its value.  The author has carefully revised and added such additional matter as to make
it more complete and practically useful.
                                      6 
                   DAWSON  (g.),  M. A., PH. D.

                     Lecturer on Photography in King's College, London.

HARDWICK'S MANUAL OF PHOTOGRAPHIC CHEMISTRY
     With Engravings.   Eighth Edition.   Edited and Re-arranged by  G.
     Dawson, Lecturer on Photography, &c, &c.   i2mo.    .        $2.oa

  1h^ °tyect of.tae Editor has been to give practical instruction in this fascinating art, and
to lead the novice from first principles to the higher branches, impressing him with the value
of care and exactness in every operation.



              HARLEY  (george),  M. D., F. R. C.  P.,

                        Physician  to University College Hospital,

THE URINE  AND ITS DERANGEMENTS:  With the Applica-
     tion of  Physiological Chemistry to  the Diagnosis  and Treatment  of
     Constitutional  as well as  Local  Diseases; being a Course of Lectures
     delivered at University College.   With Engravings.  Price     $2.75

                                  CONTENTS.
1. What is Urine?
2. Changes in the Composition of the Urine,
     induced by Food, Drink, Medicine, and
     Disease.
3. Urea, Ammonaemia, Uraemia.
4. Uric Acid.
   Hippuric Acid, Chloride of  Sodium.
6. Urohsematin, Abnormal Pigments in Urine.
 7. Phosphoric Acid, Phosphatic Gravel and
     Calculi.
 8. Oxalic Acid, Oxaluria, Mulberry Calculi.
 9. Inosite in Urine, Creatin and Creatinine,
     Cholesterin, Cystin, Xanthin, Leucin,
     Tyrosin.
10. Diabetes Mellitus.
11. Albuminuria.
  On the whole, we have here a valuable addition to the library of the practising physician;
not only for the information which it contains, but also for the suggestive way in which
many of the subjects are treated, as well as for the fact that it contains the ideas of one who
thoroughly believes in the future capabilities of Therapeutics based on Physiological facts,
and in the important service to be rendered by Chemistry to Physiological investigation.
                                       American Journal of the Medical Science.



                    HABERSHON  (s.  o.),  M.  D.,

                           Physician to Guy's Hospital, &c.

ON THE  DISEASES OF  THE  LIVER.  Their  Pathology  and
     Treatment.   Being the Lettsonian Lectures, delivered  at the Medical
     Society of London, 1872.   Price     .....    $i-5°
  These Lectures contain within a brief compass a large amount of information and  many
practical suggestions that cannot fail to  be of great value to every practitioner.
                                                       Dublin Medical Journal.


                      HEWITT (graily), M. D.,

   Physician to the British Lying-in Hospital, and  Lecturer on Diseases  of Women and Children, &c.

THE  DIAGNOSIS,  PATHOLOGY,  AND  TREATMENT   OF
     DISEASES OF  WOMEN,  including  the Diagnosis  of Pregnancy.
     Founded on  a Course  of Lectures delivered at St.  Mary's Hospital
     Medical School.   The  Third Edition, Revised and  Enlarged,  with
     new Illustrations.   Octavo.   Price in Cloth     .     .     .    $5.00
                                       "     Leather   .      .     .      6.00
  This new edition of Dr. Hewitt's book has been so much modified, that it may be considered
substantially a new book; very much of the matter has been entirely rewritten, and the whole
work has been rearranged in such  a manner as to present a most decided improvement over
previous editions.  Dr. Hewitt is the leading clinical teacher on Diseases of Women in London,
and the characteristic attention paid to Diagnosis by him has given his work great popularity
there.  It may unquestionably be considered the most valuable guide to correct Diagnosis to
be found in the English language.          7 
                   HEWSON  (addinell,)  M. D.
                     Attending Surgeon Pennsylvania Hospital, &c.
EARTH   AS  A  TOPICAL  APPLICATION   IN  SURGERY.
     Being a  full Exposition of its use  in  all the  Cases requiring Topical
     Applications admitted in the Surgical Wards of the Pennsylvania Hospi-
     tal during a period of Six Months.   With Four full-page Illustrations.
                                CONTENTS.
  Preface; Introduction; Histories of Cases; Comments as to the Effects of the Contact of
the Earth; Its Effects on Pain; Its Power as a Deodorizer; Its Influence over Inflammation;
Its Influence over Putrefaction; Its Influence over the Healing Processes; Modus Operandi
of the Earth; As a Deodorizer and other Putrefaction; In its Effects on Living Parts.
     Price,  ...........   $2.50
  It presents the results of researches by the author into "the action of Earth as a surgical
dressing, and embraces the histories of over ninety cases which occurred in the wards of the
Pennsylvania Hospital some three years since, but whose publication  has been delayed, for
the double purpose of weighing them by subsequent experience, and of interpreting their
meaning by a careful study of the various subjects which they involve.

