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antwl  irf  Obstetrics:
       THOMAS F. COCK, M.D.,
PHYSICIAN TO THE NEW YORK LYING-IN ASYLUM, PHYSICIAN TO BELLEVUE
               HOSPITAL, ETC.
(4^
       NEW  YORK:
SAMUEL  S.  &  WM. WOOD,
     2G1  PEARL STREET.
1853. 
1953
         Entered according to Act of Congress, in the year 1853, by
                    SAMUEL S. & WM. WOOD,
in the Clerk's Office of the District Court of the Southern District of New York.
R. Craighead, Printer and Stereotijper,
    S3 Vesey street, New York. 
a-
PREFACE.
The little work now offered to the Medical Public  makes no preten-
sions to originality.  It is avowedly a compilation, and hence, with a
few exceptions, no authorities are given for the statements which it
contains.  Perhaps the following reasons may serve as an apology for
attempting  to  add  another work  on Obstetrics,  to the  numerous
excellent treatises which have been published within a few years past.
Having been for several years engaged in teaching Midwifery, I have
experienced the want of some handbook for students attending lectures
on  this department,  a skeleton  collection  cf facts,  which,  by being
interleaved, might  answer  as a  syllabus  for  the  teachings  of  any
school.  I therefore took as a basis my notes of the  lectures  of Pro-
fessor Gilman, and gradually, for a number of years, added such facts
and opinions as reading and experience developed.  Without seeking
to turn aside the student  from the study of elaborate treatises, from
which alone he  can learn reasons for practice,  this little work is
designed to convey as briefly as possible, facts, as far as ascertained;
and, where  definite  conclusions have not yet  been reached, recent
opinions, so as to present, as near as may be, a miniature of  modern
Obstetrics.  To the student, it is hoped it may proved an useful and
acceptable companion, in the lecture room and in the examining class;
while the young practitioner, in his moments of emergency, may per-
haps find an issue from his trouble, suggested by a  hasty glance at its
pages.
    New  York. 
 
CONTENTS.
Paox
Bones of Pelvis,
Articulation of Pelvis,
Ligaments of Pelvis,
Divisions of Pelvis,
Recent Pelvis,  .
Uses of Pelvis,  .
Deformity of Pelvis,
Vessels, Ac, of Pelvis,
Organs of Generation,
Menstruation,
Menstruation, Disorders of,
Amenorrhoea,
Chlorosis,  .
Suppression of Menses,
Vicarious Menstruation,
Menorrhagia,
Dysmenorrhea, .
Leucorrhcea,
Ulceration of Os Uteri,
Reproduction,
Changes by Impregnation,
Signs of Pregnancy,  .
Duration of Pregnancy,
Diseases of Pregnancy,
Influence of Gestation on Disease,
Changes in the Ovum,
Placenta,   . 
CONTENTS.
Dimensions of Foetus,
Fcetal Nutrition,
Fcetal Circulation,
Fcetal Pathology,
Fcetal Death,
Superfcetation,  .
Extra Uterine Pregnancy,
Abortion,
Parturition,
Mechanism of Labor, .
Classification of Labor,
Stages of Labor,
Divisions of Labor,  .
Symptoms of Labor, .
Duties of Accoucheur in Labor,
Difficult Labor, .
Face Presentation,
Irregular Labor,
Breech Labor,
Arm Presentation,
Centres,
Complex Labor,
Convulsions,
Hemorrhage,
             Remedies for,
             Forms of,
      "      During Pregnancy,
             with Abortion,
             with Hydatids,
      "      Accidental,  .
      "      in Labor,
      "      Unavoidable,
             After Birth of Child,
      "      After Delivery of Placenta,
      "      with Firmly Contracted Uterus,
      "      with Polypus,
      "      Secondary,  .
      "      After Treatment of,
      "      Table of,
Labor, with Prolapsus of Cord, .
 . 1,"     "  Twins,  .
         "  Rupture of Uterus, 
CONTENTS.
VU
 Labor, with Inversion of Uteris
         "   Syncope,
 Sudden Death after Labor,
 Management of Puerperal State
 Attentions before Leaving,
 Laceration of Perineum,
 Vesico-Vaginal Fistula;,
 Vaginitis,  .
 Thrombus,
 Paralysis of Legs,
 Laceration of Vagina,
 Rupture of Bladder,
 Prolapsus Uteri,
 Piles,
 Sore Nipples,
 Retracted Nipples,
 Puerperal Fever,
 Pelvic Cellulitis,
 Pelvic Abscess,  .
 Phlegmasia Dolens,
 Puerperal Mania,
 Mammary Abscess,
 Operative Midwifery,
 Operations for Premature Labor,
 Version,
 Vectis, or  Lever,
 Forceps,
 Embryotomy,
 Symphyseotomy,
 Caesarian Section,
Vaginal Hysterotomy,
Chloroform,
Ordinary Management of Child,
Morbid States of Child,
Imh'.Y.....
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241 
 
MANUAL   OF   OBSTETRICS.
    Obstetrics  (from obstetrix,  a midwife).—Def.  Is that
 branch of science which treats of the Anatomy and Pathology
 of the genital organs of the human female.
    PARTURITION (parturio, to bring forth). Def—The term
 used  to  designate  the act by which irfan is introduced into
 being.
    Obstetrical  Anatomy.— Concerns the pelvis and its con-
 tents, together  with  .the Essential and Accessory  organs of
 Generation.
    Pelvis.—Situation: positively, in  the trunk; relatively, so
• as to  be articulated to vertebral column superiorly,  and to ossa
 femoris inferiorly.  Usually about middle  of body—lower in
 foetal life.  Shape, an irregularly conical cavity.  Derivat. «e\vs,
 a basin.   Uses,  to contain and protect viscera ; to afford means
 of connexion  between trunk  and inferior  extremities; and a
 point of insertion for muscles.  Number of bones composing: in
 adult four, in  early  life  more;  for obstetrical purposes, four
 principal.  Names: two  ossa innominata;  sacrum;  coccyx.
 Position of bones: innominata on either side; sacrum poste-
 riorly and  between  ; coccyx inferiorly.
    Sacrum.—So  named  from being  offered in sacrifices an-
 ciently ;  also being the largest vertebra.   Synonym; os basi-
 lare, os clunium.   Importance; most important obstetrically.
 Shape;  triangular base  above, apex  below; wedge-shaped
                              2 
10
MAKl'AL  OF OBSTETRICS.
two ways; concave anteriorly, convex posteriorly.   Analogous
to; vertebrae—false vertebrae.   Number of surfaces;  two.
Edges two.
  Anterior surface.—Shape, concave two ways.  Lines, four;
mark,  early  divisions.   Foramina, four  pairs;  give exit  to
anterior sacral nerves, which assist to form great sciatic; termi-
nate in grooves.   Muscle arising,  pyriformis, or pyramidalis;
from between openings.   Synonyms.—" Hollow."  " Concavity."
Depth of arc, ten lines; has much influence on labor.   Pro-
montory,  or sacro-vertebral  angle, formed- at union  with last
lumbar vertebra; varieties, in projection; influence, labor.
  Posterior  surface.—Shape, irregularly convex,  two  ways.
Spines, along middle, four or five—diminish as descend ; ana-
logues of spinous processes ;  called the crista.   Canal, contains
cauda equina; closed below by fibro-cartilage.   Cornua, Horns,
two, inferiorly; unite to cornua of coccyx, form foramina; give
exit to fifth pair of posterior sacral nerves.   Foramina, called
posterior sacral;  four  pairs; emit, posterior  sacral nerves;
smaller in recent than dry, also than anterior.  Groove, outside
of  spines, for sacro-lumbalis, and longjssimus  dorsi.  Rough
surfaces near edge, for posterior sacro-iliac ligaments.
   Lateral surfaces.—Shape, above, ear-shaped; below, thin
and  sharp.   Ligaments attached, sacro-sciatic.   Sacro-iliac*
symphysis, or synchondrosis;  above, unites  to ilium  ; cartilage
interposed ; almost, if not invariably, immovable; in some infe-
rior animals, is movable.  Base,  looks upwafds; rests on ver-
 tebra ; elliptical articular surface;  thickness,  2 \ inches; breadth,
 4 inches.  'Ala?, triangular;  on either side of promontory, assist
 to form internal iliac fossa;  upper edges assist to form brim of
 pelvis.   Apex, inferiorly.; shape, transversely oval; articulates to
 coccyx; motion, ginglymoid, impaired by age, and thus retards
 labor; ligaments, 2; anterior stronger for  the greater  strain.
 Size of sacrum: length, 4  to 41 inches; breadth,   4  inches ;
 thickness, 2| inches.  Composition ; externally thin layer of com-
 pact tissue; internally cancellated; weight, very light. Develop-
 ment; in foetus, 35  pieces;  at birth, 5;  in  adult, 1.   Con- 
                  manual  of obstetrics.               11

nexions;  to  vertebrae,  by inter-spinous  and capsular  liga-
ments,;, to coccyx, by ligaments  and fibro-cartilage; to ilium
by symphysis ; to ischium, by ligament.   Difference in woman
and  man : in woman, shorter, wider, and more curved.
   Coccyx.—Synon.,  Huckle-bone.  Deriv.  xoxxvg,  cuckoo's
bill.   Shape : triangular, flattened.  Number of bones : 3, 4, 5.
Situation:  articulated by  ginglymoid  inferiorly to sacrum.
Surfaces:  two.   Anterior,  smooth, concave;  lodges rectum.
Posterior,  convex;  separated from skin by  posterior  sacro-
coccygean  ligament.   Edges: give attachment to anterior or
smaller sacro-sciatic  ligament;   to ischio-coccygeus muscle.
Horns : superiorly; attached to sacral cornua;  form, foramina.
Apex : inferiorly; external,  sphincter ani attached ; direction,
usually obliquely  anterior; variations,  backwards,  sideways,
anteriorly at a right  angle; shape, rounded ;  variation,  bifur-
cated.  Development: five or  fewer pieces;  rudiments  of the
tail.   Composition :  external, compact; internal, spongy.   Mo-
bility :  one inch antero-posteriorly ; continues through men-
strual life;  false anchylosis,  sometimes  in  sedentary;  frac-
tured rarely in labor ;  treat  by rest of bowels; injury not per-
manent.   Importance : very great to accoucheur.
   Os  Innominatum.—Synon.:  Coxal,  Iliac.  Haunch   bone.
Shape : quadrilateral, twisted  in middle.  Greatest breadth, 6
inches; height, 7 inches.  Divisions:  Ilium,  Ischium, Pubes.
Situation: ilium superiorly ; ischium inferiorly;  pubes  ante-
riorly; meet in acetabulum.
   Ilium.—Synon., Hip  or Haunch  bone.    Size: largest.
Shape : quadrangular. Position:  superiorly.  Surfaces : inner,
or internal iliac  fossa; or venter.  Shape: concave,  smooth ;
filled by  iliacus  internal muscle.   Supports  large intestine;
nutritious foramen at lower part.   Outer, or external iliac fossa,
or dorsum : shape, irregular, convex; marked  by  curved lines
for origins of glutei.   Base : thickest part enters into acetabu-
lum, of which it forms two  fifths.   Ala :  the  flaring  portion ;
direction, outwards, upwards;  terminates in crista.  Crista, or
crest, surmounts  ala; shape, twisted like an /.   To  outer lip 
12
MANUAL OF  OBSTETRICS.
are attached, oblique external  latis. dorsi muscles, and femoral
aponeurosis.  To inner, the transversalis and quadratus lumbo-
rum.   To  middle,  the oblique internus.   Terminates,  ante-
riorly in anterior superior spinous process, to which are attached
the tensor vag. femoris, sartorius, iliacus muscles, and Poupart's
ligament.   Ends, posteriorly in post. sup. spin, process, to it a
ligament.   Below each process respectively, a notch for nervous
filaments;  a notch for tendon of iliacus and psoas; the  anter.
infer, spinous process for rectus femoris.  To poster, infer, spin.
process, ligaments attached.   Sciatic, or ischiatic notch.—Situ-
ated posteriorly.  Converted into  two foramina by sciatic liga-
ments.   Upper foramen is larger,  and emits three arteries, the
gluteal, sciatic, and  pudic;  two nerves, sciatic and  pudic; one
muscle, pyriformis.   Lower is smaller; emits one muscle, obtu-
rator internus; through it re-enter the pudic artery and pudic
nerve.  Internal face : smooth, concave; filled by iliacus inter-
nus ; posterior part is rough, to form symphysis.  Sacro-iliac
symphysis, or synchondrosis, or junction.   Formed by sacrum
and ilium,  with interposed  fibro-cartilage,  one eighth to one
sixth of an inch thick;   this always adheres  to sacrum  if
wrenched asunder;  object  is to break shocks.  Linca-ilio-pec-
tinea forms the  dividing edge between false and true pelvis;
formed by sacrum,  ilium,  and  pubes.  Connexion^ to ischium
and pubes  in acetabulum; to sacrum at sacro-iliac symphysis.
   Os Ischium.—Synon.,  Sedentarium, Seat-bone.  Size, next
to ilium.   Position, below ilium. Divisions, base  or body,
spine, tuberosity, ascending  ramus.   Base,  thickest;  forms
about two  fifths of cotyloid cavity.   Spine, the inferior termi-
nation  of  great sciatic  notch;  half an  inch  lono-;  direc-
tion  downwards, sometimes  internally,  and  then  interferes
seriously with labor.  Attached to it is anterior or lesser sacro-
sciatic ligament; also  ischio-coccygeus  muscles.   Tuber  or
tuberosity,  is inferior extremity.  To  it are attached posterior
or great sacro-sciatic ligament; to the outside, the quadratus
femoris and adductor  magnus; to middle,  biceps flexor, semi-
tendinosus,  and  semimembranosus ;  to  inside,  the  gemellus 
MANUAL OF OBSTETRICS.
13
 inferior  and great sacro-sciatic ligament.   Ascending ramus,
 rises obliquely upwards and forwards; meets descending ramus
 of pubes.  Connexions, to ilium and pubes in acetabulum ; to
 pubes  by  the rami; to sacrum by ligaments.  Planes, inter-
 nally, are smooth; converge;  give foetal head the motion of
 rotation.
   Os Pubis.—Synon., Pecten, Share-bone.   Size,  less than
 two preceding.    Situation, anteriorly.  Divisions,  base or
 body, two rami, spine, symphysis, crest.  Base, thickest, assists
 to  form cotyloid  cavity, one fifth. Horizontal ramus, thin,
 narrow ; breadth,  half an inch ; triangular;  meets its fellow at
 symphysis; its superior inner edge forms part of linea ilio-pec-
 tinea.   Symphysis,  at junction of- the two  pubic bones;  a
 layer of  fibro-cartilage interposed ;  existence of synovial mem-
 brane  doubiful;  mobility  in  woman  questionable; in some
 lower animals unequivocal; the cartilage in  the pregnant state
 said to  be swollen.   Descending -ramus, flat, thin,  narrow;
 direction, downwards and outwards ; unites to ascending ramus
 of ischium ; to external  lip is attached  the gracilis, to internal
 the transversus perinei and pelvic fascia ; to interstice above the
 corpus cavernosum and  erector muscles; below, the prolonga-
 tion of great sacro-sciatic ligament and  the tendon of adductor
 magnus.   Spine, near pubic end of bone ; Poupart's ligament
 attached.   Arch, the  angle formed by rami; in woman, 90°—
 100° ; on its size greatly depends facility of parturition.   Edges
 of rami are bevelled;  assist exit of  head.  Connexions, to ilium
 and ischium, in acetabulum; to ischium, by descending ramus;
 to its fellow, at symphysis.  Four muscles connected to upper
 edge, the oblique,  transversalis,  rectus, and pyramidalis.
  Obturator  foramen.—Synon., F. thyroideum, ovale, sub-
 pubic.   Shape, triangular ; long diameter, down and outwards ;
edges, sharp.  Situation, below os  pubis, anterior to  cotyloid
cavity.  Formed by the  rami of pubes  and  ischium.   Filled,
in recent, by ligament, which consists of two layers of perios-
teum.  At upper part is a groove from within outwards, which
transmits  the  obturator  vessels and nerves.   Gives origin to 
14
MANUAL OF OBSTETRICS.
obturator  externus and  internus.   Object, lightness.  Said  to
be triangular in female,  oval in male ; recently doubted.
  Brim of pelvis is composed by sacrum, ilium, pubes.  Out-
let,  by coccyx, ischium, pubes.   Cavity, by sacrum, ischium,
pubes.  Deformities  of  sacrum are most serious to brim;  of
ilium least.   To outlet, deformities of  ischium are most injuri-
ous, because immovable.
  Articulations,  or Symphyses.—Four, viz. two sacro-iliac,
symphysis pubis, sacro-coccygeal.
  Symphysis  pubis.—Each pubic face is covered by fibro-car-
tilage, thicker in front; the articular  surfaces are covered by
cartilage, and are said to have a synovial membrane.  Secured
by  four ligaments, anterior-pubic, posterior-pubic, supra-pubic,
infra-pubic.   Mobility, doubtful^
  Sacro-iliac . symphysis,  composed  of  articular  faces  of
bones; an intervening fibro-cartilage, one sixth  to one eighth
of an inch thick, and powerful ligaments ; most conspicuous on
posterior part.  Sacrum acts the part of a double wedge.
  Sacro-coccygeal, composed  of  a fibrous disc, like those
between  vertebrae, of  anterior and  posterior sacro-coccygeal
ligaments, and a capsular  ligament, that embraces whole joint.
Motion, ginglymoid.
  Ligaments.—Great Sacro-sciatic, or posterior sacro-
sciatic ligament.   Arises  from posterior inferior spinous pro-
cess of ilium, posterior  tubercles  of sacrum, inferior margin of
sacrum, and border of coccyx; contracted in middle;  inserted
into internal  lip of tuber ischii and-its ascending ramus ; direc-
tion downwards outwards.  Protects internal pudic vessels and
nerves.
  Lesser  Sacro-sciatic  or Anterior.—In  front  of last;
crosses it.  Arises, anterior lip of  edge of sacrum and part of
coccyx; crosses in  front;  inserted into summit  of  spine  of
ischium.   These two ligaments convert the sciatic notch into
two foramina: 1st.  Large,  irregularly oval;  transmits, a mus-
cle,  four  nerves,  three  arteries, and three  veins.   2d. Small
long, triangular, transmits a muscle, artery, vein, and nerve. 
                 manual  of obstetrics.                15