                     HODGE  (hugh l.), M. D.
                   Emeritus Professor in the University of Pennsylvania.
HODGE    ON    FOETICIDE,  OR   CRIMINAL   ABORTION.
     Fourth Edition.   Price, in paper covers,     ....   $0.30
                          "     flexible cloth,    ....    0.50
  This little  book is intended to place in the hands of professional men and others the means
of answering satisfactorily and intelligently any inquiries that may be made of them in con-
nection with this important subject.

                 HOLDEN (edgar), A. M.,  M. D.,
                             Of Newark, New Jersey,
             CONTAINING THREE HUNDRED  ILLUSTRATIONS.
THE  SPHYGMOGRAPH.   Its  Physiological and  Pathological In-
     dications.   The Essay to which was  awarded  the  Stevens  Triennial
     Prize  in the College of Physicians  and  Surgeons in  New York, April,
     1873.    Illustrated by Three Hundred  Engravings on  Wood.  One vol-
     ume  octavo.  Price.   •■■-....$


               LEBER &  ROTTENSTEIN  (drs.).

DENTAL CARIES AND ITS  CAUSES.    An  Investigation  into
     the Influence  of  Fungi in the  destruction of  the Teeth, translated by
     Thomas H. Chandler, D.M.D., Professor of Mechanical Dentistry in
     the Dental School of Harvard University. With Illustrations.  Octavo.
     Price...........^.so
  This work is now considered the best and most  elaborate  work on Dental Caries. It is
everywhere  quoted and relied upon as authority by the profession, who have seen it in the
original, and by authors writing on the subject.

                     LEGG  (j. wickham), M. D.
                     Member of the Royal College of Physicians, &c.
A GUIDE  TO  THE EXAMINATION OF THE URINE.   For
     the Practitioner and  Student.  Third Edition.  i6mo.  Cloth.  Price, $0.75
  Dr. Legg's little manual has met with remarkable success; the speedy exhaustion of two
editions has  enabled the author to make certain  emendations which add greatly to its value.
It can confidently be commended to the student as a safe and reliable guide.
                                     8 
                         LEWIN  (dr. george).
Professor at the Fr.-Wilh. University, and Surgeon-in-Chief of the Syphilitic Wards and Skin Diseases of
                            the Charity Hospital, Berlin.
THE TREATMENT OF SYPHILIS  by  Subcutaneous  Sublimate
     Injections.  With a Lithographic Plate illustrating the Mode and Proper
     Place of administering  the Injections,  and of the Syringe used for the
     purpose.   Translated by  Carl Prcegler,  M.D., late Surgeon  in the
     Prussian Service, and E. H.  Gale, M.D.,  late Surgeon in  the  United
     States Army.  Price    ........   $2.25
  The great number of cases treated, some fourteen hundred, within a period of four years,
in the wards  of  the Charity Hospital, Berlin, only twenty of which were returned on
account of Syphilitic relapses, certainly entitles the method of treatment advocated by this
distinguished syphilographer to the attention of all physicians under whose notice syphilitic
cases come.
                           •          l

                        LIZARS  (john), M.D.
            Late Professor cf Surgery in the Royal College of Surgeons, Edinburgh.
THE  USE  AND  ABUSE OF  TOBACCO.    From  the  Eighth
     Edinburgh Edition.  i2mo.   Price, in flexible cloth,      .     $0.60
  This little work contains a History of the introduction of Tobacco, its general characteris-
tics ; practical observations upon its effects on the system; the opinion of celebrated profes-
sional men in regard to it, together with cases illustrating its deleterious influence, <fcc, &c.