  Sub-pubic or Obturator.—Closes obturator foramen.
  Articulations with other bones.—Superiorly with verte-
bral  column by amphiarthrosis.  Outwardly and  downwards
with ossa femora by enarthrosis.
  Sacro-vertebral by anterior  and posterior vertebral liga-
ments ; the yellow, the intervertebral substance thicker in front,
the interspinous and two synovial  capsules;  also sacro-verte-
bral ligament, ilio-lumbar, and ilio-vertebral.
  Divisions of Pelvis.—GREATER AND LESSER.—
Separated by linea ilio-pectinea.  False and  True.
  GREATER OR FALSE.—All that above  Mnea ilio-pectin.
Shape, irregular.  Anterior wall, wanting in skeleton ; in living,
formed by muscles, &c.  Posterior, formed  by projection of
last lumbar vertebra;  on either  side of which is a gutter for
psoae  muscles.  Lateral, formed  by internal iliac fossae, which
lodge the iliacus internus muscles.
  LESSER OR TRUE.—Situated below linea ilio-pectinea.
Sha])e seen best by removing the ilia by horizontal section; is
then seen to be a curved canal; larger in middle than at extre-
mities.  Ls divided into two straits and a cavity.
  Abdominal or Superior Strait or Brim.—Formed, behind
by promontory and anterior border of alae of sacrum; laterally,
by edge of iliac fossa; anteriorly, by  superior  edge of pubes
and horizontal ramus.  Shapel said to be heart-shaded ; better
a truncated triangle, with base behind, apex in front.   Circum-
ference, fourteen  inches.  Has four diameters:—1st.  Antero-
posterior, or sacro-pubic, or conjugate, or  straight, four inches.
2d. Transverse, or lateral, or bis-iliac, five and a quarter inches.
3d and 4th. Oblique, or diagonal, five inches.   Sacro-cotyloid,
one  on each  side;  from  promontory to  acetabulum, three
inches ten  lines.
   Inferior or Perineal  Strait  or Outlet.—Boundaries,
the  inferior  part of  symphysis  pubis  and the descending
ramus ; the ascending ramus and tuber ischii, by inferior mar-
gin of great  sciatic ligament, and  by the border and  point of
the coccyx.  Shape, oval, interrupted by three osseous projec- 
16               MANUAL  OF OBSTETRICS.

tions.   Circumference, thirteen inches six lines.   Has four dia-
meters:  1st. Antero-posterior, or  coccyx-pubic,  four  inches,
increased to  five by  recession of coccyx.   2d.  Transverse, or
bis-ischiatic,  four inches, immovable.   3d and  4th.  Oblique,
four and three quarter inches, increased by elasticity of sciatic
ligaments.
   Cavity,  the space  between the superior and inferior straits.
Dimensions.—Height in front, one  and a  half inch ; on  sides,
„aree and three quarter inches.  The chord of arc of sacrum,
four and a quarter inches ;  following face of sacrum, five and
a  quarter  inches.   Has four diameters, taken at centre: 1st.
Antero-posterior, four and three quarters to five and one eighth
inches.   2d.  Transverse, four and  three  quarter  inches.  2d
B,ndx$d.\-X)blique, four and three quarter inches.  By dividing
the  cavity equally,  by sections at right  angles, two  sets of
inclined planes are seen, which are supposed greatly to  influ-
ence the changes in direction necessary for the  foetal head to
perform in its descent;  some, however, say that the motion of
rotation is executed  when  the head is below the influence of
these planes.  The  anterior  planes  are directed from without
inwards; from above, downwards;  and from behind, forwards.
   The posterior are from without inwards; from above, down-
wards ;  and from before, backwards.
   Arch of Pubes.—The angle formed by the descending rami
of pubes, and ascending rami of ischium; 90° to 100°.   At
base, is  three to three and three-quarter inches broad ; at  apex,
two inches.
   Base of Pelvis presents, posteriorly, the notch filled by the
promontory of sacrum; laterally, the iliac crests; anteriorly, the
spinous  processes; notches  for muscles and nerves, the spine,
horizontal rami, and symphyses of pubes.
   Apex presents, posteriorly, the coccyx ; laterally, the sacro-
sciatic ligaments and  tuber ischii; anteriorly,  the rami of the
ischium  and pubes.
  Direction of Pelvis  is   not horizontal, but  the plane of
superior strait inclines at an angle  of 55° to 60° from above 
MANUAL OF OBSTETRICS.
IT
downwards, and  from behind  forwards;  its inclination  alters
with position and in gestation.   Advantages of this position,
to prevent protrusion of pelvic contents, and to afford support,
both in pregnant and unimpregnated condition.
  Axis of Superior Strait is a line drawn perpendicular to
the centre of the plane of the strait; terminates anteriorly, near
umbilicus; posteriorly, at union of upper two thirds  of coccyx
with its inferior third.
  Axis of Inferior Strait, a line  from above  downwards,
and from behind  forwards, running from first piece of  sacrum,  #
and falling at a right angle upon the middle of the bis-ischiatic
space.   The axes of the  two straits cross in the cavity, forming
an obtuse angle.
   Axis of Cavity, a curved line parallel to curve of sacrum;
is the curve the foetal head must follow in its expulsion ; " cufve
of Cams."
   By  comparing  the diameters  of brim and outlet, it will  be
seen that a complete change  is effected in the relative lengths,
which  necessarily influences the passage of  the head.  At the
brim, the antero-posterior diameter is four inches ; at the out-
let it may become five.  The  transverse, at the brim, is five
and a quarter; at the outlet,  four.  These changes are effected
by degrees, so that the advancing head  is gradually turned
from  having its  long diameter in the oblique diameter of the
brim to the antero-posterior or  long diameter of the  outlet.

                     other  dimensions.

Between two anterior superior spinous processes, 9£  inches.
Between highest part of crests  of ilium, 10i inches.
From  crista ilii to tuber ischii of same side, 7 inches.
Symphysis of pubes, vertically 18 lines; thickness, 6 lines.
Base of sacrum,  anteriorly posteriorly, 2i inches.
        "       transversely, 4  inches.
Coccyx in length, 11 to 12 lines.
 From sacrum to pubes,  externally, 7  inches.
                             2* 
 18               manual  of  obstetrics.

 From sacro-iliac symphysis of one side, to opposite tuber ischii,
        C inches.
 From sacro-iliac symphysis of one side, to opposite ramus ischii,
        5 inches.
 From anterior margin of sacro-sciatic notch to opposite side,
        6 J  inches.                                      •
 From anterior margin of descending ramus of ischium to oppo-
       site side, 4f inches.
 Circumference of superior strait, 13 to 17 inches.

        differences  of male and  female  pelvis.
            Male.
 Ala of ilium, more perpendi-
   cular.

 Sacrum, straighter.

 Coccyx, earlier united.
 Brim, long diameter, anterior-
   posterior.
 Cavity,deeper; funnel-shaped.
 Tuberosities converge; three
   inches apart;  outlet  less ca-
   pacious.
Arch of pubes, 70°—80°.

 Foram. thyroid., oval.
Depth  of symphysis, at  least
   two inches.
A line drawn from sacro-iliac
   symphysis directly forwards,
   cuts off but little of superior
   strait.

   Recent Pelvis.—The  soft parts entering into the composi-
tion  of the pelvis serve to smoothe angularities, to protect the
AI03 of  ilium, larger,  wider,
   shorter,  lighter.   Capacity
   greater.
Sacrum, shorter, more con-
   cave, wider; not so thick.
Coccyx, more movable.
Brim,  long  diameter  trans-
   verse.
Cavity, more shallow.
Tubera ischii further apart.


Arch of pubes, angle  90°—
   100°.
Foram. thyroid., triangular.
Depth of symphysis, 18 lines.

Cuts off much more. 
MANUAL  OF OBSTETRICS.
19
nerves and vessels during labor, to deaden  shocks in moving,
and at the same time materially change the shape.
  The superior strait is influenced by the iliacus internus late-
rally, by the psoae posteriorly ;  while anteriorly the abdominal
muscles are inserted, which assist in expulsive efforts.
  Superior Strait.—The psoae, rising from the  sides of the
lumbar vertebrae, pass down, filling the fossae alongside of the
promontory, and are inserted conjointly with the  iliacus inter-
nus into  the trochanter minor.  By them the shape is changed
from oval to triangular, with the base in  front; the transverse
diameter is shortened half an inch ; they  can be compressed in
labor, but in very muscular women their action may retard the
process;  they  should  be  relaxed by flexing the thighs on the
trunk.  (In the recent state, the pelvis is widest  between the
ilio pectineal eminences;  the  transverse  diameter being four
inches and some lines, while the bis-iliac is  one and  a half to
four inches; beneath  the promontory,  the transverse is five
inches.— Velpeau.)
   Cavity is influenced posteriorly by the sacral plexus, the
hypogastric vessels, pyramidalis  muscle, and rectum;  ante-
riorly, by bladder, obturator  internus, obturator vessels,  and
nerves; laterally, by adipose tissue; vertically, by the perineum;
composed of two layers,  1st, superior, concave above, formed
by  levator  ani  and  ischio-coccygeus;  2d, inferior, concave
below, formed by sphincter  ani, transversus-perinei, ischio-
cavernosus, and constrictor vaginae.  The perineum closes the
inferior strait; is pierced by urethra, vagina, and rectum.
  Inferior Strait, influenced by sacro-sciatic ligaments, coccy-
geus, adipose tissue, fascia.
  Uses  of the  Pelvis.—A foundation for the trunk; a fixed
point for muscles ; to protect the  pelvic contents  in the unim-
pregnated; to  support the gravid uterus; to direct the foetus in
parturition. Two arches  are formed: a  posterior or superior
by the ilia and sacrum;  an anterior or inferior  by ilia, ossa
pubis, and ischia.  The ilio-femoral  articulation serves as an
abutment to both. 
20
manual of  obstetrics.
  Deformities of the Pelvis,  may influence, first,  the
whole pelvis; second, some parts; third, may modify the incli-
nation, and change the direction of the apertures and axes.
  DEFORMITIES  OF THE  WHOLE.—First, by  excess;
second by diminution.
  By excess, primA facie not objectionable, but is so ; in the
unimpregnated state  the uterus is liable to ante,  or  retro-
version, or prolapse.   In pregnancy,  the uterus falls too low,
and compresses rectum, bladder, vessels, and nerves, producing
rectal and vesical tenesmus, fecal  accumulation, piles, varices,
oedema,  and cramps.   Late in pregnancy, these symptoms
recur with more or less intensity; in labor, the expulsive efforts
may extrude the uterus, may lacerate the cervix or  the  peri-
neum, may cause haemorrhage by premature separation of the
placenta, may rupture cord,  may produce inversion of uterus.
   By diminution, may be uniformly diminished.
   DEFORMITY OF PARTS.—First, by excess; second, by di-
minution.  May affect either  greater or lesser pelvis. The diame-
ters most affected are anterior posterior of the brim, and trans-
verse of outlet.
   Greater Pelvis, affected,  first, by too great curvature of
the  vertebral  column, which  causes  obliquity, and  delays
labor; second, the alae may  be too wide; or third, too narrow.
 .  Lesser or True Pelvis, affected in Apertures, Cavity, or
all parts.
   Of Superior Strait.—Cordiform shape, or  reniform, figure
 OO, triangular, trapezium; more frequently than  any  other
 part.   Antero-posterior diameter most affected, and  all di-
 mensions occur, from four inches to three lines.   Caused,  first,
 by projection of the  base of  the  sacrum; second, by turning
 back of the horizontal rami  of the pubes ; third, by both com-
 bined-  Transverse diameter affected, first,  by  approximation
 of the ilia; second, by projection of  ossa pubis, both of which
 changes  also  increase the  antero-posterior diameter.   Ob-
 lique  diameter affected, first,  by projection inwards of  ilia •
 second,  by  projection inwards of  one side of pubes, while 
manual of  obstetrics.
21
the  other  bulges outward; produces the  "obliquely ovate"
pelvis;  not  uncommon.   A  woman thus  affected may  be
readily delivered if the long diameter of the head presents in
the great oblique diameter, and the bi-parietal in the contracted
diameter;  while the reverse presentation may require instru-
mental aid; in these cases, version  may possibly remedy the dif-
ficulty.
   Inferior  Strait.—Affected, antero-posterior, by  projection
forwards of coccyx, by turning up  the  base of the sacrum;
though a mobile coccyx relieves this.  Transverse, by approxi-
mation of the tubera ischii; is the worst form, because of the
immobility.   Oblique, by  vitiated  direction  of  ischio-pubic
rami.  Arch  of Pubes may be contracted  like male pelvis.
Spine of ischium may curve inwards.  The deformities of the
two  straits may  be compensating; i. e. one enlarged and the
other contracted, and vice versA ; so that labor delayed in one
stage may in another stage be quite rapid.   Sometimes, but
rarely, both straits may be contracted, as when the sacrum has
too  great  a  curvature, the antero-posterior diameter  of the
cavity is increased,  while the same  diameter of each  strait is
decreased.
   Cavity,  affected, first, by turning back  of ossa pubis; second,
by projection  inwards of inter-pubic fibro-cartilage;  third, by
excessive length of  symphysis pubis; fourth, sacrum too much
curved, increases antero-posterior diameter; head rests too long,
or else,  occiput not  advancing,  produces  extension, which
results in face presentation; fifth, sacrum too flat, head cannot
rotate, may cause death of child, or  great compression  of soft
parts of  mother; sixth, by morbid  growths, exostoses, fibro-
cartilage.
   Defective Inclination  of Pelvis.—Usually results' from
deformities.   The inclination may be increased or diminished.
   Causes  of Deformity.—First, and most common,  is Ra-
chitis, or Rickets, a  disease of early life, in which the earthy
part  of the bone is imperfectly elaborated ; second, from Mala-
costeon (Osteo-malacia, Mollities Ossium);  occurs later in life ; 
manual of
obstetrics.  •
the earthy matter is deficient; third, from exostoses, mal-united
fractures, morbus coxarius, unreduced dislocation, anchylosis of
sacro-ooccygeal articulation from inflammation.  Known by.—
Inspection  or Pelvimetry.   A true pelvis  should have well
rounded hips, and of equal height;  the anterior spinous pro-
cess, eight or nine inches apart;  from iliac crest to tuber ischii,
seven inches ; tuber ischii, four inches apart, and on same line.
If the hips are projecting and elevated, or the sacral region flat
or convex, or arch of pubes narrow, or tubera ischii narrow, or
unequal, suspicion  will be excited.   Pelvimetry,  by Baude-
locque's calliper, Coutonly's pelvimeter, or simply by the hand.
By  Baudelocque's, the limbs  are  placed  on  pubes and on
sacrum ; should measure seven inches; subtract two and a half
for sacrum, and one and a half for pubic bones.  For oblique,
place one end on trochanter major, the other  over sacro-iliac
symphysis ;   should measure nine inches;  subtract two and
three quarter inches; plus, twenty lines.  Inaccurate.
  By the hand.—Reach for promontory of sacrum ; if it cannot
be  reached,  the  antero-posterior diameter  is probably suffi-
cient ; exceptions to this rule occur.   Examine height of sym-
physis, width of arch, spines  of ischium, shape  of  the  straits.
Of course, manual examination is permissible only in the mar-
ried, and in  these alone is it likely to be required.   Fortunate-
ly,  American practitioners see  comparatively  few deformed
pelves ;  such abnormalities are almost invariably found among
our foreign population.

       vessels concerned in  obstetrical practice.
  Ext. pudic artery, a  branch of femoral;  course  transversely
inwards ; distributed to labia.
  Gluteal, a branch of int. iliac; course backwards ; emerges
from great sciatic notch.
   Vesical, a, branch of int. iliac.
   Vaginal, a branch of int. iliac.
   Obturator, a branch of int. iliac; emerges  from upper border
of foramen. 
manual of obstetrics.
23
   Uterine, a branch of int. iliac;  is very tortuous ; ascends in
the folds of broad ligament.
   Ovarian, from aorta.
  Int. pudic, branch of int. iliac; emerges through great sciatic
notch ;  re-enters smaller foramen, crosses to the ramus ischii;
supplies the vagina.
  Ischiatic, branch of int. iliac; emerges from greater foramen.
   Veins, usually accompany  the  arteries.  The  external iliac
vein at the brim lies behind the artery.  Pressure produces
oedema or varices.
   Nerves.—Anterior  crural,  arises from second, third,  and
fourth lumbar ;  passes outside of femoral artery ;  distributed to
rectus, etc.  Pressure  on it produces cramps of inner and fore
part  of thigh,  occurring during  gestation.  Obturator,  from
third and fourth lumbar ; emerges from obturator foramina ; dis-
tributed to abductors ; pressure produces cramps of th,e inside
of  thigh, as head  enters pelvic  cavity.  Sciatic, from fourth
and fifth lumbar,  and first, second, and third sacral; emerges
by side of pyriformis ; supplies posterior part of thigh, leg, and
foot; is subject to pressure during parturition, and cramps are
caused in calf of leg and sole of foot; relieved by pressure and
friction, sometimes very severe.   The fourth sacral supplies
bladder and rectum ; hence pressure produces irritation. Pudic
from third sacral;  supplies clitoris and external organs.
   Certain Muscles are  also  interested.  Pressure upon  these
 causes pain on motion and in defecation.
   Levator ani.—Origin, pubes below the brim, spine of ischium
 and obturator aponeurosis ; direction, by  side of vagina ;  inser-
 tion, sphincter ani.
    Obturator internus.—Origin, obturator ligament and around
 obtur. foram.;  direction, tendinous around spine of  ischium ;
 emerges by small sciatic foram;; insertion,  digital fossa.
    Coccygeus.—Origin, spine of ischium ; insertion, coccyx.
    Transversus perinei.—Origin,  tuber ischii; insertion, sphinc-
 ter ani, and vagina, and into  perineum.
    Organs of Generation.—Divided into  EXTERNAL 
24
MANUAL OF  OBSTETRICS.
 and INTERNAL, or better into FORMATIVE and COPULA-
 TIVE.   These may be  divided  into, Essential  and Acces-
 sory.
   Accessory.—Mons Veneris, Labia Majora, Labia Minora,
 Clitoris, Vestibulum, Meatus urinarius, Hymen, Fossa navicu-
 lars, Fourchette.
   Essential.— Vagina,  Uterus, Fallopian tubes, and Ovaries.
   The term Vulva includes all the parts external to the vagina
 embraced by the  labia majora.
   Pudendum is applied to the whole  external genitals.
   Mons Veneris.—A triangular prominence of  fatty tissue;
 situated at lower part of hypogastrium ;  extent, three inches
 broad by two deep; covered by hairs after puberty ;  composed of,
 adipose tissue, vessels,  and nerves from external pudics, by ter-
 mination  of round ligaments, skin,  and . sebaceous glands;
 use, in coitus; subject to, abscesses, eruptions, excessive growth
 of hair.
   Labia majora, or Externa, are two rounded  folds, which
 bound  orifice of  vulva laterally;  direction, from above down-
 wards ; formed, externally of skin, internally of mucous mem-
 brane, with adeps interposed, and vessels, and  nerves from ex-
 ternal pudics ; covered  by, hairs; length, three inches ; thickest,
 anteriorly; in contact, anteriorly; separate, posteriorly ;  their
 union, anteriorly, forms anterior commissure of vulva; posterior,
 post-commissure or fourchette ; use, to protect  inclosed  parts;
 in labor they distend greatly ; subject to, excessive development,
 inflammation, abscesses,  eruptions, pruritus,  encysted tumors,
 lipoma, hernia, varix thrombus, oedema.
   Labia Minora, or Interna,  or  Nymphs, are two membra-
 nous folds, lying between labia majora;  arise,  just  above clito-
 ris ; descend ; terminate,  near middle of vagina ;" shape like a
 cock's  comb; cover, vestibulum, meatus, and part  of vagina;
 unite,  superiorly,  and  form preputium clitoris; composed, ex-
 ternally of mucous membrane ;  internally of erectile tissue • in
 young, are smooth, rosy, and firm ; in old, flaccid and pale' in
fcetal life, salient; use, supposed to be to direct the urine • do 
MANUAL OF OBSTETRICS.
25
not  dilate in labor; subject  to, inflammation,  laceration  in
labor, enlargement, " Hottentot apron."
   Clitoris.—A small elevation, usually about one eighth of
an inch long; situated, at the union of nymphae, the lower edge
of symphysis pubis ; composed of, two corpora cavernosa, which
arise from  the  crura of the pubes,  embraced  by erectores,
ascend and unite below, and in front of pubes, to which  a sus-
pensory ligament  attaches it; terminates, in a glans; covered
by a prepuce, which is continuous with nymphae;  is erectile ;
analogue of the penis, but is imperforate ; vessels and nerves from
pudic; disproportionately large in foetus; use, supposed seat of
venereal  gratification ; doubtful; subject to, enlargement; one
case osseous: is  an element in cases of doubtful sex.
   Vestibulum.—A triangular smooth  space;  bounded,  above
and in front by clitoris, below and behind by urethra, laterally
by nymphae ; length, an inch.   In this space Lithotomy.
   Meatus Urinarius.—A  rounded opening.   Situation,  an
inch below clitoris; diameter,  one fifth of an inch, edges  thick-
ened.   Knowledge  of  its  situation essential  in introducing
catheter.  Rule: Pass the  forefinger into the vagina, press it
gently against the symphysis, then pass an elastic male catheter
along  the palmar  aspect directly in the median line; patient
should be supine, and no exposure should be tolerated.
   Urethra, the urinary canal.  Extends, from meatus to blad-
der ; length, twelve to fifteen  lines ; diameter, one fifth of  an
inch, but very dilatable, so much so as to permit impregnation
in cases of uterus communicating with bladder ; direction, back
and upwards ; variations in direction occur in pregnancy, retro-
version, prolapsus uteri;  separated from  symphysis by  lax
areolar tissue; subject to, tumors,  tumefaction, prolapsus.
   IIymen (Flos virginitatis, Clauslrum virginale).—A  mem-
brane partially closing orifice of vagina.  Not peculiar to human
female.   Composed of,  mucous  membrane, nerves, vessels ;
shape, crescentic  concavity upwards, circular, cribriform;  value
as a test  of virginity, none; other  causes besides coitus may
destroy ;  abnormalities, imperforate, and thus prevent catame- 
26
MANUAL OF OBSTETRICS.
nial discharge, conception, or coitus ; dense, thick, fibrous;  may
embarrass parturition.  Meigs thinks he has seen it at a second
labor.
  Caruncul^e myrtiformes.—Two pairs  of round red tuber-
cles at orifice of vagina;  supposed  to be remains of hymen, but
sometimes  the two organs said  to co-exist; use, supposed  to
increase capacity of vagina in labor; abnormity, excessive de-
velopment.
  Fossa naviculars.—A depression between  the orifice  of
the vagina and the posterior commissure of vulva.   Extent, six
lines.   Generally obliterated  by first labor.  A frequent  seat
of chancre.
  Fourchette.—A sort of bridle, forming the  posterior com-
missure.   Consists of a fold of mucous membrane, meeting the
union of the labia; ruptured in first labor frequently, though
not invariably.
  Perineum.—The musculo-membranous floor of trunk.  Ex-
tends from,  vulva to anus;  composed of, skin, adipose tissue,
aponeurosis, muscles, raphe on median line; extent, from anus to
vulva,  one and a quarter inch, but at instant of head passing,
much more dilated, four  to four  and  a quarter inches ;  use, to
complete the floor of pelvis; abnormities,  too broad, too thick,
too narrow ; the seat of hernia.
  Vagina.—A membranous sheath, extending  from vulva  to
uterus.   Situation, one  and  a half inch  below symphysis;
shape,  cylindroid, anterior wall concave, posterior convex; di-
rection, slightly oblique upwards and backwards; lies nearly in
axis of inferior strait; dimension, from four to six inches long;
one in diameter of orifice; is longer in girls; widest in middle,
most contracted inferiorly; anterior wall the shorter.   Use  to
afford  passage to and from uterus.  Relative anatomy,  ante-
riorly, with urethra and bladder; laterally, with ureters, broad
ligaments, sacral plexus,  levator ani;  posteriorly, with rectum •
inferiorly,  guarded by   hymen;  superiorly,  embraces cervix
uteri, forming a cul-de-sac before and behind  it; of these the
posterior is  deeper, and  hence the  posterior lip of cervix  feels 
MANUAL* OF OBSTETRICS.
27
 longer;  peritoneum  covers superior one fifth, and  is  thence
 reflected on rectum.   Assists to form, in front, the vesicovagi-
 nal  and urethro-vaginal septa; posteriorly,  the  recto-vaginal
 septum.   Inferiorly departs from rectum, leaving a triangular
 space.  Its walls are  in contact, and normally secrete mucus, in
 disease, give rise to " leucorrhcea."   On opening, rugae are seen
 disposed in columns, and  also transverse;  most distinct infe-
 riorly, and in virgin ; smoother by age.   Numerous  follicles
 exist, which  may become enlarged.  Textures: first, mucous
 membrane, pink color, in old yellow or  bluish, covered by tes-
 selate epithelium ; second, areolar tissue ; third, fibrous muscu-
 loid tissue, resembling that of uterus, pearly grey, one and a
 half  Jjnes thick inferiorly, less near uterus;  above resembles
 uterus, below  is more muscular and vascular; a  congeries  of
 vessels surrounding lower 'part exists, and is called plexus reti-
 forme;  fourth, areolar tissue;  fifth,  peritoneum  over superior
 one fifth.  Arteries from, the  uterine, which are from internal
 iliacs.  Veins go to  plexus  retiforme.   Lymphatics, to hypo-
 gastric plexus. Abnormities, variations,  in  length and width,
 double;  cicatrices, callosities, atresia, adhesion, cul-de-sac, im-
 perforate hymen,  inflammation, malignant disease.
   Uterus, OoVepa, jasrpa, matrix.—A hollow  viscus, the use of
 which is to receive, protect,  and expel the product of concep-
 tion.  Situation, in  true pelvis, above vagina, below small
 intestines, behind bladder, in front of rectum;  not  to be felt
 superiorly in unimpregnated state, unless in very thin females,
 for fundus is below superior strait.   Direction,  of  upper
 extremity, upwards and forwards; lower, down and backwards,
 Shape,  like a small pear,  flattened from  before backwards.
 apex  below, base  above;  posterior  surfaces more convex, and
 covered  throughout  whole  extent  by  peritoneum;  anterior
 covered  over  superior  two  thirds.   Divisions, into  Fundus,
Body, Cervix,  and  Os, also two  regions, three margins, three
angles.   Fundus, that part above orifices of Fallopian  tubes,
a few lines high;  body, between fundus and cervix is  the
largest;  neck, below body, ten or twelve lines long;  os, the 
28
MANUAL  OF OBSTETRICS.
 inferior opening in the cervix.  Two regions ; anterior, smooth,
 polished, slightly  convex;  posterior,  more convex.    Three
 margins, the upper convex, assists to form  fundus; two lateral
 margins, irregular convex superiorly; in virgin drawn out at
 insertion of tubes analogous to cornua of  inferior  animals;
 concave inferiorly, located between the two folds of broad liga-
 ment.    Three angles, the two superior, formed  by the  meeting
 of lateral and  superior edges, are  prolonged into the tubes;
 inferior, results from meeting of two lateral margins.   Dimen-
 sions, weight, in virgin, seven to eight drachms; in multipara,
 one  and a half ounces, the result of increased nutrition; just
 before menstrual period, weight is increased; length,  two and
 three quarter to three inches; breadth,  two  and three eighth
 inches; thickness, eight lines; superficies, sixteen inches. Cavity
 of body, shape ; triangular, superior angles  leading to tubes, the
 apertures of which admit a bristle; capacity, about a drachm of
fluid ; usually contains mucus more or less  sanguinolent.  Ca-
 vity of neck, separated from that of body  by a division mark-
 ing  "internal  os  uteri;"  appearance in virgin, plaits, like  a
 leaf called arbor-vitae;  often disappear after delivery; shape,
 oval; length,  eleven to  fifteen lines, five to six broad  ; one to
 two  lines from front to rear.  On this surface are seen ovula
Nabothi, which are muciparous follicles, the office of which is to
secrete  the mucous  plug which closes the  canal of the cervix
after impregnation.  A viscid white of egg discharge indicates
inflammation, and demands use of speculum.   Os uteri or os
 tincce, the vaginal  orifice  of the uterus;  appearance in virgin,
transverse, smooth, regular, small, firm,  thin, close, one to two
lines in  extent;  in multipara, irregular,  deformed,  gaping,
softer, thicker, fissured, especially on  left side.   Gives a sensa-
tion like the tip of the nose.   Most  authors say anterior lip is
longer, but this arises from mode of touching; in autopsies the
lips are  usually found equal.  The  os in normal state is not
sensitive.  Os internum sometimes closed in old.
  Texture. 1st. Peritoneum ;  rises over bladder, covering pos-
terior three-fourths of  it, thence reflected from neck to uterus 
MANUAL OF OBSTETRICS.
29
 and  covers  superior  two-thirds,  then over uterus and  down
 over superior one-fifth  of-vagina, then to rectum; laterally
 forms the broad ligaments ; connexion intimate above, loose
 below.  2d. Areolar  tissue.  3d. Muscular tissue, resembling
 a network of fibres;  color, dirty yellowish  gray, with a tinge
 of red, but  at  menstrual period is deeper red (but the cavity
 of cervix does not participate) ;  is difficult to  be recognised in
 unimpregnated state; resembles middle  coat of arteries; is
 unstriped; neck has more areolar and less muscular  structure
 than body.   As  to  muscularity, it  is  masked  in  unimpreg-
 nated, but  manifest in   pregnant state.  Alleged  layers  are
 the product of dissection.   4th. Mucous membrane ; denied by
 some.  Is not arranged in folds  like mucous membranes gene-
 rally.  Considered mucous from functions, and  action during
 disease; ex. gr. catamenia, haemorrhages, catarrh, decidua, dys-
 menorrhoea,  polypus.  Epithelium is of ciliated variety.
   Functions.—First, to secrete mucus ; second,  to  eliminate
 menses; third,  to develope decidua; fourth, to  receive and
 nourish embryo ;  fifth, to expel foetus.  Arteries, four in num-
 ber, are very tortuous, anastomose frequently;  ovarian, arising
 from aorta or renal supply of the body ; uterine, from hypogas-
 tric go to cervix.  Veins, called sinuses ; have no valves ;  empty
 into  internal  iliac;  increased  greatly  in  pregnant condition.
 Nerves,  not  yet entirely settled.  Robert  Lee says are very
 numerous; first set arising from sacral plexus distributed to
 cervix ; second from  sympathetic.
   Lymphatics.—First  set run  to  lumbar and sacral;  second
 through round ligament  into gioin ;  develope greatly in gravid
 state.  Abnormities, may be wanting, os strictured, or closed ;
 canal strictured ; malformations ;  imperfect development; dou-
 ble ; displacements;  flexious.
   Broad Ligaments  (Alee  vesperlilionis)  are  quadrilateral
folds  of peritoneum ; extending from uterus to sides of pelvis;
divides pelvis into two  compartments.  Three folds;  upper
contains  Fallop. tubes; posterior contains ovary  and ligament
of  ovary ;  anterior  has  the round  ligament; between  these 
30
MANUAL OF OBSTETRICS.
layer; run  the  vessels,  nerves,  and  absorbents,  in  areolar
tissue.
  Round  Ligaments.—Two in number;  arise  on  front of
uterus, a little below Fallop. tubes;  contained in anterior fold
of broad ligament; direction, outwards y from below^ upwards ;
termination, in areolar tissue of mons; appearance, greyish white,
fibrous; length,  six  to  seven inches;  structure,  as observed
during gestation, contains vessels, nerves, absorbents,  areolar
tissue, and some striped muscular fibre.   Use, to support organ
forwards, prevent retroversion, a  point of action during labor;
does not depress uterus in coitu; are more manifestly vascular
during pregnancy or inflammation ; hence over them is a good
place to apply leeches; affected  in  malignant disease; afford
an  explanation  of pains  in  groins  in  course  of uterine dis-
ease.
  Other  Ligaments.—Anteriorly, vesico-uterine; posteriorly,
recto-uterine.  Are merely folds of peritoneum.
  Fallopian Tubes are two cylindrical canals ; calibre, various
in different parts, contracted near  uterus,  expanded towards
ovary, admit a  bristle,  crow-quill;  shape, conical,  flexuous.;
situation, in upper  edge or middle fold of broad ligament;
extent, from lateral angles  of uterus  to near iliac fossa; length,
four inches ;  composed of,  externally, peritoneum, middle mus-
cular, transversely and obliquely, erectile mucous lining, ciliated
epithelium ; termination, fringed, called " fimbriated extremity,"
" morsus diaboli," "  infundibulum," has one fringe  attached to
ovary;  is  erectile;  by stimulus curves over,  and embraces
ovary; tubes enter  uterus obliquely at fundus;  vascularity
manifest in menstruation. and pregnancy ; function to emit
ova, to transmit sfcmen ; proofs  of this by Haighton's  and Bi-
schoff's experiments; also by tubal pregnancy ; vessels, ovarian ;
nerves, hypogastric#plexus, and  sympathetic ; abnormities, im-
pervious, inflammation,  malignant disease.
  Ovaries,  testes   muliebres.—Two oval,  flattened  bodies;
lying in posterior fold of broad ligament, behind and  below
Fallopian tubes;  one and  a half inch from uterus  on either 
MANUAL OF OBSTETRICS.
31
side ; length, one and a quarter to one and a half inch ; breadth,
one half to five-eighths; thick, one quarter ; surface, in virgin
smooth, in old  numerous  fissures, the result  of oviposition ;
superior margin is  convex and loose; the inferior is straight
and attached.
  The ligament of the ovary is a fibrous cord attaching the
organ to the uterus; length, one and a half inch ; is impervious
and dense.  Ovary is composed of, first, peritoneum shining
and exhibiting linear  cicatrices;  is called  also '•' indusium ;"
second, tunica albuginea; the proper  coat is an  expansion of
the ligament; is dense and fibrous.  It forms septa, which tra-
verse the organ forming cells, in which, third, the " stroma," the
true ovarian  structure is found.  The stroma is of pale rose
color, and developes  the ova or  Graafian  vesicles; of these,
there can usually be seen fifteen to thirty, varying in size, but
to microscope they are innumerable; the largest found near the
surface.   (The existence of " stroma" as a distinct form of tissue
is questionable.)  It is  important  not  to confound the vesicles
with the  so called hydatids, which are frequently noticed in
connexion with the ovary.  Blood  is supplied through the ova-
rian vessels,  analogous to the  spermatic  of the male.  The
nerves are from the renal plexuses.  Function to supply ova,
the periodical maturation of which constitutes the effective sti-
mulus  to menstruation.   When  the ovaria are removed the
female  loses  her  sexual  characteristics.   Subject to, entire
absence, few or no vesicles, inflammation, malignant disease,
dropsy, hydatid cysts, displacement.  Examples show  that a
very small portion of, stroma suffices to afford an impregnable
ovum.
  Menstruation is the term applied to the series of  pheno-
mena that attend the  rupture of a Graafian vesicle; usually  is
said to be a periodical, sanguineous discharge from the female
genitals.  It  is a natural function.  An  analogous discharge
attends the period of heat in  some  of the inferior animals.
Synonyms, Menses, Catamenia, Oviposition, Ovi-ponte, Month-
lies, Monthly Discharge, Show, Regular, Time, Periods, Unwell, 
32                MANUAL OF  OBSTETRICS.
" Seen nothing," or otherwise " So," Flowers,  Shedding.  The
appearance of the menses is an evidence of capacity for concep-
tion, but instances  of impregnation before menstruation are on
record; again the discharge has  been known to appear only
during pregnancy.  Age of appearance, usually fourteen ; varia-
tions, nine years,  twenty-four years.  (Two  cases of woman
attaining forty-eight years and never menstruated, though pos-
sessing  sexuality, uteri,  and ovaries.— Oldham.)  Instances of
nine months, eighteen  months,  two  years,  three years,  etc.
(Query.—Should girls ever marry until menstruated?)  Influ-
ence of climate, said to be delayed in cold, to be hastened in hot.
Exceptional cases are found favoring such an opinion, but more
accurate researches prove a decided uniformity of age of access.
Nevertheless, extremes of climate make about three years' dif-
ference.  Mode of life.-^-Is later in country girls  with  labori-
ous and simple habits ;  while  luxurious life, balls, plays, excit-
ing books, pictures, and the use of stimulants, hasten it.   Fac-
tory girls, according to  Whitehead, are not precocious in men-
struation.    Sanguineous temperament  accelerates.  In  some
families, a transmitted tendency  to premature menstruation is
noticed.
  Premonitory  Symptoms, inequality of  spirits, headaches,
lassitude, uneasiness, weight in loins or perineum, pain in back,
tension  in  epigastrium,  pruritus  of vulva, mucous  discharge,
dark shade under eyes, pain in thyroid  body, colicky pains, skin
a peculiar odor, and disposed to eruptions ; congestion of mucous
membranes, as shown by epistaxis, <fec.; irritation  of breasts.
More or less of these  are usually noticed, in varying shades of
severity,  and some may attend each  appearance of the dis-
charge.   To this assemblage of symptoms the term " menstrual
molimen" or " menstrual nisus" is sometimes applied.   Varia-
tions.—Sometimes menstruation commences without precursory
signs.  Not unfrequently the first few periods are irregular as
to time of return  and amount of discharge,  so that the first
period is not a type of future menstrual life.  Effect of Appear-
ance.—-Even before the  menses  appear, the manifestations of 
                  MANUAL OF OBSTETRICS.                33