                         MACNAMARA  (a).
Surgeon to the Ophthalmic Hospital, and  Professor of Ophthalmic Medicine in the Medical College, Calcutta.
MANUAL  OF THE  DISEASES  OF  THE EYE.   The Second
     Edition,  carefully  Revised; with Additions,  and  numerous  Colored
     Plates, Diagrams of  the  Eye, many Illustrations on Wood, Snellen's
     Test Types, &c, &c.   Price      ......  $5.00
  " This work when first published took its place in medical literature as the most complete,
condensed, and well-arranged  manual on ophthalmic surgery in the English language.
Arranged especially for medical students, it became,  however, the work of reference for the
busy practitioner, who could obtain nearly all that was best worth knowing on this subject,
tersely stated, and easily found by the aid of the excellent marginal  notes on the contents
of the paragraphs." — Philadelphia Medical Times.

                   MACKENZIE  (morell),  M. D.
               Physician to the Hospital for Diseases of the Throat, London, &c,
GROWTHS  IN THE LARYNX.  Their  History, Causes,  Symp-
     toms, Diagnosis, Pathology, Prognosis, and Treatment.   With  Reports
     and Analysis of One Hundred Consecutive Cases treated by the Author;
     and a Tabular  Statement of every published  case treated since the in-
     vention  of  the  Laryngoscope.   With numerous  Colored and other
     Illustrations.  Octavo.    Price    ......  $3.00
  Dr. Mackenzie's position has given him great advantages and a large experience in the
treatment of Diseases of the  Throat, and for many years he has been regarded as a leading
authority in this department of Surgery.  The Illustrations have been prepared with great
care and expense.
              OTHER WORKS BY SAME AUTHOR.
THE  LARYNGOSCOPE  IN DISEASES OF THE THROAT.
     With an Appendix  on  Rhinoscopy, and  an Essay on Hoarseness and
     Loss of  Voice.   With  Additions  by J. Solis  Cohen,  and Numerous
     Illustrations on Wood and Stone.  Price   .     .    .     .     $3-°°
PHARMACOPOEIA OF  THE HOSPITAL  for  Diseases  of  the
     Throat; with One  Hundred and Fifty Formulas for Gargles, &c, &c.
     Price   .      .     .........#1.25
                                      9 
                   MAUNDER  (c  f.),  F. R. C. S.
      Surgeon to the London Hospital j formerly Demonstrator of Anatomy at Guy's Hospital.
OPERATIVE  SURGERY.    Second Edition,  with  One  Hundred
     and Sixty-four Engravings on Wood.
                                 CONTENTS.
Chap. 1. Compress, Splint,  Bandage  Strap-
Chap. 7. Operations on the Surface of the
         Body.
  "  8. Amputation.
  "  9. Lower Extremity.
  " 10. Upper ditto.
  " 11. Special Operations.
    ping.
2. Ligature.
3. Operations on the Vascular System.
4. Operations on Arteries.
5. Ligature of special ditto.
6. Operations on the Bones.
 Price..........$2.50
                         MARTIN  (JOHN H.).
                         Author of Microscopic Objects, &c,
A MANUAL OF  MICROSCOPIC  MOUNTING.   With Notes on
     the Collection and Examination of Objects,  and upwards of One Hun-
     dred  Illustrations  on   Stone  and  Wood,  drawn   by  the   Author.
     Price...........$3-°°
  " This book is more than its title indicates.  It gives a description of the apparatus neces-
sary for  microscopical  research, as well as the methods of preparation and preserving the
various objects.  It is a complete and well-illustrated work on its subject, which is daily
becoming more valuable to the scientist and more cultivated as an elegant and  interesting
study." —Scientific American.