the approach of puberty are seen in the development of the
mammae, the expansion of the hips, the rounded contour of
the body and limbs, the development of hair on the pubes, the
development of voice, while  the  mental charfges  are  equally
striking; reserve takes the place of forwardness, and the plays
of the child  are exchanged for the pursuits of womanhood.
   Duration, from a few hours to  a week, or even more.  Ave-
rage 4 to 5  days.
   Quantity, usually from 3  to 6 ounces.   Variations are tp
almost any extent.   Change of climate, from cool to hot, is said
to produce excess.   Change from country to  city is said to in-
crease.   Women of bilious  temperament  said to menstruate
most profusely.
   Nature and Color.—Is blood mixed with  vaginal mucus
and uterine  epithelium.   Is thin, and  of a dark venous blood
color,  with  a  faint  unpleasant  odor.   Collected  from the
uterus, it is  alkaline and coagulable ; discharged from vagina,
it is  acid,  not usually coagulable, and contains  lactic  and
phosphoric  acids.   Is  not liable  to decomposition.  The pre-
sumed characteristic of non-coagulability depends entirely .upon
the rapidity of discharge; if profuse, it has  not time to mix
with the acid vaginal mucus, which is the preventing agent to
coagulation.
   Mode of  Discharge, guttatim.   On  the first day, it  is  quite
fluid, less highly colored, and less in quantity ; these properties
gradually become more striking,  and then decline in the same
way.    Many  variations.   Marriage  frequently  changes   a
woman's menstrual habits.
   Return usually every 28 days.  Varieties,  22 days, 20, 18,
15, or 32, 35,  40;  these  varieties are  consistent with  health ;
the most important element being the regularity of return.
There  are also variations in individual cases.  Some women
constantly anticipate their period  ; others are subjects of retard-
ing menstruation.   Instances  of  one year, or even two years'
interval occur.
   Cause, the maturation  of  a Graafian vesicle; cause of the
                             3 
34                MANUAL OF OBSTETRICS.
 periodicity, not known farther than this.  Menstruation depends
 on the ovaries ; the proof is, that when these organs are absent,
 diseased, or removed, even if the  uterus  be normal, the cata-
 menia are absent, or cease ; while even though the uterus be
 absent, the menstrual molimen will give evidence of the ex-
 istence of ovaries.
   Seat, usually from cavity of body of the uterus, not of neck;
 sometimes  vaginal, as a compensating discharge.   Proof of
 uterine origin, in Procidentia, Inversion, Occlusion of Os, by
 speculum.
   Source, the uterine capillaries by rupture.
   State of uterus, arteries and veins distended ; uterine tissue
 looser, more pink ;  os more  patulous ; Fallopian  tubes more
 vascular ; hypertrophy of mucous membrane like decidua.
   Cessation, usually at 45  to 50 years.   Variations, 3G, 30,
 26, 24, or 55,60, 70, 91.  Varies with general health,  number
 and kind of  pregnancies, trials, and  perhaps  precocity, or
 otherwise, of first appearance.
   Duration of menstrual life about 30 years.  A difference of
 one or two years only in hot and cold climates.
   Period of final cessation, called also " change of life," " turn
 of life," » critical time or age," « dodging time,"  menopause.
 Evidences, flaccid mammae;  cheeks flaccid,  wrinkled;  skin
 yellowish ; eyes lose brightness ; sometimes a quasi-beard!
 #  Influence on Longevity.—Vulgarly is  supposed to be a critical
 time.   Women disposed  to cancer  are  liable to develope it at
 this time, but this risk is more than compensated by the absence
 of the perils of childbirth.   Fewer women than men die be-
 tween  40 and 50.
   Varieties  in mode of cessation, sometimes gradually some-
times excessive at one time, and then scanty ; cease and'return
even at considerable intervals ; irregular in  time and quantitv'
by a mucous discharge'.                                    } '
   After cessation the health is established on a firmer basis
   " Reciprocal influence of acute disease and menstruation —1st
All acute diseases exert a pretty similar effect on menstruation' 
MANUAL OF OBSTETRICS.
35
2nd. This influence varies accordingly as the disease is  deve-
loped during an epoch or during an interval.   3rd. In the first,
the menses are usually suppressed completely or incompletely,
and may reappear after some hours or days, usually diminished.
\th. In the interval, if the next epoch is near, menstruation is
favored by the increased  hemorrhagic condition of the organs.
5th. The  menses are usually absent, or notably diminished, at
the periods that occur during the decline of disease or in con-
valescence ; lasting from  one  to three months.  6th. The men-
strual eruption nowise predisposes to disease.  1th. It exerts no
appreciable influence  on  the  issue of acute febrile, affections.
8th. No  special  therapeutical indication  in  the treatment of
acute febrile disease is derivable from the  state of the menses,
and we  must act  without reference  to  menses.  9th. Blood-
letting does not in general prevent  their appearance or con-
tinuance.   10th. Suppression  by acute febrile disease, or con-
secutive amenorrhcea,  does not, in general, call for special treat-
ment."—Herard.
   Disorders of Menstruation, in four ways. OBSTRUC-
TION,  SUPPRESSION, MENORRHAGIA,  DYSMENOR-
RHEA :  Some add  a fifth,  VICARIOUS OBSTRUCTION ;
more usually AMENORRHEA  is applied  to  cases in  which
there is no catamenial discharge.  The maturation and  elimi-
nation of ova, however, are essential features in the function, as
much so  as the discharge.  But every failure of manifestation
of this evidence of puberty at the usual  age, is not  to be re-
garded ;;s a disease;  for we  meet with girls not menstruated
at 17 or  18.  Nevertheless, such cases  frequently come  under
the notice of  the practitioner, and require judicious  advice, to
prevent improper attempts to force the processes of nature.  In
such  cases, it is important to  ascertain  whether the general
health is suftering from the delay, before interfering ; and also
to ascertain whether the other evidences of puberty have begun
to manifest themselves.
   Again, the non-appearance may be due to malformation, and
accurate  investigation is necessary to determine its nature; for 
36
MANUAL OF OBSTETRICS.
while some abnormities are  remediable, others are beyond the
reach of art.
  It may depend, 1st. On absence of ovaries by extirpation, or
from  atrophy occurring.   Recognisable,  by the  unfemiiiine
mind, coarse voice, hair on chin, masculine figun., undeveloped
mammae, indisposition  to  sexual  indulgence, absence  of men-
strual molimen.
  This condition not remediable.  Should not marry.
  • 2nd. On  certain  deviations of uterus, absent, or extirpated ;
distinguished from first,  by menstrual  nisus occurring, and
presence of sexual characteristics.   Two classes present.
  a. Occluded os prevents  exit of fluid.  Sometimes from cauter-
ization.
  b. Occlusion of  vagina.  Sometimes follows  severe  labor;
indicated by  menstrual molimen  and no flow;  tumor felt per
rectum and over pubes;  sometimes fluctuation.  Imperforate
hymen.
  If unrelieved, terminates fatally by rupture of uterus, or tube,
or gradual  breaking of health.
  Operation.—Introduce a finger into rectum and a .catheter
into bladder; scalpel and  trocar.
  Use bandage to abdomen.  Wash out vagina with tepid fluids.
  Danger from peritonitis.—Is apt to close; requires careful
use  of bougie or cylindrical speculum.
  Imperfect development of uterus—irremediable.
  Functional Amenorrhoea, is to be regarded not so much as
a disease, as a symptom of constitutional derangement, or lesion
of the organs, on which depends  the  stimulus of the uterine
function ; viz. the ovaries.   Hence,  in  treating of it,  more at-
tention is to be given to its producing cause, than to the mere
absence of the function.  Nevertheless, inasmuch as we yet see
obscurely the causes, we must treat effects.
  Two forms  recognised.  1st.  Entonic, or Sthenic, or Active.
2d.  Atonic,  or Passive.
  Entonic form, occurs in those in whom plethora is combined
with irritability. 
MANUAL OF OBSTETRICS.
37
   Symptoms, headache of upper and back part; flushing of
face;  active circulation ; hot skin ;  pain  in  back, loins, legs;
pruritus of genitals.  Sueh symptoms  manifest themselves in
paroxysms, with rigors; lumbar, sacral, hypogastric, and femoral
pains; sometimes a leucorrhceal discharge.   In the  interval
pretty good  health is enjoyed.   If unrelieved,  -the patient's
digestion  becomes  impaired;  spirits dull;  lethargic;  com-
plexion pale ;  constipation occurs;  headache and ' backache
constant; hysterical  paroxysms.   Passes into  Atonic  form,
which is considered under the head Chlorosis.
   Treatment, when simply delayed.—First, relieve any general
or functional derangement.   If weak  and  delicate, give  the
various preparations of iron, with full  diet.   If  plethoric, use
light  diet, gentle  exercise, and alteratives, or salines.   Better
at home than at school.  These failing,  more decided measures
are justifiable, as noticed hereafter.
 .  Of Entonic Form.—Sometimes a moderate venesection Coin-
ciding with menstrual nisus may be of service, but it is important
to recollect that some amount of hyperemia is necessary for men-
struation.  Better than general blood-letting is the application
of leeches; the best situation is near the vulva ;  if these are not
to be had, cupping to the loins, or sacrum, will be serviceable;
and if the withdrawal of blood is not indicated, dry cups  will
be useful for  revulsive effect.  Follow these with  the hip-bath,
sinapised or not; and repeat this for three or four nights every
four weeks.   Large sinapisms to breasts and thighs alternately
at same periods ; left on but for short time.   Pediluvia sina-
pised. Poultice over hypogastrium  if there is pain—linseed
and laudanum.
   Aloetic purgatives may be used at these times.
   In  the intervals, the bowels should  be kept free by laxatives ;
of which  the best  is Aloes in its various preparations, Mass
Hyd., also Magnesia.
   Free ablution, followed by the flesh-brush, or by towel, soaked
in  brine and dried,  is useful.
   Attention to regimen is of paramount importance.
                            3* 
38
MANUAL OF OBSTETRICS.
  Strict and systematic attention  to exercise, which should be
taken daily, and, if practicable, always in the open air.   Walk-
ing is preferable to riding, though horse exercise is very useful,
both for mental and physical effects.
  Exercise should  not be taken early in the morning, without
some  trifling  aliment "  to  stay  the  stomach ;" never imme-
diately after a full meal;  never to fatigue.  Increase gradually.
  Plethora is  better subdued .by exercise than by purging.
  Diet should be light, unstimulating.
  Mode  of life  should be  regulated ; a  steady employment,
which should  not be  sedentary, but active, so that exercise, as
a task, shall be studiously avoided.
  Travelling  forms an excellent adjuvant to stricter  remedial
measures.  Low miasmatic  districts should be avoided.
  If advice be requested as to marriage, the cause of non-ap-
pearance forms an important element in the decision.
   CHLOROSIS, is  a disease marked by a " pale yellowish
green complexion, languor,  debility, depraved  appetite,  with
occasional nausea or  sickness, and disorder of the sexual secre-
tions ; generally occurring about puberty or soon afterwards."
   It is a blood disease, the  most striking  peculiarity being the
deficiency in red corpuscles  ; the standard 127 in 1000 may be
reduced  to 60, or  even 40,  while the water may increase from
 790 to 915.
   It  is not a disease of the uterus, but the usual attendant
 amenorrhcea is a mere symptom of the morbid state of the blood.
   Is most frequent in girls about the age of puberty ; some-
 times occurs in married, especially widows;  and has its ana-
 logue in the feebly-developed of the other sex.
   Predisposing Causes.—Feeble, undeveloped constitution ;
 residence in damp, miasmatic countries;  insufficient, unwhole-
 some, watery, vegetable  food ; acid drinks; inattention to di-
 gestive functions ; excess  in warm bathing ; tight lacing ; factory
 life, amid high temperature  and noisome  smells;   sedentary
 occupations.
   Exciting Causes.—The main one is the approach of puberty. 
MANUAL  OF OBSTETRICS.
39
(To change  the girl into  the procreative woman, requires  an
exercise of vital  energy that demands all the powers of the
system; if the attempt fails, the health deteriorates, and the
girl  is left  an invalid.)   Depressing passions; disappointed
affections; menorrhagia;  excessive  venery; manustupration; . <
constipation.
  Symptoms,  may be  described as  incipient  and confirmed.
Often comes on insidiously ; marked by gradual loss of strength ;
susceptibility to influence of cold; chilliness;  languor; indis-
position to exertion ; dulness of spirits, with listlessness,  and  in-
clination to solitude;  derangement of alimentary canal; con-
stipation ; appetite capricious and irregular.
  As disease progresses, it is marked by pasty and harsh dry
skin ; hands and feet cold and clammy; exercise fatigues, and
causes palpitation and dyspnoea; pulse quick, weak, and com-
pressible ;  tongue  white  and pasty;  breath  offensive;  sleep
disturbed  and  unrefreshing;  headache,  and pain in the side,
most commonly the left hypochondrium.  Auscultation detects
an anemic systolic bruit along the aorta  and great vessels.
  Fully developed, the skin has the  peculiar  yellowish dirty
green color, is  husky, and scales off; lividity is  shown under
the eyes and oedema; tongue pale', flabby, indented, or smooth
and glossy, rlssured ; extremities cold ; ankles cedematous ; ap-
petite depraved, and craves chalk, slate-pencils, pickles  (Pica) ;
nausea;  cardialgia; sadness, and  disposed to insanity, melan-
choly ; finger nails brittle, and disposed to split; skin husky,
scaly; hair dry, foxy, and falls  out; pain in side; sometimes
a cough ; constipation alternating with diarrhoea, stools some-
times ochrey ;  emaciation ;  oedema ; hysteria ;  hemorrhages,
epistaxis,  hemoptysis, hematemesis, melena, occur.
  Towards  close, inflammatory diseases are sometimes simu-
lated ; sudden  and violent  pain  in head or  side,  sometimes
with hot  skin,  and bounding pulse, with pain on pressure;  in-
duce incautious to treat for inflammation of brain, pleura, spleen,
or peritoneum.
   Patients sometimes die suddenly, and no lesion is found. 
40
MANUAL OF OBSTETRICS.
  Sometimes effusions are found in the arachnoid, pleura, peri-
cardium, or peritoneum.
  Phthisis, however, is the great outlet  of chlorotic life; tho
spanemic state highly favoring the development of tubercle.
  Diagnosis, mainly resembles Anemia, or rather Spanemia ;
but this may result from other and organic diseases ; hence it
is necessary to seek whether the cachectic state is  the result of
chronic hepatic,  splenic, renal disease; or  of digestive organs,
of which  pallor is  a characteristic.   A  curious anaesthesia of
one side of the  body is said to occur in Chlorosis, but not in
simple Anemia.
  The most  important error is, the  mistaking the  pseudo-
inflammatory symptoms,  and treating erroneously  for  these.
Again, the effects of vs. often deceive ;  apparently at first bene-
ficial, it only aggravates, and, if repeated, destroys.
  Look carefully to history, constitution, and physical signs.
  Prognosis, is always chronic; is usually cured unless com-
plicated ;  fatal  from  associated  organic  lesions.   Unfavorable
symptoms are, cough, dyspnoea, emaciation, oedema, effusions,
hemorrhages.
  Treatment.—Indications are to remove  the cause, and to in-
duce the formation of normal blood.
  Remove the  patient from the influence of miasmata, and
sleeping  in low  damp apartments;  change occupation and
mode of life.
  Then regulate  the  alimentary canal by  laxatives  and diet;
Aloes in  its various  preparations, Vinum Decoctum, Tinctura,
Tine.  Comp., Aloes et Guaiac,  Aloes et Assafet., Pil. Aloet.
Comp., Pil. Prand.
  When  the tongue is clearer, and  bowels are free, conjoin
Iron with Aloes, Tine. Ferr. Mur., Vinum Ferr., Mist. Ferr.
Comp., Carbonate, Iodide,  Sulphate, Acetate, Lactate, Citrate,
Persesquinitrate, Pulvis Ferr., or " Quevenne's Metallic  Iron,"
Vallet's Mass, Iron  with  Myrrh,  Carb. Ferr.,  Pulv.  Myrrh.
et Pulv.  Zingib., Sulp. Ferr. et Sulp. Quin.,  Ferri  et  Potass.
Tartcas. 
MANUAL  OF OBSTETRICS.
41
  The milder  preparations of Mercury, as Pil. Hyd., or Hyd.
cum Cret., are sometimes advantageously conjoined with Aloes,
to regulate the secretions, but salivation is to be scrupulously
avoided.
  All  drastic  cathartics are  objectionable.  Where Iron pro-
duces headache, heat, and dryness of the skin, with flushes of
heat, stop it;  and substitute vegetable tonics, as infusions of
Calumb., Gentian, Quassia, Anthemis, Quinine.  Diet to be full
and nutritious ; travelling useful; chalybeate waters of service ;
sea-bathing  also advantageous, and  if the cold  salt bath can-
not be borne, as shown by producing persistent cold, chilliness,
headache, and  languor, after its  use, a hot salt bath is bene-
ficial, followed in both instances by free friction,
  Flesh brush useful; hot salt pediluvia.
  For cold feet, a tea-spoonful  of Cayenne  Pepper shaken up
in the stockings,  and  worn, will counteract.  It is of service to
change both shoes and stockings during the day.
  Clothing to be warm, and  gauze flannel, or merino, next to
the skin.
  Exercise is  essential;  walking  and horseback  the most
useful.
  With these  means the catamenia will frequently, perhaps
usually, occur spontaneously.
  If the menstrual effort is apparent, it should be aided by the
means spoken of under Obstruction.
  By  some Tine. Cantharid, is favorably regarded, beginning
with  doses of 30 drops  three times a  day,  and pushed lo
strangury.   Tine. Guaiac  Arainon. has  been lauded.   Gal-
vanism may be of service.
  The pseudo-inflammatory symptoms are to be treated; Blis-
ters kept on  to redness ;  Sinapisms ;  Turpentine ; sometimes
Cups or Leeches used  with  discretion ; Aconite; Veratria;
Chloroform externally ;  a liniment of Chloroform, Aconite, and
Olive  Oil,  covered  or not  with oilskin, is a useful  counter-
irritant.  Internally, Narcotics  are the most reliable.
  SUPPRESSION   OF   MENSES;  disappearance  of the 
42
MANUAL OF  OBSTETRICS.
menses;  independent of pregnancy, lactation, or menopause.
Two forms, Acute and Chronic.
  Acute, when the result of some suddenly applied cause.
  Chronic, resulting from continued application of some per-
sistent cause.  May cease suddenly or gradually.
  Acute.—Is caused mainly by cold or mental emotion.  No
cause is  more common than wet feet, produced accidentally,
or, as is  sometimes foolishly done,  by design.  Cold by iced
water, ices,  insufficient  clothing, bathing, &c.   Emotions, as
fear, grief, anxiety, also operate.  Violence, by drastics, emetics,
falls, blows,  coitus during flow.  Diseases, as fevers and acute
diseases.   A very common cause is recognised in  immigrants
in the sea-voyage and concomitants.
  Symptoms  will  vary in  different  cases.   In young and
plethoric, congestion, or even inflammation, may result;  a sen-
sation of weight,  and  pain  in head and loins; tension, and
acute pain in uterine region, increased by pressure,  and indica-
tive  of inflammation of uterus, ovaries, or ligaments; short
breathing; hot skin ; full, hard, rapid  pulse; hysteria; deli-
rium ; apoplexy ; epilepsy; transient paralysis ;t inflammation
of brain, lungs, or alimentary canal;  aphonia  and  nervous
cough;  vertigo;   headache ;  retention  of urine;  sometimes
vicarious hemorrhages;  sometimes rapid effusions  of serum
into the great cavities, which  may be fatal.
  Pathology, metritis; ostincae tender, and also hypogastrium.
  Diagnosis, by history.
  Treatment. Two indications.  1st. To treat existing symp-
toms.  2nd. To restore the menses.
  If inflammation actually exist, a moderate venesection of six
or ten ounces,  followed or  superseded  by leeches  to  vulva,
and  warm semicupium.   CC  to sacrum, and  bath.  Active
purging.   Fomentations.  Enemata.
  The Acute form may occur, and more frequently does, in
delicate,  nervous,  irritable females.  In them the  symptoms
will be less  indicative of inflammations, but abdominal pains
may occur;  fits of hysteria and  syncope will  be  more marked 
MANUAL OF  OBSTETRICS.
43
features. In these cases vs. is inadmissible, and even leeches are
not usually advantageous.  Active purgatives, but not drastics ;
warm baths ; sinapised baths and poultices ;  with antispasmo-
dics by  mouth, or rectum,  will  constitute treatment.  These
means failing, as they  often do at the period,  reserve active
measures till next month ; meanwhile give Aloes twice a week,
avoid cold, keep the feet warm, avoid emotion, use  exercise on
horseback, or by swinging, &c.  As period approaches, increase
Aloes; sinapisms to breasts, or  loins,  or  thighs;  pediluvia;
semicupia,  &c.
   Chronic Suppression, may result from an acute attack, or
gradually, as the effect of some permanent irregularity in the
secreting power of the uterus, as ill health, organic disease, &c,
preventing the maturation of ova by the ovaries;  organic dis-
eases of the uterus or ovaries;  change in mode of life; a sea-
voyage is a frequent cause.
   May disappear gradually,  with  a scanty, irregular, painful
pale, serous discharge.  Sometimes a painful monthly nisus, but
no discharge;  sometimes leucorrhcea s.upersedes,which, at first,
may be periodic, but becomes continuous and persistent.
   Symptoms, connected with the head are noticed, in vertigo,
headache, muscae volitantes,  dilated pupils;  with the surface
irregular, heat and chills, dryness, susceptibility to cold ; bowels
constipated from loss  of muscular contractility; urine abun-
dant and limpid;  thoracic dyspnoea, palpitation,  wandering
pains ; appetite  depraved.
   Treatment, essentially the  same as for Chlorosis, into which
this often merges.
   Emmenagogues;  are  medicines which are supposed to
excite the uterus to the production of the menses.
   Whether such remedies exist, independent of  the improve-
ment that may be effected in  the general health, is problemati-
cal ; still it has  been deemed advisable to present a summary
of such medicaments.
   Value.—If deficiency of ovaries or uterus,  or malformations
exist, they never do good.  If puberty is slowly developed, and 
 44               MANUAL OF  OBSTETRICS.

 no menstrual discharge occurs, it is improper to employ any
 other than  the  mildest emmenagogue.  In  ameiiorrhcea, with
 dropsy, or phthisis, or in Amen, with uterine plethora, they in-
 crease mischief.   If the uterus is inactive, puberty having been
 established, and neither plethora nor debility exists, they may be
 used.  May be useful in delicate, irritable, and hysterical, after
 tonics have failed.  Used in chronic suppression, unconnected
 with organic disease.   Are contra-indicated  by plethora, loaded
 bowels, fever.  Premise diet, purging, and local depletion.
   Two  Classes.—Local, Constitutional.
   Local.—Electricity, in pallid and  weak, after  improving
 general health.   Pass through the loins  and  pubes.  Not
 usually  effectual alone.
   Galvanism by Electro-magnetic truss.
   Leeches to qs,  of service in congestive state.  Apply through
 a Speculum, and push up with cotton..
   Sometimes enter os, remove by salt water.
   Sometimes applied to the vulva, thighs, or knee.
   Cups to sacrum, either dry or wet.
   Stimulating injections, Aq. Amnion. 3ss. to milk Oss.   To be
 useful, must cause slight tingling.  Not to  be used in uterine'
 congestion.   Begin three days before expected period.  Retain
 with napkin.  Injections into cavity are hazardous.
   Sinapised baths are amongst the most useful  means ; Seini-
 cupium, Pediluvium.
   Sinapisms to sacrum, thighs, or mammae.
   Fomentations, and sitting over hot water.
   Stimulating enemata per rectum ;  01. Tereb. ; Aloes.
   Iron, exceedingly useful in  anemic and delicate.   Before
 using it, regulate the  alimentary canal; the tongue should be
 clean, bowels regular, secretions healthy.  If its use-is followed
by headache, giddiness,  flashes, quick full pulse, stop it, and
substitute  a  vegetable tonic.  Commence with small doses, and
expect to continue its use for a long time.
  The compounds of vegetable  acids  are less apt to offend the
stomach than of mineral. 
MANUAL  OF OBSTETRICS.
45
  Preparations, Acetate, Tine. Dose, gtt. xx.;  Carbon as grs. v.
—3ss.;  Citras. grs. v.; Ammonia? Citras. grs. v.;  Ferrocyani-
dum grs. iij.;  Ferr. et Potass. Tartras. grs. x—3ss.;  Ferr.
Ammoniatum grs. iv.—xij ;  Ferr. Tartarizat. grs. v.—x. ; Ferr.
Iodid. gr. j.; Syrup. Ferr. Iod. gtt. xx.—L.; Lactas Ferr. grs. ij.;
Liq. Ferr. Nitrat. gtt. x.; Mist. Ferr. Comp. ^ss.;  Phosphas. grs,
v.—x.;  Pulvis  Ferr. or Quevenne's Metallic Iron grs. ij.—vj.;
Rubigo Ferr. grs. v.—9j.; Pil. Ferr. Carb.; Pil. Ferr. Comp.;
Sesquioxid.  3ss.; Sulphas, gr. j.—iv.; Tine. Ferr. Mur. gtt. x.—
xx.; Valerianas gr. j.; Vinum ^ss.—%].
  Ergot, in relaxed and debilitated, especially if a  nisus is
marked.  Give 10 drops  of the Tincture thrice  daily for a
week; if no effect,  stop.
  Strychnine, said to be serviceable ; dangerous.
  Madder,  rarely used.
  Savine, injurious in plethoric and irritable;  suitable for feeble
and languid.
  . Tansy, in common use;  in infusion, unobjectionable ; in oil,
dangerous.
  Nitre, has some effect.
  Aloes, one of most efficient.  Preparations,  Pulvis Aloes,
Dose, grs. v.—x.;  Decoctum ?ss-.—?ij.; Extractum grs.  v.—
xv.; Enema ad-libit.;  Pilul. Aloes  grs. v.; Pil. Aloet. Comp.
grs,  v.—xv.; Pil. Aloes  et  Ferr. grs. v.;  Pil. Aloes et Assaf.
grs. x.—xx.;  Pil. Aloes  et  Myrrh,  grs. x.—xx.; Pulvis Aloes
et  Canell  grs. v.—xv.;  Tine.  Aloes  3ij.;  Tine.  Aloes et
Myrrh.  3ss— 3j.; Vinum, 5ss.—gij.; Pil. 1'randii.
  Tinct. Cantharid., applicable to  leucophlegmatic, inirritable
habit with slow languid  circulation, not in nervous.   Give 80
—60 drops thrice daily, and carry  up the  dose to  strangury.
   Tinct. Guaiac. Ammon., highly praised by Dewees, not so ser-
viceable in other hands.   Can be used  in more delicate consti-
tutions  than Canthar.   Thirty drops thrice daily  in milk.  If
it purges, mix Tine. Opii, or  Sol. Sulph. Morph.; if constipates,
give Pil. Aloet.  Continue for six weeks.  If a nisus occur, aid
it by pediluvia, <fec.
                               4 
46
MANUAL OF  OBSTETRICS.
  Seneka, praised by Chapman ; but little used.
  Chloroform, has been affirmed to have effect.
  VICARIOUS  MENSTRUATION.—A discharge, generally
of blood, from some other part than the uterus;  superseding
menstruation, and sometimes periodical.
  Occurs  usually  in the unmarried; and if in the married,
conception is rare.
  Nature, usually blood, sometimes leucorrhceal.
  Seat, Nipples,  Ears, Gums,  Umbilicus, Bladder,  Axilla,
Ulcers,  Wounds.  Any part of skin or  mucous  membranes.
Occurs as Epistaxis, Hemoptysis, &c.
  Symptoms.—Local pain.   Hysteria.
  Causes.—Suppression of accustomed secretion ; plethora.
   Prognosis.—Rarely, if ever fatal.  Usually recover.
   Treatment.—If there are premonitory symptoms, and no ple-
thora contra-indicates, use Emmenagogues. If uterine engorge-
ment, use Leeches locally.  Sometimes an  active Aloetic purge
will anticipate and prevent.
   Sinapised semicupia useful.   If sudden and  severe, use
mineral acids, Acet. Plumb,  et Opium ;  Ergot; 01.  Tereb.;
 Tannin; Gallic Acid.
   MENORRHAGIA.—Metrorrhagia. Is profuse,  prolonged,
 and too frequent  menstruation ; either  type separately, or all
 conjoined.
   But  all women do not menstruate alike ; a discharge normal
 in one  female, may be menorrhagic in  another ; each has her
 own standard.  Dewees knew a woman  regular two thirds of
 her menstrual life.
   Climate  exercises an influence ;  hot increasing the flow, and
 vice versa.
   Occurs, 1st, as connected with a plethoric; 2nd, with an ex-
 hausted state : hence divided into, 1st, Active; 2nd, Passive.
 (But in reality excluding tumors, polypus, and cancer ;  menor-
 rhagia rarely exists  for a  continuance, without inflammatory
 disease of the cervix, or body, unless at the cessation : the divi-
  sions recognised depend upon the effect of the hemorrhage on 
                  MANUAL OF OBSTETRICS.               47

the constitution ;  sometimes under the  influence of  transitory
causes, profusion is noticed for one or two periods, but this is
not permanent)
   Active or Acute, occurs in early  life;  and in robust;  but
is  quite rare.
   Symptoms ;  for some days are noticed  headache, hot skin,
full pulse, flashes of heat, pain and weight in the back, hips, and
pelvis.
   When the discharge occurs, relief ensues.
   At the following period, the same  premonitory signs occur;
and the same relief ensues;  and the normal type is resumed,
or exhaustion is produced by the repetition.
   Passive form ; much more frequent.
   Causes,  assigned ; hot rooms, frequent abortions,  uterine
leucorrhoea, delicacy of constitution.
   (Most usually, some uterine or ovarian lesion will  be recog-
nised by vaginal examination; which, in the married, is indis-
pensable in  prolonged menorrhagia; and, even  in  the virgin,
is  advisable'under certain restrictions, whenever anemia threat-
ens existence.   Such  lesions are found to be inflammation, con-
gestion, enlargement of the body or cervix of the uterus; endo-
uteritis ; ulceration of cervix ; sub-acute oophoritis said to be
a  common  cause.   Congestion of the  portal  circulation, con-
nected with hepatic or abdominal lesions, will  produce menor-
rhagia.)
   Exciting Causes ;  blows, falls, excessive venery, long walk,
constipation, prolonged  lactation.  Most frequently occurs in
the married ; often originating after  Abortion or Labor ; hav-
ing its cause in ulceration of the  cervix, with or without disease
of the body of the uterus.
   Connected with pregnancy, menorrhagia usually  has its seat
in ulceration of the cervix ;  and such discharges are often mis-
taken for returns of regular menstrual periods.
    When  about to cease, the menses are often profuse and  irre-
gular ;  the result of congestion and ulceration  of the cervix.
   The mode of flow, may be  either in  gushes, or continuous ; 
48
MANUAL  OF OBSTETRICS.
 the first being severer in its immediate, the latter in its perma-
 nent, effects.
   The old distinction  between menstruation and  menorrhagia,
 as depending on the absence or presence of clots, is erroneous ;
 the slowness or rapidity of  discharge allowing  or preventing
 the mingling of the dissolving element, the vaginal mucus.
   As it progresses, the health breaks, and the symptoms are
 those of Anemia,  often with Hysteria.   The  pseudo-plethoric
 signs are evinced  in  the pain  in the head, flashes of heat, tin-
 nitus aurium, throbbing carotids, &c.; or pain in the left side
 and dyspnoea, with hot skin  and  sharp pulse;  derangement of
 stomach and bowels; palpitation  of heart,  and  threatened
 syncope ; hysterical  mania; oedema, anasarca, and  effusions
 into serous cavities;  tuberculous developments often  ensue.
 Late in life  malignant uterine disease.
   The Diagnosis  requires only  a  study of the history, and
 vaginal  examination.  Polypus uteri will be thus recognised,
 also ulceration, &c.
   The  most  dangerous error is, in mistaking  the pseudo-
 inflammatory symptoms of Pleuritis, Phrenitis, &c.
   Treatment varies with form, also  at the period, and the in-
 terval.
  The  first  step  is to regulate  the posture, which is to be
 strictly  and unhesitatingly horizontal, if the discharge is at all
 severe.
  The bed to be hard; the  covering light; all sources of ex-
ternal stimulation removed,  as light, friends,  <fec.; the  drinks
cool, iced lemonade, Elix. Vitriol  in  water, " Cream of Tartar
Punch,"  iced water.
  Venesection in the active form  may be  practised to a  mode-
rate extent, gvj. to gviij.; but if the  affection is of some  stand-
ing, avoid venesection.
  Purgatives  are  valuable;  avoid   drastics;  salines useful,
S'eidlitz  Powder, Bitart. Potass.,  Rochelle Salt, add a minute
portion of Tart. Antim. if much excitement.
  Digitalis is too uncertain and dangerous. 
MANUAL  OF OBSTETRICS.
49
   Ipecacuanha, in doses of half a  grain  or one grain every
 three or four hours, is useful.
   Nit. Potass. 3j.—3ss.; in Barley water 3ij.
   Lead and Opium.   After  the force of  the circulation  is
 reduced,  and  the  bowels unloaded, this is  a most valuable
 remedy.   To be  used  boldly, but  not continued  too long.
 Acet. Plumb, grs. j.—v., with Opium, gr. 1—£, every three
 hours.   If severe, use a pill of Lead, grs. v., to Opium,  gr. iss.,
 every two  hours,  for three doses,  then diminish.   Solution,
 objectionable from  its nauseating properties.   If rejected from
 the  stomach, use  the combination  as  an enema  with  starch,
 Acet. Plumb. 3j., Tine.  Opii 3j.  For vaginal enemata, other
 astringents are preferable to Lead ; ex. gr. Alum.
   Ergot is useful, if  the flow is rapid.   Tincture 3j.  every half
 hour till pain in the back is produced.
   Tine. Cannabis Indica, has been highly recommended.  Dose
 5 drops.
   Tannin, in doses of l to 5 grains;  and Gallic Acid,  in 5
 grain doses, are valuable astringents.
   Tine, of Matico, recently used.
   Oxid. Argent., in doses of gr. £ to grs. ij., is useful where no
 inflammatory action exists ; it  blackens stools.
   Savine, in powder, has been  recommended.
   Vaginal injections, are useful; Sol. Alum 3j.—Oj. may be
 used during  the flow.  Cold water if vagina is irritable.   To
 be efficient, the  injection must be given in  the horizontal posi-
 tion, the hips elevated, and  the posture maintained.
   Injections of the cavity of the uterus have been  practised.
 A solution  of Alum, 3ss.—Oj. is made, and of  this 3ij.  in-
jected through a bougie introduced into the uterus.  Is  appro-
 priate only to extreme cases ;  is  dangerous from fluid passing
 through Fallop. tubes, causing  peritonitis.  There is  no  fear of
" too sudden a check" in using remedies.   If pain ensues,  fol-
lowed by expulsion of clots, it is a  favorable .sign.   Cold to
vagina, by pieces of ice, is  preferable to use of cold  cloths on
the hypogastric region.
                            4* 
50
MANUAL  OF OBSTETRIC o.
  Cold enemata per rectum, are  useful both  for direct effect,
and also unload bowels.
  In the use of cold it is well, unless the hemorrhage be ex-
cessive, to wait until the normal duration of the catamenia has
passed, lest, if the physiological afflux be checked prematurely,
congestion or inflammation ensue.
  The Tampon, as a last resort, is permissible, but probably in-
stead of a vaginal plug, it would  be better and neater to insert
a few pieces of cotton into the os uteri through the aid of the
speculum ; to  these should  be attached a thread, by which
they may be withdrawn.  Sponge will answer.
  An excellent local astringent, is a piece of alum, two inches
long by one in diameter, pressed against the cervix, and  suf-
fered to remain 24  hours.   I have  known it cause intolerable
irritation.
  Blisters to the sacrum are  useful as derivatives ;  and should
be  kept  open with Ung. Sabiu. alone or with Cantharides.
Ung. Antim. Tart.
  If much reduced, stimulants are required ; of which Carb.
Ammon. with  Mist. Camph. is  one  of the  best.  Brandy in
various forms.
  During the interval, improve the  general health and equalize
the circulation.  An emetic,  followed  by alkaline alternatives,
then give light tonics.  Keep the  bowels regular ; avoid coitus;
cold hip bath, followed  by active friction ; sea-bathing;  open
blisters over sacrum ;  cold  injections; wear  flannel next the
skin ;  avoid too much  clothing about the  hips;  avoid the
wearing of " skirts" maintained in situ by cinctures around the
waist.
  The various preparations of Iron  are of service for improving
the general  health, and thus retaining  the  flow  adapted to
anemic cases.   (See page 44.)
  About  the period  of cessation,  in some  cases, the uterus
seems  to assume a  function vicarious of the liver; the portal
circulation being congested.  After  resisting ordinary treat-
ment, such cases yield to brisk purging. 
MANUAL OF OBSTETRICS.
51
  If inflammation of the cervix obtains, care as to diet will be
requisite;  too generous a diet will oppress the stomach.  In
some cases of this kind, a few leeches to the cervix, after the
discharge  has ceased, may prevent a recurrence of hemorrhage.
Scarification and free cauterization, with Nit. Arg., will be use-
ful in cases connected with ulceration.
  Diet and exercise are of primary importance.
  Diet  to be easy of digestion  and nutritious; eggs, oysters,
light meats.
  Exercise within the bounds of fatigue; walking or carriage ;
avoid horseback; avoid swinging.
  DYSMENORRHEA.—Painful and difficult menstruation.
  In  this disease, the  usual symptoms  of menstruation are
greatly exaggerated; the  pain in  the head  is distressingly
severe, compared at times to the sensation  of an iron band en-
circling the head ; the pain  in the sacrum, or extremity of the
coccyx, is  agonizing, and extends to the pubes and thighs ; some-
times convulsions occur ; not unfrequently the breasts are irri-
tated and painful; and  finally  the discharge supervenes with
relief.
   May occur in plethoric, or in nervous and exhausted ;  most
frequently in old maids ; more  in maids than  in married; de-
livery usually  cures,  though dysmenorrhoeic women are less
liable to  conceive.   Severity of symptoms will vary with state
 of the system, whether plethoric or otherwise.
   Causes.—Usually from cold at the menstrual epoch ; shocks
 to the nervous system;  sometimes no  assignable cause ; occa-
 sionally a constricted os or  cervix, as set forth by Mackintosh.
 Not  unfrequent  after the new relations incident to  marriage,
 depending on ulceration.  Even in virgin state, ulceration may o
 cause it.  Dysmen. is a prominent and  ordinary sign of inflam-
 mation and  ulceration of cervix.  Sub-acute ovaritis a not un-
 common  cause.  Occasionally it is noticed after labor.
   Symptoms.—General  restlessness; heat of  system ; flushed
 face;  chilliness; pain, weight, and oppression of head ; pain in
 the back, coccyx, pubes, thighs, sometimes constant, but more 
52
MANUAL OF OBSTETRICS.
usually paroxysmal, and  sometimes so severe as  to  produce
syncope; the pain in the back may alternate with  pain in the
head ; the pain is not equally intense at every period, varying
with hygienic and  normal causes ; sometimes it lasts a day or
two, sometimes through the period ; fatigue, anxiety,  and ex-
citement increase  it;  if  plethoric, tenderness is noticed in
hypogastrium;  tympanitis is not unfrequent in this, as also in
other menstrual difficulties.
  After some time, the pain becomes  " bearing  down,"  and
the discharge ensues, not usually profuse, but scanty, shreddy,
and  membranous; it gradually increases in quantity  and the
pain diminishes, but  usually the amount is less than  normal,
sometimes in gushes.
  Occasionally a substance is expelled in shreds, in membrane
or sac, as described by Morgagni and  Denman, which is but
the exaggeration,  under the influence of inflammatory excite-
ment, of the deciduous membrane that occurs normally at the
menstrual period; the expulsion  of this  gives rise to  the  dis-
tressing uterine tormina.  These casts do  not  occur  at  each
period, and are comparatively rare.
  When the period is over,  a sense of exhaustion is left, from
which the system  recovers more  or less completely until the
next epoch, when the symptoms  recur,  and under reiterated
attacks the system succumbs.  In some women the effects are
less discernible; in some, and these are the young  and  ple-
thoric, but little influence on the general health is produced.
Not  so, however, in the nervous and  irritable; in them the
effects are more decided ; exhausted by  the  recurring- parox-
ysms the strength fails, the health becomes  shattered, the di-
gestive organs become deranged, the appetite capricious, cache-
mia ensues,  leucorrhcea,  sometimes amenorrhcea  occurs, also
hysteria; with health, strength, and appetite gone, the woman
falls a prey to phthisis, or general exhaustion.  All menstrual
disorders are apt to awaken phthisis in the  disposed.
  Women  subject to Dysmenorrhoea, are liable to cancerous
development after  the cessation. 
MANUAL OF  OBSTETRICS.
53
  Pathology. —Some  say Neuralgic:  some  Inflammatory-
Inflammation of body, or cervix uteri, common.   Physical im-
perfection  of cervix,  contraction of os internum.  Sub-acute
ovaritis.  The decidua, and the dysmenorrhceal  membrane, are
structurally identical.  As  in pregnancy, ovarian  congestion is
followed as a sympathetic action by engorgement of the uterus,
and by a rapid development of the uterine mucous membrane;
so in membranous dysmenorrhcea, a primary morbid congestion
and irritation of the ovary calls forth a local determination of
blood to  the womb, congesting it,  and occasioning  a similar
enlargement of the uterine follicles.  As the mucous membrane,
when thus altered by the glandular growth, never shrinks again,
but is cast off as a deciduum, leaving the uterus bared of mucous
membrane till it is reformed ; so in Dysmenorrhcea, this change
of its membrane is followed  by exfoliation in shreds, fibres, or
moulds ;  and this moulting occurs monthly.
  Diagnosis, mainly from abortion, which it resembles in pain,
bloody discharge, and membrane ; differs in history.   Patients
with Dys. not unfrequently pass a period or two, and then a
profuse discharge occurs with pain, closely simulating abortion.
No inference can be  drawn from the  coagulability or fluidity
of the blood ; this depending on the rapidity of discharge.  The
sac of Dys. is said to be less  dense, and less flocculent exter-
naHy, than the true decidua.    As to the  absence  of the ovum,
it may occur from its dissolution of embryo, if small.  Frank
says,  if discharge precedes  pain,  it  is  abortion ; Dys.,  vice
versa ; confirmed by Lachapelle.
  Treatment; that for paroxysm—and  that for  interval.
  For Paroxysm.—If  plethoric, leeches to vulva, or  cups to
sacrum, followed by  hip bath, and  sinapised or simple  linseed
poultice to  hypogastrium; confine to bed ; Ipecac, or  Ant.
Tart in nauseating  doses, with' Spts. Minder., Pill of Hyoscy-
amus. grs. iij., with Camph. gr. j. every two hours  ; Ext. Bellad.
gr. \, with Ipec. gr.  ss. every two  hours; Starch and Lauda-
num Enema, excellent;  Chloroform  inhaled,  or Chloroform
with  Camphor internally;  Pulv.  Doveri; Lupuliue;  Lactu- 
54
MANUAL OF OBSTETRICS.
carium ;  Conium ; Musk ; Valerian.   If  more  decided  effects
desired, Opium, Sulph. Morph., Acet, Morph.
  Suppositories of Opium, Ilyoscy., Belladonna.   Opium is the
surest anodyne, but its constipating properties render it not so
advisable in  ordinary  cases.  If there  is  a distinct  effort to
expel coagula, Ergot may be of service.
  Some  advise Colchicum and Guaiac.
  (Some formulae.  R£ Gum. Camph. 3ij. ss., Ext. Bellad. 3ss.,
Sulph. Quinin. 3ss., Ft.  pil. 80.   One every two hours.   Rj.
Sulph. Quinin. grs.  iij., Prussiat Ferr. grs. iij.   One  such pill
three times a day during interval).  Tine. Guaiac. Amnion.
  In the interval, attend to  general health.
  Girls suffering from constitutional dysmenorrhcea should not
be sent to boarding schools.
  Mackintosh called attention to contracted €fs, as a cause of
Dysm.   In many cases will be found a longer and more project-
ing cervix, of  a  peculiar conical shape ;  also a contracted state
ofOsand canal of cervix.
  This state is relieved by dilatation, and thus sterility is some-
times cured.
  For  dilatation, probes, metallic bougies, and sponge tents are
requisite.
  Directions.—Pass in axis  of superior strait, if point becomes
entangled, " humor" it;  a  kind  of  nauseating  sensation is
experienced when the  fundus is  reached ;  intervals about five
days.  During this  mode of treatment coitus should be avoided,
lest pregnancy, and  subsequent -unintentional abortion, should
ensue.
  Leucorrhcea.—" Whites ;" " a light  colored discharge
from the female genitals, varying in hue from a whitish or
colorless to  a yellowish  light  green, or to a  slightly red or
brown;  in consistence, from a  limpid  serum  to a tenacious
ropy substance ; and in quantity, from a slight  increase of the
healthy secretion to several ounces in the 24 hours."  The old
opinion was  that it was  a catarrh of the  uterus and vagina,
but we now know that the discharge is merely a symptom of 
MANUAL OF OBSTETRICS.
55
irritation, congestion,  inflammation,  or ulceration of  cervix.
Ulceration does not always exist.
   Sometimes, but rarely, a catarrhal affection.
   Divisions.—Acute and Chronic.
   Acute.— Causes. Cold; local  irritation,  by coitus or pes-
saries ; violence;  piles; calculus.  Acrid injections may  con-
vert chronic form  into acute.  Important to recollect that coitus
may cause, and thus in newly married character may be saved.
   Symptoms.—At first itching, heat, sense of fulness, weight in
pelvis, pain  in urination ; sense of bearing down, relieved by
sitting still, more by lying; swelling if from injury; febrile
symptoms.  In continuance, a  thin  acrid  discharge  occurs,
which soon becomes thick and  more  bland, and relief ensues ;
but the sense of bearing down and of weight increases.
   Terminations.—Resolution or Chronic.
   Chronic ; or  Sub-acute is usually a sequel of Acute, some-
times primarily in leucophlegmatic.
   The almost invariable cause is ulceration of cervix. Assigned
causes : hot baths, working in hot rooms, coitus, frequent labors,
pessaries, accumulations  in- rectum, cold, too free living, preg-
nancy, abortion, dysmenorrhcea, said  to be endemic in parts of
Europe.
   Diagnosis, from Gonorrhoea only;  and this at present is im-
practicable ; the two  discharges do not differ in seat, have no
appreciable  difference in appearance, as to  cessation  during
menses it affords  no proof, as to contagion  both are capable of
producing a urethral discharge.   The only ground for diagnosis
is the character of individual;  and this, with all its fallacies, is
the~only  reliance.
   Treatment.—Requires to be adapted to each form and to con-
stitution.  If acute  and no ulceration, use  antiphlogistic mea-
sures, leeches or cups, and hip bath ;  afterwards saline cathar-
tics,  and  repeat  them.   For married,  use  vaginal injections,
tepid  water, Sol. Acet. Plumb., flax-seed tea, &c.
   Continue treatment for some time; cold  injections for two
or  three  months;  avoid  over-exertion; keep bowels free; 
56
MANUAL OF  OBSTETRICS.
food light; dress lightly, and Hot too much about hips ; avoid
coitus rigidly.
  In Chronic, make early examination for'ulceration, and treat
that if it exists.  If cervix is healthy, attend  to general health,
to bowels, to appetite, to anemic state, and  use vaginal injec-
tions.
  If it resists these measures, use Tine. Canth. pushed rapidly
to strangury; if it  fails, do not repeat it.   Copaiba;  Tinct.
Mur. Ferr.;  Lugol's Solution, Ergot.
  Local.—Blisters dressed with Savine to sacrum; astringent
injections; Sol.  Alum. 3j. to %iv.;  Sol. Alum. 3ij., Sulp. Zinc.
3j.  to  3j.;  Infus. Querc. Alt. §j.  to  3j.;  Tannin  3i. to 9j.,
Sol.  Nit.  Arg.  3ij., 3ij. to 3j.; Green Tea, Ciuchona,  Log-
wood,  Ergot,  Catechu,  Aq. Rosar.,  Goulard,  Infus.  Galls.
Sponge wet with solutions and  pushed up  against os.   Medi-
cated pessaries.
  Commence with weak infusions or solutions.
  Always wash out with water before using injections.
  Position recumbent; introduce slowly.
  Oak bark will produce accumulations of coagulated albumen;
Alum will coat vagina.
  Stopping suddenly is  not injurious unless the case b"e ill
chosen ;  ex. gr., congestion of cervix.
  Shower bath  to loins and  " pickled towels."
  Open air exercise.
  Ulceration and Congestion of Os Uteri, is the true
pathology of the vast majority of cases of so-called Leucorrhoea.
Exists  in virgin, in  non-pregnant,  and pregnant, but most in
multiparas.
  Much dispute recently as  to  existence of true ulceration;
usually do not find, loss of substance, but merely abrasion.
   Causes.—Coitus ; imprudence during menstruation, as work-
ing/standing, walking, lifting, &c.; very frequently from pre-
mature efforts after  abortion  or  labor, a pathological state  is
induced, which want of care  developes into  ulceration.
  Symptoms.—Most usual is leucorrhoea, which varies in quality, 
                  manual of obstetrics.                57