                    MEADOWS  (alfred), M. D.
          Physician to the Hospital for Women, and to  the General Lying-in Hospital, &c.
MANUAL  OF  MIDWIFERY.  A New Text-Book.  Including the
     Signs and Symptoms of  Pregnancy,  Obstetric  Operations, Diseases of
     the Puerperal State, &c, &c.   First American from the Second London
     Edition.   With numerous Illustrations.   Price      .     .     .   $3.00
  This book is especially valuable to the Student as containing in a condensed form a  large
amount of valuable information on the subject which it treats.  It is also clear and methodi-
cal in its arrangement, and therefore useful as a wrork of reference for the practitioner.  The
Illustrations are numerous and  well executed.
                       ■

                   ' MILLER  (james), F. R. C. S.
                      Professor of Surgery University of Edinburgh.
ALCOHOL, ITS PLACE AND  POWER.   From  the Nineteenth
     Glasgow  Edition.   i2mo.   Cloth flexible.  Price .     .     .   $0.75
  This work was prepared by Professor Miller at the special request of the Scottish Temper-
ance League, who were anxious to have a work of high authority, presenting the medical
view of  the subject that could be freely disseminated among all classes.


                    NORRIS  (GEORGE w.), M.D.
                      Late Surgeon to the Pennsylvania Hospital, &c,
 CONTRIBUTIONS  TO   PRACTICAL  SURGERY,  including
      numerous Clinical Histories, Drawn from a Hospital Service  of Thirty
      Years.   In one volume, Octavo.   Price.....#4.00
                                                                  IO 
                   RINDFLEISCH  (dr. edward).
                  Professor of Pathological Anatomy, University of Bonn.
TEXT-BOOK OF PATHOLOGICAL  HISTOLOGY.   An  Intro-
     duction  to the  Study of  Pathological Anatomy.   Translated from the
     German, by Wm. C. Kloman, M.D., assisted by  F.  T. Miles,  M.D.,
     Professor of Anatomy, University of Maryland,  &c, &c.   Containing
     Two  Hundred  and Eight elaborately executed Microscopical Illustra-
     tions.   Octavo.  Price, bound in Cloth,      .     .     .     .   $6.00
                          "      "      Leather,    ....    7.00
  This is now confessedly the leading book, and the only complete one on the subject in
the_ English language.  The London Lancet says of it: " Rindneisch's work forms a mine
which no pathological writer or student can afford to neglect, who desires to interpret aright
pathological structural changes, and his book is consequently well known to readers of Ger-
man medical literature.   What makes it especially valuable is the fact that it was originated,
as its author himself tells us, more at the microscope than at the writing-table. Altogether
the book is the result of honest hard labor.   It is admirably as well as profusely illustrated,
furnished with a capital Index, and got up in a way that is worthy of what must  continue
to be the standard book of the kind."

              ROBERTS (FREDERICK T.).,  M. D., B.  Sc
Assistant Physician and Teacher of Clinical Medicine  in the University College  Hospital j Assistant Physician
                          Brompton Consumption Hospital, &,c.
A  HAND-BOOK  OF THE  THEORY   AND PRACTICE  OF
      MEDICINE;   One volume  medium octavo, containing  over  1000
      pages.   Price.........$5-oo.

   This work has been prepared  mainly for the use of  Students, and its object  is to
present in as condensed a form as the present  extent of Medical Literature will permit,
and in one volume, such  information with regard  to  the Principles and Practice of
Medicine, as shall be sufficient not only to  enable them to  prepare for  the various
examinations which they  may have to undergo, but also to guide  them in acquiring
that Clinical Knowledge which can alone properly fit them for  assuming the  active
duties of their profession.  The  work  is also adapted to  the wants of very many
members of the profession who are already  busily engaged in general Practice,  and
consequently have but little leisure and few opportunities for the  perusal of the larger
works 011 Practice or  of the various  special  monographs.
            REYNOLDS  (j. russell),  M. D., F. R. S.,
         Lecturer on the Principles and Practice of Medicine, University College, London.

LECTURES ON  THE  CLINICAL USES  OF  ELECTRICITY.
     Delivered at  University  College Hospital.   Second  Edition, Revised
     and Enlarged.   Price   .....-••  $


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                                     11 
                    SWERINGEN  (hiram  v.).
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                                    12 
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                                     14 
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