mucous, purulent, starchy ; in color milky, greenish, yellowish,
brownish ;  often'tenacious  masses of mucus, like  starch made
with cold water, come away.
  " Falling of womb" (a  frequent  expression)  is denoted  by
pain in back and loins, increased  by exertion; pain in sury
pubic region; heat in vagina; coitus painful, sometimes fol-
lowed by blood ; menses disordered, painful, and often scanty ;
bowels irregular, constipation and diarrhoea ; bladder irritable ;
pain in left side a common attendant.
  Vaginal examination.—Position on back; covered completely;
aperture in sheet for speculum.
  Examine first with finger,  find cervix lower  than normal;
lips large and tumid ; especially anterior, soft, spongy, hotter
than adjacent part;  if ulcer, there is  a feeling  different  from
rest of cervix, said to be velvety ; pressure shows tenderness,
though not always.
  Specula.—Varieties of, glass, metal; in shape, cylindrical, bi-
valvcd, tri-valved,  quadri-valved.  In  using, always introduce
finger first to find exact position; use cotton or lint  to  clean
surface of cervix ; not always easy to engage cervix.
  Varieties of ulcers.—In  size, from pea to half dollar; may
extend into cervix.   In appearance, bright red, deep red, deep
red  granular and  bleeding, whitish patchy, with base coated
and edges angry.
  Authors  make  divisions.—Granular,  cockscomb, bleeding,
superficial erosion, varicose ulceration,  fissured ulcer, follicular.
  Constitutional symptoms assume all  varieties of dyspepsia,
hysteria, neuralgic pains, cough, dyspnoea.
  Prognosis.—Probably no  disease so  severe in effects is  so
easily cured.
  Treatment.—If  congestion exists,  use leeches freely;   or
equally well  scarification, by cutting freely across  in different
directions, just through mucous membrane.  Hip baths, warm,
to follow depletion ;  emollient injections ; saline purgatives re-
peated every three or four  days ;  rest  and perfect sexual  absti-
nence imperative;  blister  to sacrum, kept open ; cold  injec-
                             5 
58
MANUAL OF OBSTETRICS.
 tions.   Locally, iodine in  ointment, or vaginal suppository ;
 Tannin.  Attend to general health.   If  ulceration exists with
 congestion,  treat latter first  by leeches  or  scarification; then
 use Nit. Argent, in substance to  surface of  ulcer, repeat every
 six days.   Other caustics are, acid nitrate of mercury ; caustic
 potass. ; actual cautery.  Collodion  used to form artificial sur-
 face.  If ulceration detected during  pregnancy, this state does
 not interfere with treatment.
   Adhesion may follow caustic.
   Reproduction.—Comprises, 1st. Generation, or the forma-
 tion of  the germ.   2d. Fecundation, or  the vivification of the
 germ.   3rd. Conception, the retention  of the  vivified  germ.
 4th. Gestation, or pregnancy.  5th.  Parturition, the expulsion
 of the ovum.
   FECUNDATION depends on some action of a fluid secreted
 by the male, exerted on an ovum maturated by the female.
   Office of the  male.—1st, To elaborate the  semen;  2nd,
 To bring it into contact with the germ.
   Semen  is a thick, tenacious, whitish  grey  fluid, nearly in-
 odorous when pure, but of a peculiar smell as ejected.  Con-
 sists of,  1st, A viscid fluid (liquor seminis); 2nd, Spermatozoa;
 3rd, Cells which  form  spermatozoa  (granula seminis).   Or  of
 albumen, salts of phosphoric  and chlorohydric  acids, and an
 animal substance, spermatine.  The  relative proportions  of its
ingredients differ with age; and in inferior animals with season.
  In the  young  few or no spermatozoa are found;  while  in
vigorous and  mature  the whole  mass seems  made of them.
The cells are seen in birds at the commencement of the pairing
season, also in lambs.  The spermatozoa were at first thought
to be animalcula,  but  they have no organization ; they are
mobile particles, moving from side to side,  and also  progres-
sively, resemble vibratile ciliae; the mobility is retained seven
or eight days in the female organs.
  After coition, the semen traverses the  Fallop. tubes, reaches
ovum, and fecundation, ensues in the  outer third of the tube.
  Of the office of these bodies : they have been supposed, Is*. 
                   MANUAL OF OBSTETRICS.                59

 To penetrate ovum and form  some  constituent part, as  the
 cerebro-spinal  axis.  A single observation by M. Barry is  ad-
 duced to favor the idea of penetration.  2nd. Thought to assist
 in  converging sperm  to ovary.   3rd. That the  mobility is
 essential to the vitality of the fluid.
   Of the mode of action of the semen on the ovum, nothing is
 yet known, whether by endosmosis, catalysis, &c.  The sper-
 matozoa are essential to procreation ; proved by experiment.
 They differ in appearance in  different animals; but those of
 kindred genera resemble; consists of a broad part or head, and
 a long  tapering tail; dimensions, ji„  to 3-^ of an inch.
    Office of the female is more complicated,  and extends over
 more time.  1st,  To eliminate ova; 2nd, To afford a nidus
 for their development;  3rd,  To  expel the  product  of con-
 ception.
   This  process extends over about thirty years ;  is co-extensive
 with menstrual life.
   Graafian vesicles are small eysts ; shape, round ; containing
 a fluid  ; size, varying from  a pin's  head (as seen by the un-
 assisted eye), to a  large pea, according to progress towards ma-
 turity ;  the largest are  nearest the surface;  number, 15 to 30
 to naked eye.  Negrier says they are found quite early  in life ;
 in old are not seen.  Consist of two coats intimately adherent;
 the outer adheres  loosely to the stroma by soft cellular mem-
 brane, in which the vessels ramify;  is called the  "tunic of the
 ovisac;" the inner is vascular, is called the  "ovisac ;"  within
 each vesicle is a layer of granules, covered by a tenacious fluid,
 is called tunica granulosa ; within this layer is an albuminous
 fluid; in this layer, just where it is in contact with the peritoneum,
 is the ovule.  The ovule  is rounded and very minute, ~- of a
 line;  consisting of  a  vitelline  membrane, yelk granules,  the
germinal vesicle,  and germinative dot or spot.   The vitelline
membrane is an elastic, thick hyaline structure;  it is filled by
the vitellus, a  granular  viscous mass.  The  germinal  vesicle,
discovered  by Purkinje,  is seen within the vitellus as  a clear
spot, Jff of a line in diameter.   The germinative dot, discovered 
60
MANUAL OF OBSTETRICS.
by  Wagner, exists usually  single,  rarely double, within  the
germinal vesicle.
  Mammalian ovule first described  by Von liner, of K'onings-
berg, in 1817.  It appears as a dark sphere, the vitellus, sur-
rounded by a ring, the vitelline membrane.
  Graafian vesicles rupture independent of coitus, and ova are
discharged into the tube, as  demonstrated in animals, and very
recently by Letheby in two  human females.
  When successful coitus occurs, the germ is fecundated in the
tube, and  certain  changes  ensue;  before- its arrival in  the
uterus, a nidus is prepared for its reception and development.
  In the uterus, at each  menstrual period, the mucous mem-
brane is hypertrophied and  cast off;  but on the occurrence of
conception, the development is greatly exaggerated, the expul-
sion occurring subsequent to parturition.  To this change the
title decidua is applied.
  Membrana-Decidua,  called  also  caduca,  ankistous  mem-
brane.—Is independent of the presence of an ovum, as shown in
extra-uterine pregnancy,  though not invariably.
  The glandular utriculares become  elongated, enlarged, and
contorted,  their secretion increases, the vessels of the mucous
membrane  become larger  and more numerous,  a substance
composed of nucleated cells  fills up the interfollicular spaces in
which the  blood-vessels  are  contained.  The effect  of  these
changes is an  increased  thickness, softness, and  vascularity of
the mucous membrane,  which  itself forms  the membrana-
decidua.
  The structure exists over  the internal surface of the uterus,
except the cavity of the  cervix, but extends into  the oviducts.
At  an early period  of gestation it is readily detached ;  as it be-
comes more vascular, hemorrhage occurs when it is separated.
Is thickest during  two first months.   Its outer surface, when
detached, is spongy  and flocculent;  its inner,  smooth, with
striae and  depressions which  lead into canals.
  The ovum enters the uterus, and  becomes  imbedded in the
soft decidua; by a new action, excited  by  its presence at its place 
MANUAL OF OBSTETRICS.
61
of contact, a prominent ring rises over and incloses it, constituting
the " decidua refiexa," so called to distinguish it from decidua
vera.   As  the  ovum grows, a new structure developes itself
between the ovum and the uterine wall, called " decidua sero-
tina."  In  young ova, examined in the  uterus, both decidua
vera and reflexa are found ;  but in  aborted ova this is not the
case, a portion is retained in utero.   As the ovum grows, both
the decidua vera and reflexa are brought into contact, and  at
the third month the  cavity between them is obliterated.
  To return to the ovum.   The ovarian  ovule  exists  in the
Graafian vesicle, having in all mammalia the following essential
parts, viz.  1st, The vitelline sac or zona pellucida,  a structure-
less bag, which is seen in the fowl's egg inclosing the yelk;
2nd, Within  this  the yelk, consisting  of  fat globules  and
nucleated cells;  also, 3rd, The germinal  vesicle ;  4th, Within
this vesicle the germinative dot, which is a cell with a nucleus;
in some ova several nucleated cells exist,  as in those of fish.
  Lining the internal  membrane of the G. vesicle, is a layer
of nucleated cells, forming a kind of tunic, called the membrana
granulosa; this surrounds  the ovule.   At one part the cells
are more  numerous than elsewhere, forming the proligerous
disc.
  About the time the ovum leaves the ovary, the germinal
vesicles disappear, and also the germinal spot.  The cells  of
the membrana granulosa, near the ovum, become club-shaped,
and  subsequently  quite round.   The yelk also contracts, and
leaves a clear space between  it and the  zona pellucida.   As the
ovum  approaches the middle of the  oviduct, an albuminous
substance forms on the exterior- of  the zona pellucida ;  at the
lower part  of the tube it becomes thicker, and is converted, to-
gether with the zona pellucida, into the chorion.
  During  its passage  along the lower  part of the tube, the
" cleaving of the yelk" occurs, breaking into 2 parts, 4, 8, 16,
32, 64, &c.   Each  segment contains a transparent vesicle.
The cleaving ceases about the time of  the ovum reaching the
uterus, and it now resembles a granulated mass.
                            5* 
62               MANUAL  OF OBSTETRICS.

  Soon  each of these  segments becomes surrounded with a
membrane, and thus converted into a cell; these cells arrange
themselves into  a kind of secondary  vesicle, the  " vcstcula
blastodermica" or germinal membrane ; this rapidly becomes
thicker,  and within its substance shortly appears the first trace
of the embryo.
  The time occupied in the transit of the ovum from ovary to
uterus in the human  female, is  probably eight to ten days.
Coitus, to be successful, must probably occur within this period
after menstruation, or else a few days before a period.
  Changes by Impregnation.—IN THE OVARY AND
TUBES, vascular turgescence;  one  or  sometimes both  tubes
firmly embrace their respective ovary,  and  the corpus luteum
remains.
  Corpus Luteum.—A yellow body found  in the ovary after
oviposition ; either connected with, or independent of impreg-
nation.
  At each menstrual period one or  more Graafian vesicles
mature, protrude from the surface of ovary, rupture, and  be-
come filled with blood.  If successful coitus  occur  near this
period, impregnation ensues; a yellow  body of some consider-
able persistence remains in the ovary, the true corpus luteum :
if no  vivification occur, the ovum is discharged, and perishes,
leaving in the ovary a yellow body, which rapidly changes, and
is known as the corpus menstruale, the corpus luteum of virgins,
or,  as it is sometimes styled, a false corpus  luteum.   The con-
nexion of the formation of these bodies with simple menstrua-
tion is  a result  of quite  recent investigation,  and perhaps is
not yet definitively settled.  It is believed that at each menstrual
period an ovum matures, approaches the surface of the ovary,
producing a well marked  protrusion,  it distends the tunica
albuginea, pushes it aside for a space, so that the final rupture
involves the peritoneal coat alone.  At what period during the
flow rupture occurs, is not known ; probably at the termina-
tion.  The  appearance of the vesicle depends on the size  and
on  the quantity of blood effused at the time of rupture, influ- 
MANUAL OF OBSTETRICS.
63
enced by the vital  energy of the female.   Soon  after the rup-
ture, the corpus begins to form ; the proper membrane  of the
vesicle becomes hypertrophied, the growth being a soft, yellow-
ish, friable substance, and the membrane folds upon itself, pre-
senting convolutions.   The blood effused into the cavity  left by
the escape of the ovum, has its fluid part absorbed, and becomes
pale.  The vascularity of the surrounding parts continues, and
at three weeks after menstruation the corpus menstruale is com-
plete.  It is then  recognised  as a prominence on  the ovary,
ovoid in shape, with a small linear cicatrix marking the site of
the peritoneal rupture ; is soft and yielding ; has no cavity, but
an  internal  coagulum,  grey or greenish, which is in contact
with the yellow wall;  this wall is quite thin.  The yellow de-
posit  consists  of granular  cells  with  oil globules, and is the
growth  of the proper  membrane of the vesicle; it has not  a
lining membrane, but has an external, transparent, vascular
membrane, which  dips between the  convolutions.  More exter-
nally still, are vascular layers of areolar tissue, which formerly
surrounded the G. vesicle.  The substance of the corpus is not
vascular.  After three weeks  the corpus menstruale  begins to
retrograde; it diminishes, the  coagulum  is absorbed, and  it
collapses laterally; the color becomes a brighter yellow, which
depends on  the presence of oil;  it becomes softer and less con-
voluted, and a faint, whitish, stellate, central cicatrix is left.   In
about eight weeks it exists as a simple compressed sac.   In
connexion  with these  ovarian  changes, at each  period  the
uterus forms and expels a decidual coat.   Several corpora men-
strualia  may  be seen  in various stages of retrogression under
favorable circumstances.  The corpus luteum of pregnancy, in-
stead of reaching  its maximum  of development in three weeks,
continues to develope, and is found  after parturition.   Other
corpora are  not found with  it, for the function of the ovaries
is suspended during  gestation, and  new vesicles do not pro-
trude.   The  external wall is more  thick, firm, and  highly
organized than in the corpus  menstruale.   The color is differ-
ent ;  not bright yellow, but of a dull hue, and the central coagu- 
64
MANUAL OF OBSTETRICS.
 lum is whitish.   It is not known when it reaches its maximum
 of development, probably between three and six months.  It is
 slower in development than corpus menstruale, and more per-
 sistent ;  is more highly organized internally ; its  convoluted
 wall may be £ inch thick;  is not so bright yellow ; is not in
 company with unruptured vesicles in process of active develop-
 ment.
   Some obscurity still  shrouds this subject, from the rarity of
 favoring circumstances for its study ; and this fact will be more
 obvious  when  we  consider the short existence of the corpus
 menstruale, that grave disease always suspends the ovarian func-
 tion, and that death during menstruation is of only occasional
 occurrence.  Recent investigations, however,  have  sufficiently
 shown that the presence of a yellow body in the ovary, is no
 longer to be regarded as an evidence of pregnancy.
   CHANGES  IN  UTERUS.—First effect is congestion.  The
 Decidua is formed.   The uterine  vessels enlarge, and form an
 intricate network ;  the tortuous  course more seen ; they do not
 return to their  ante-impregnated condition, for  their coats are
 thickened;  the  calibre  of the arteries is less than that of the
 veins,  the effect of this  is  to  retard  circulation.  The veins,
 called sinuses, have thin coats, and increase greatly in diameter,
 sufficient to admit the finger.
   The uterine  tissue is soft, succulent, and relaxed;  is more
 manifestly muscular.
  The lymphatics are easily traced in latter months.
  The nerves are enlarged.
  In dimensions, from a length of 2f inches, breadth of If, and
 thickness of 1 inch, with a superficies of 16 inches, the uterus
 developes gradually to 12 or 14 inches long, 9 to 10 broad,*8
 to 9 thick, and  superficies 339 inches.   Its virgin capacity is f
 inch ; at term, 408  inches.
  The increase  in size is  not dependent on attenuation of its
 walls ;  for the three first months the walls  augment  a little; at
five months they are as before impregnation ; at term the organ
is thicker at site of placenta thau elsewhere, thinner at neck. 
MANUAL OF OBSTETRICS.
65
   In weight, the increase is from eight drachms to two or even
 four pounds.  The increase begins in the fundus, then  in the
 body, lastly the neck is flattened down ; the posterior wall in-
 creases most rapidly.  By  these changes  the shape becomes
 " pear-shaped," subsequently ovoid.
   In Position.—At first the uterus sinks, the os is lower than
 normal; fundus is tilted back:  this occurs most with multipara?
 of lax fibre.  During first three months is in pelvis, the  fundus
 at fourth month felt just above symphysis;  at fifth month is
 midway between pubes and umbilicus; at end of sixth  month
 at umbilicus, which  begins to protrude; at seventh midway
 between umbilicus  and xiphoid cartilage ;  at eighth at  ensi-
 form cartilage;  fills abdomen, the intestines being above and be-
 hind ; during ninth month does  not ascend, and in latter part
 actually descends.
   In Os and Cervix.—Soon after impregnation, the lips of os
 begin to soften,  and this change gradually progresses upwards ;
 less marked and slower in primiparae.
   The volume of cervix increases, but it does not elongate; the
 cervix does  not shorten till near term ; the os uteri  internum
 does not open.
   The shape of cervix at commencement in  primiparae  is con-
 tracted and more  pointed; the os from a linear slit becomes
 circular.  A little later, the middle of the cavity of the cervix
 enlarges, giving a fusiform shape ; the os is rounded and smooth.
 In multipara?, the cavity resembles a funnel, the base below.  Os
 uteri externum  remains closed in primiparae  up to  term ; in
 multipara is widely open.  The whole cervix disappears in the
 last fortnight, and until then preserves its length.
   The canal of cervix is filled with a plug of tenacious mucus,
 the product of the ovula Nabothi, which are  often felt like
 shot.
  In direction.—At first the increase in size and weight tilts the
fundus backwards ;  as it rises,  it follows axis of superior strait
till it reaches promontory, then turns towards right hypochon-
drium, influenced by the superior strength of the right round 
66
MANUAL OF OBSTETRICS.
ligament   The os  at  term  lies  backwards,  and inclining to
left.   This  position  is  of importance  at times  during partu-
rition.
   In mucous coat.—The decidua.
   In serous.—Is extended, and the sub-peritoneal tissue seems
looser.
   In function.—The menses cease usually.
   CHANGES IN VAGINA.—During first months, is shorter
and  wider,  from depression of cervix ; later, the cervix is drawn
upward, and the vagina is elongated and conical ;  near term,
becomes relaxed and secretes copiously.
   IN TUBES.—Retained against  sides of  uterus by  broad
ligaments, which unfold ; are more vascular, especially the one
which has transmitted the ovum.
   ROUND LIGAMENTS.—Enlarged, redder, and muscularity
more evident.
   BLADDER.—Rises  above the superior strait;  sometimes is
bent over pubes;  sometimes  depressed below cervix in vagina,
where it has been punctured.  In catheterizing, these displace-
ments should be borne  in mind.
   URETHRA.—Becomes more vertical; sometimes bent down-
wards, requires care with catheter;  use a male elastic catheter.
   RECTUM.—From pressure on  it, and hindrance to action of
diaphragm, constipation occurs ; sometimes irritability.
   SMALL  INTESTINES.—Usually  towards right lumbar
region ;  or  directly upwards against colon; or in recto-vaginal
excavation ; sometimes pressure causes colicky pains.
   DIAPHRAGM.—Towards close is pressed up, and sometimes
dyspnoea ensues.
   STOMACH.—In  latter months vomiting occurs from  pres-
sure.
   SKIN.—Of abdomen is thinned;  cracks and silvery streaks
called linece albicantes ensue, which are permanent;  the  tin.
alb.  widen, and may separate;  and  thus disunion  may be
persistent.
   UMBILICUS.—Becomes more salient. 
MANUAL OF  OBSTETRICS.               67
  VESSELS.—Pressure gives  rise to  hemorrhoids,  varices,
oedema.
  NERVES.—Cramps from pressure.
  PELVIS.—Said to relax.
  ON  GENERAL HEALTH.—Sometimes improves; some-
times deteriorates.  A hyperemic state seems to prevail; some-
time anemia  rapidly developes.  Buffy  blood is not always
found,  and is not pathognomonic of inflammation.
  Temper, sometimes irritable ;  sometimes ameliorated ; tend-
encies to insanity are matured.
  The  feverish symptoms, sensation of fulness, rapid pulse, dry
skin, and deranged  secretions,  all indicate a reduction of ali-
ment, which is often contravened by the erroneous impression
that additional food is needed for the foetus.

                 Signs of Pregnancy.

   Importance.—Opinion may affect, life, character, happiness,
fortune.  Pregnancy sometimes complicated by disease.  Facts
sometimes perverted without evil motive.  Concealed in mar-
ried or unmarried.  Feigned to extort money.   Difficult and
obscure in early months.
   Effects  of Pregnancy.—On  Vascular  system:  Pulse
fuller,  harder,  stronger, quicker.   Fibrine increased.   Blood
sometimes buffy.  Animal heat increased.
   On Nervous  System :  Irritability increased, weariness, lassi-
 tude.  Alterations in taste, disposition, intellectual power.  Pal-
 pitations.    Spasmodic  cough.  Vomiting.  Faintness.  Neu-
 ralgic  pains.   Antipathies.  Longings.   Sometimes freedom
 from spasmodic difficulties, as asthma.
   On  Digestive function: Dyspepsia,  or improved digestion.
 Cardialgia.   Acidity.  Vomiting.
   On  Alimentary  canal:  Secretions altered in  quantity and
 quality.  Diarrhoea.  Constipation.
   On  Stomach :  Intense acidity.   Ropy mucus copious.
   On  Saliva :  Salivation.   White, tenacious, frothy sputum. 
68
MANUAL OF  OBSTETRICS.
   On Skin and Countenance : Tale or florid.  Sallow.  Blotches.
Nose sharper.   Mouth larger.   Eyes sunk, lividity around.
Moles larger and darker.  Odor peculiar.
   On Breasts:  Larger.    Veins  enlarged.   Areola.   Milk.
Silvery lines.
   On Urine: Increase.  Kiestine.  Albumen.
   In detail.—CESSATION  OF  MENSES.—Calls  attention
early.  Usually obtains.
   Fallacies.—Next period after conception  may be unusually
copious.   A bloody discharge may occur  monthly for  several
months,  or  even through  whole  gestation.   Source in these
cases, ulcer or abrasion of cervix.
   Menses during pregnancy only.
   Pregnancy may occur  before menses established ; without
return since labor ; during suppression from  disease.
   Catamenia suppressed  from disease, cold,  mental  causes,
marriage relations, sea voyage, change of residence and mode
of life.   Uncertain at " change of life."
   Simulated by staining linen to avoid suspicion.
   Value: A valuable,  but not  absolute sign.   If pregnancy
has been incurred, and general health is not impaired, woman
is probably pregnant.
  IRRITABILITY OF NECK OF BLADDER.—Micturition.
   Occurs early.   Cause :  Partakes in general pelvic irritation ;
not from pressure ; quantity not increased.
  Fallacies: From other causes  than pregnancy ; " a cold,"
dysmenorrhcea, hemorrhoids.
   Value : A good and common sign.
  NAUSEA.—" MORNING SICKNESS."
   Occurs about third week.   Varieties : Six  days, fifth or sixth
week.  Character : As soon as erect in morning, sudden, with-
out nausea,  duration  ten  minutes to an hour, relief follows,
appetite continues.
   Ceases about  fourth month.  In some till term.
  Fallacies: From  other   causes,  diseases.   In night only.
Sometimes all day.  May not occur, and yet pregnant. 
MANUAL OF  OBSTETRICS.
69
    Value: Valuable in conjunction ;  alone  doubtful;  majority
 have it.
    Sudden and early cessation excites apprehension for ovum.
    If absent, gestation thought not to be so regular as if present.
    MAMMARY CHANGES.—Three Varieties.—1st. Enlarge-
 ment.   2nd. Secretion of Milk.  3rd. Changes of Areola.
    Enlargement and  Sensations.— Occur about  third month,
 sometimes not till eighth or ninth month, not till delivery.  Sen-
 sations, uneasiness, fulness, shooting,  prickling, tingling pain,
 tension, tenderness, knotty, " lumpy feel," nipple  puffy.
   Fallacies: May proceed from  acute  suppression, dysmenor-
 rhcea, polypus, fibrous  tumors, fat, ordinary menstruation, un-
 certain especially at " turn of life."
    Value : Not much reliance.
   Secretion of Milk.—Occurs about fifth or sixth month;
 varies ; continues from  time to time.
   Fallacies : May exist in non-pregnant, in young girl, in the
 male, may continue for years, may occur at cessation of menses.
    Value: None.
   Areola.—Def. A  circle surrounding  nipple, somewhat
 darker even in the virgin than neighboring skin.
   Color varies with complexion ; in blondes a pink; in brunettes
 tawny.  Hence, mere color no  evidence of pregnancy.
   Changes by pregnancy:  Darkens progressively, follicles be-
 come developed  and elevated.  Areola seems  puffed,  emphy-
 sematous.  A brownish yellow fluid exudes from follicles, stains
 linen.   Nipple turgid, erect.  Extent of areola, 1 inch to 14-, or
 even  3.   Begins to darken in second month ; progressively
 varies  in tint, from light brown till nearly black; in negress
jet black.  Permanency of discoloration; is to certain extent
 persistent; does not disappear in brunette.
   Fallacies: Uterine irritation, as dysmenorrhcea may dis-
color.
   Follicles often  seen where neither pregnancy nor nursing.
   Pregnancy may exist with but slight discoloration.
   Value : Only in primiparae.
                            6 
70
manual of obstetrics.
  If areola presents changes, pregnancy  is probable ;  if no
change, highly improbable.
  Puffy emphysematous feel most unequivocal if present.
  Other mammary changes :  Silvery streaks appear after sixth
month from distension ; are permanent, and hence of no value
after first pregnancy.
  KIESTLNE.—Def. A pellicle  formed  on certain  varieties
of urine; consisting of  minute crystals of triple  phosphate in
fatty matter.
  Noticed first by Nauche in 1821.
  Said to exist frequently in urine of pregnancy; from fourth
week to term.
  To procure it:  Expose urine in wide mouthed open vial to
air at 60°.
  Appears third or fourth day;  on fifth and sixth, begins to
break up and fall  to bottom ; odor cheesy.
  Fallacies:  Not peculiar to pregnancy.
  Pregnancy may exist without it.
   Value : Though not infallible,  it  is a fair presumptive proof.
  Entire absence  is good negative proof.
  (Authorities differ as to value, and microscopic research fails
to identify any peculiarity in the pellicle as indicative of preg-
nancy.)
  ALTERATION OF  COLOR OF VAGINA.—/, a. a bluish
dark purple of the vaginal mucous membrane.
  " Jacquemin's test" confirmed by Parent Duchatelet.
  Fallacies :  Exists during menstruation.
  Marks merely venous congestion,  which may be independent
of pregnancy.
   Value : Not reliable; usually inapplicable.
  INCREASED PULSATION OF VAGINAL ARTERIES.
—Considered  important by Osiander.  May result from other
causes.
  ENLARGED ABDOMEN.—Vulgarly thought positive evi-
dence.  In two first months said  to  flatten.
   Begins to enlarge about third or fourth month. 
manual of obstetrics.                71
  Fallacies: Enlarged from  Ascites.  Retention of urine or
menses.  Flatus.   Ovarian disease.  Hydatids.  Fibrous  and
other tumors.   Fat.
  Ascites and pregnancy may co-exist.
  Requires careful investigation of history, also by palpation
and percussion.
  Examine during expiration, both standing and lying, bladder
to be emptied.
  Volume different in primiparae and multipara?.
   Value : If pregnancy is possible, enlargement is a probable
sign.
  Feel  of pregnant  uterus:  Is' peculiar; firm,  hard,  elastic,
well-defined ; preserves its form in all positions.
  UMBILICAL CHANGES.—In two first months umbilicus
sinks ;  produces dragging pain, because womb descending drags
on bladder, and that on umbilicus by means of urachus.
   Value: Not  often observed; impaired by  occurring from
other uterine causes.
  At sixth month, navel effaced.
  At seventh, eighth,  and ninth, various degrees of protrusion or
" pouting."
  Fallacies: Ascites may cause  protrusion.   May be no  pro-
trusion.
  QUICKENING.—Def. The  mother's first  perception  of
motion.
   Sensation : A feeble fluttering or pulsation, sometimes with
nausea, faintness, or  syncope.
   Cause: While  uterus is in  pelvis  which has not nerves of
sensation, motion is not perceived ; rising into abdomen, motion
is appreciated.
   Not from life then imparted ;  not from sudden rising.
   Occurs : Usually  sixteenth week after last menstrual period.
   Varieties: Not at all;  not before fifth month ; different in
different pregnancies; varies with size  of pelvis, quantity of
liquor  amnii, bulk of child.
   Value:  Woman's testimony not to be relied on. 
manual of  obstetrics.
   FOTAL  MOTION.—Perceptible to  accoucheur,  also  to
woman ;  sometimes violent; perceptible under dros.
   Examine  by applying  cold  band  to  abdomen, wet  with
cologne or water.  By pressing sides gradually.
   Fallacies: May deceive self and accoucheur by contractions
of abdominal muscles.   Flatus.
   Also irregular contractions of uterus  itself  where menses
retained.
   Value : If clearly distinguishable, good presumptive proof.
   AUSCULTATORY SIGNS.—F,rtal heart  first noticed by
Mayer in 1818 ;  forgotten till Kergaradec, in 1823, noticed two
kinds of sounds.
   1st.  Placental Murmur.—Placental bruit, bruit placentaire.
   Resembles ordinary  cardiac systolic murmur.
   Situation: At attachment of  placenta, verified by Kohl  in
90 autopsies.  Usually in right  iliac region, midway between
umbilicus and anter. spinous process.
   Source uncertain.
   Thought  to  be from utero-placental  circulation.   Not so.
Also in uterine arteries leading to site of  placenta.   Also  from
pressure  on  iliac arteries.  Also  from  numerous  vessels  in
abdominal parietes.
   Is synchronous, with maternal pulse.
   Time of finding :  Tenth week, fourth  month, fifth month.
Difficult to detect; heard one day, and not next
   Fallacies, tumors may cause.  May be  heard after death  of
foetus ; after delivery when degenerated into moles.
   Value  : Authors differ.  Some say unerring ; others merely
a bruit from an impeded artery.
   2nd. Fcetal heart, sound of :
   Resembles ticking of a watch under a pillow.
   Situation, usually left side, midway between umbilicus and
anter. spinous process ; sometimes over the whole abdomen.
   Number of pulsations :  120,  140; synchronous with  foetal
pulse.
   Time of hearing : Depaul says at the end of twelfth week ;
seldom before fifth month. 
♦
                  MANUAL OF OBSTETRICS.                73

   Obscured by :  Excess of liq. amnii;  thick abdominal  parie-
tes ;  feeble ftelus ; ascites.
   Value: If heard, proof positive of a living foetus ;  if not
heard, pregnancy may still exist; foetus may be dead.
  Rules :  Requires skill; use a wooden stethoscope.
  Empty bladder and bowels beforehand.
  Woman to be  on bed, on her back, with knees drawn up.
  Press away fat by kneading ; press stethoscope firmly.
  Do not  lean over woman ; sit or kneel.
  If cannot find,  try another day.
  Funic  Souffle.—Described by Naegele, Jr.
  Def.: A sound synchronous with foetal heart;  caused  by
compression of cord between uterine walls and some part of
the foetus.
   Value: Not generally recognised.
  SIGNS  APPRECIABLE BY  TOUCH.—Woman's  posi-
tion to  be  on side, or on back with knees drawn up; or  stand-
ing.
  Operator to be sitting or kneeling.
  lie should be ambidextrous; should wear no  rings; nails
pared close; use  index finger,  or  two first;  oil well,  both for
woman's sake and also own.
  During two- first months of pregnancy :  Uterus is heavier,
lower in vagina, less  movable, increased  in  volume; uterine
tissue feels softer and looser, spongy, compressible.
  Fallacy : Just before catamenia may feel like pregnant.
  At third month: Volume, weight, and fixedness increase;
fundus  just felt in hypogastric ;  neck inclines backwards;  uterus
must rise in axis  of superior strait.
  At four months:  Fundus  four fingers above symphysis;
neck a trifle higher  than in  third month ; direction  same ;
ballotement aids.
  At five  months :  Fundus two fingers below umbilicus; hy-
pogastrium projects; vagina elongated and  narrowed;  neck
more elevated.  Foetal motions.  Ballotement easy.
  At six months : Fundus at umbilicus ;  umbilicus begins to
                             6* 
74                MANUAL OF obstetric;-;.

project; vagina  elongated  and contracted;  neck  at superior
strait, shorter, less firm, larger.  Ballotement easy.
  At seve?i  months : Fundus  two fingers  above umbilicus;
cervix disappearing.
  At eight months: Fundus at epigastrium ; os-softens.
  At nine months: Fundus sinks ; cervix effaced.
  The above scale of development is  subject  to numerous
variations. \
  BALLOTEMENT.—Performed  by placing one finger on
cervix anterior to os; the other hand on fundus, and commu-
nicating impulse to uterine contents with finger ;  foetus ascends
in liq. amnii  and returning causes a slight shock; woman's
position to be standing.
  Period: Best between five and  six months, because before
that foetus is too small to jar, afterwards too large to float in
liq. amnii.
   Value : Proves  a body is in utero; that  it is a  foetus, but
nothing as to life.
  Fallacy :  Placenta praevia obscures it;  also a small  foetus;
a long cervix.
  Twin Pregnancy may be diagnosticated if two foetal hearts
are heard  by two observers simultaneously, the beats not being
isochronous.  Not to be on same plane.
  Fallacy: The foetal  heart may be traced  across median
line. 
table op the signs of pregnancy.				
1st and 2nd months.	3rd and 4th months.	5th and 6th months.	7th and 8th months.	9th month.
Micturition.				Micturition.
Suppression of Menses.	Suppression.	Suppression.	Suppression.	Suppression.
Morning sickness.	Vomiting.	Sickness ceases.	No nausea.	( Vomiting. ( Dyspnoea.
Depressed Umbilicus.	( Umbilicus less de-) ( pressed. j	Umbilicus effaced.	Navel begins to pout.	Navel pouts.
Tumefied breasts.	( Breasts swollen. ) { Changes in areola. )	Areola deeper, follicles.	( Deep areola, follicles. 1 Milk.	Changes more marked. Silvery streaks.
Augmentation of cer- ) vix in size and > weight. )	Fundus above pubes.	r Hypogastric pro- \ j minence. 1 j Fundus at or f ' above umbilicus. )	Fundus in epigastrio.	Fundus sinks.
Descent of uterus.				Cervix effaced.
Kiestine.	Kiestine.	Kiestine.	Kiestine.	Kiestine.
		Fcetal heart.	Fcetal heart.	Heart.
		Placental souffle.	Placental souffle.	Souffle.
		Fcetal motion.	Motion.	Motion.
		Ballotement.	Ballotement in 7 th mo.	(Piles. ■] CEdema. (Varices.
 
76
MANUAL OF OBSTETRICS.
   Duration of Pregnancy.—Is usually calculated  from
last menstrual period ; from which 9 months are allowed, or 40
weeks, or 280 days.
   By females the reckoning is corrected by the first perception
of motion,  which is considered to be A\ months.   That the
duration may be less than 280 days, no one doubts ; but much
controversy has arisen as to the possibility of gestation being
prolonged beyond  280 days.   It  may be prolonged.  Desor-
meaux's case (singlecoitus), 9 months and a fortnight, 28*7 days ;
Girdwood, 274 days; Montgomery, 280 ; Rigby, three cases of
single coitus,  260, 264, 276 ; Lockwood, four cases single coitus,
270, 272, 276, 284; Lee, a single coitus,  287 days; Dewees,
one coitus,  286 days;  Beatty, 291 days ; Skey, 293 ; MTlvain,
293  or 296 ; Ashwell,  300;  Asdrubali believes that a preg-
nancy of 13 months and 22 days, and Meigs, that 420 days does
not vitiate  chastity.  Reid gives  25 cases of single coitus ; of
these labor occurred, 263rd day in 1 case ; 264, in 1 ;  265, in
1; 266, in 2 ; 271, in 2 ; 272, in 1 ; 273, in 1; 274, in 6 ;
275,in 2 ; 276, in 3 ; 278, in 1; 280, in 2 ; 287, in 1; 293, in 1.
   Dr. Reid, in another table, gives 500 cases of the days inter-
vening  between the last menstruation and labor, of these 23
terminated in 37th week;  48 in 38th; 81  in 39th;  131 in
40th ;  112  in 41st; 63 in 42nd;  28 in 43rd;  8 in 44th; 6 in
45th week.
   Merriman's tables of 114 cases show that the greatest pro-
portion  terminate in the 40th week ; a considerable number in
41st.
   Murphy, 182  cases; in 39th  week,  24 ;  in 40th,  25 ; in
41st, 32 ; in 42nd, 25.
   In the case of animals, where accurate records are practicable,
considerable variations occur.
  Diseases of Pregnancy.—May be regarded under two
heads,    ls^.  THOSE  OF  WHICH PREGNANCY  is  the
cause.   2nd.   DISEASES MODIFIED by  pregnancy.  Are
mostly of 1st class.  Ordinarily, are aggravations of ordinary
symptoms. 
MANUAL OF OBSTETRICS.              77
  The sympathy between uterus and stomach  is well  marked
even  in  the unimpregnated state, for uterine derangements
have usually dyspeptic symptoms.   Of the gastric phenomena
the most marked is
  Nausea.— Occurs usually about fourth to sixth week.   Con-
tinues six weeks to two months ; not usually after four months.
Variations,  throughout;  very  soon  after conception ; not till
seventh or eighth  month; sometimes not till after meal; at
bed-time; in night;  all  day ; not at all;  only from special
articles.   Character, occurs on assuming erect posture ;  some-
times nausea without vomiting; lasts from ten minutes  to an
hour; appetite undiminished.
  Bad effects.—Miscarriage;  want of  nutrition may  cause
sinking;  death.    Good  effects:  Prevents  formation of too
much  blood.  Nature of fluid : Thin, watery,  glairy, colorless,
bile,  blood, greenish or  blackish, excessively acid.   General
Symptoms : Reduction of strength ; pain in epigastrio ; loaded
tongue ; constipation.   Causes : In  mild cases by sympathy ;
towards end from  pressure ;  in violent by gastritis;  sometimes
odors, indigestible food, articles that  readily acidify,  acescent
vegetables, salt meats;  torpid bowels the great cause.
   Treatment.—First regulate diet, then  use cathartics ; if these
fail  use  anti-emetics.  If plethoric  or pain on  pressure  over
epigastrium, with  dry red tongue ;  leeches and  blister,  purga-
tives,  seidlitz, magnesia, mass. hyd.  and  hyoscy., ext. coloc.
comp., salines.   Counter-irritants, &c, to epigastrium :  blister,
sinapisms, hot turpentine and  flannel, cloth\s  wet with  lauda-
num, mint poultice, spice plaster.
   Narcotics.—Avoid constipation ; effervescing draught with
T. opii or sol. morph.;  starch and laudanum enema.
   If add, use alkalies,  and if these fail,  use acids ;  charcoal 3j,
every two or three hours with or without soda  or  magnes.,
charcoal and  milk, lime-water and milk.   Anti-emetics: Hy-
drocyanic acid, kreasote,  strong coffee, clove tea, 20 to Oss, ice,
soda water,  spearmint  tea,  ol. tereb., infus. calumbae, mineral
acids with bitter infusions, trisnit. bismuth.,  tinct. nuc.  vomic, 
78
MANUA.L OF OBSTETRICS.
 acet. plumb, et morph.  Diet:  Lightest kind ;  no stimulants ;
 very little at a time; observe if stomach will  bear better  at
 some period of the day ; solids sometimes best;  quantity small,
 and position supine; sometimes total abstinence for 24  hours;
 sometimes  a single  article, cold arrow-root, gum arabic, iced
 water and cracker ; lemonade ; food cold ;  champagne.
   In later months, the only resource is horizontal posture.
   If all remedies fail and life is jeoparded, excite premature labor.
   Dubois, in thirteen  years, met with twenty fatal cases.  Au-
 topsy revealed  no lesion.  When gestation is arrested spon-
 taneously or artificially, the  vomiting ordinarily ends.  Ho
 says: Do not perform it whexi the signs of  extreme exhaustion
 are present, as loss of vision, cephalalgia, coma, somnolence, and
 mental disorder.   Abstain from operating when the vomiting,
 though  violent and  frequent, allows  some   aliment  to  be
 retained,  when the patient, though wasted  and feeble,  is not
 obliged to keep her bed, when the suffering has not yet induced
 intense and continuous febrile action,  and when other  means
 still remain untried.  The proper time is marked by, 1st. Al-
 most incessant vomiting, by which  all  alimentary substances,
 and sometimes  the smallest drop  of water,  are rejected.   2nd.
 Wasting  and debility, which condemn the patient to  absolute
 rest.   3rd.  Syncope, brought on  by the least  movement  or
 mental emotion.   4th. A  marked  change in the features.
 5th. Severe and continuous febrile action.  '6th. Excessive and
 penetrating acidity of the breath.  1th. Failure of all other
 means.   Stoltz relates four  cases, three of which proved fatal,
 the  other was saved by the operation.  He advises a timely
 interference.
  Nutritious enemata will sustain life for a long time.
  Transfusion might be demanded.
  Emetics will  frequently  cause  abortion, while  puerperal
nausea rarely does.
  Heartburn.—Cardialgia, pyrosis,  water-brash.
  Occurs  frequently;  sometimes  quite early;  usually  not
troublesome till last months ; often in hysterical  and nervous. 
MANUAL  OF OBSTETRICS.
79
   Causes.—Sympathy;  certain  articles of diet;   some  say
alteration of gastric juice ; bile in stomach ; affection of eighth
pair of nerves ; mental emotion.
  Symptoms.—Pain and heat in epigastrio, extending along
oesophagus; eructations  of sour and bitter fluid;  aggravated
by eating ; sensation of dragging from stomach towards spine;
fluid bilious, clear, bitter, acid, acrid ; usually no constitutional
disturbance;  appetite impaired.
   Diagnosis  from inflammation of oesophagus and stomach by
absence of fever, also is intermittent.  Pregnancy a presumptive
proof of heart-burn.
   Treatment.—Diet, exercise, attend  to bowels.
   One  article  of  food,  rice,  oysters,  milk, stale bread, sweet
butter, ship-bread.
   Counter irritation to  epigastrium, blister, anodyne liniment.
   Antacids.—Magnesia, ammonia, aq.  calcis, carb. soda, liq.
potass., mis. cretse. The unlimited use of antacids is objection-
able ; magnesia may accumulate.
   Acids.—Citric, elix. vitriol, ice water, soda water.  Attend to
bowels; give mist, eccoprot., magnes., ext. coloc. comp.  May
require opium.  Mild bitters in enfeebled.  Trisnit. bismuth.
   Constipation.—A very common attendant.   Duration : days,
weeks,  or  months.  In slight degree,  inconvenient  only; if
prolonged, is injurious.   No  woman should be permitted  to
fall in labor with constipated bowels.
   Causes.—Pressure, altered vitality.
   Attendant phenomena.—In slight cases, uneasiness,  discom-
fort, headache, increased heat; sometimes small, liquid, daily
stools, and yet  accumulation.  If  prolonged, headache, sleep-
lessness, restless, sense of weight and fulness, irritability, nausea,
vomiting, pains in abdomen, irritation of mucous membrane,
tenesmus,  bloody  mucous discharges,   scybalse,  false pains,
abortion from straining, per vaginam can feel enlarged rectum,
and sometimes a channel.   Always inquire in the diarrhoea of
pregnancy whether constipation has  preceded.
   Consequences during  gestation, inflammation, fever, sphace- 
80                MANUAL OF  OBSTETRICS.

lus,  piles;  at the time  of labor,  delay,  peritonitis, convul-
sions.
   Treatment.—Mild means first; manna, rhubarb, magnesia;
mist, eccop. with tine, jalap ;  ol. ricin. 3j. every night; ext. col.
comp.; coloc. and hyosc.  seidlitz ; confect. senn.; Johnson's pill
 fy Ext. coloc. comp. 3j.;  calomel grs. xv.;  ant. tart. grs. ij., ol.
carui. gtt. ij. Ft. in pil. 24, 2 for a dose ; ext.juglans ; fell. bov.
insp.;  warm enemata.  Diet, gruel, mush and molasses, brown
bread, fruits, vegetables.
   If medicine is  ineffectual, scoop out rectum.
   DIARRHCEA.—Not  so  frequent as constipation.   Those
costive before pregnancy may be loose; vice versa ; constipation
may precede; alternate, or co-exist.
   Occurs  at any  period; often  an  early symptom of preg-
nancy.
   Causes.—Constipation, quasi  vicarious  of  menstruation;
cold ;  emotion ;  intestinal irritation.
   Phenomena.—Varieties in frequency and character of stools;
watery, dark, offensive, acrid, pain,  tenesmus.
   General symptoms, in  slight cases, languor, no fever; but in
severe, especially if ulceration exists, great pain, burning  sensa-
tion, quick pulse, dry tongue, hot skin, great thirst, anorexia,
vomiting, frequent offensive stools.
   Sequences.—Oftener  than constipation  it  causes  abortion,
especially about third month ; arises from tenesmus.
   Treatment.—Not always wise to  stop suddenly, especially if
periodical.   Mist, cretac. with kino or catechu ; hyd. c. cret. et
P. Doveri,  opium ; starch and laudanum enema ;  01. ricin.  et
t. opii; pil. plumb, et opii;  blisters ;  flannel.
   Diet mild, milk boiled, rice, arrow-root.
   If the  result  of precedent  constipation, use 01. ricin. and
enemata.
   HEADACHE.—Cephalalgia; is very common.
   Occurs in  hysterical  and  nervous; in robust and plethoric;
in  early months is usually nervous'; in later ones, from plethora.
   Causes  of nervous,  mental   emotion,  food,  constipation, 
MANUAL OK OBSTETRICS.               81
fatigue.  Of  Plethoric:  errors in  diet, stimulants, warm bath,
exertion.                                             ^
   Seat over  part or whole :  hemicrania, megrim,' migraine;
in vertex, occiput.  Kind of pain : constant, paroxysmal, dull-
aching, acute throbbing;  without  or with intolerance  of light
and sound.
   In  plethoric,  pulse  quick,  full, strong, carotids throbbing;
face flushed; eyes bright or  suffused;  eyelids heavy ; photo-
phobia.  Pain dull or acute, over eyebrow; constipation may
complicate either form, and  then tongue is loaded,  and bad
taste  in  mouth.
   Prognosis.—In Nervous, not dangerous ; in Plethoric, to be
guarded.
   Treatment.—In Nervous, Valerian infusion or Tine. Valer.
 Ammon.,  Hyosc.   et  Camph.,   Hops,  Hop-pillows,  Ether,
 Chloroform,  Cologne,  Blister  behind ear.   Brisk purge.
   In Plethoric.—Venesection, Leeches,  Antiphlogistic, Blister
 to nape. Special attention to diet and exercise.
   Plethora.—A certain amount  is normal, and  needs  no
 attention beyond a moderated diet and active  exercise.
    If more  marked, use purgatives; ipecac.  \ gr. 3 times a
 day.
    If  manifested by  headache,  somnolence,  flushes   of heat,
 vertigo, dyspnoea, depressed spirits, high  colored  urine, and
 full  frequent pulse ; or by indications of uterine hyperemia, as
 sensation of weight in  pelvis, groins, and thighs, tension, &c.;
 small venesections may be practised ; if the uterine symptoms
 indicate threatening abortion, opiate enemata and venesection.
 Leeches are objectionable.
    Piles.—Hemorrhoids ; are frequent.
    All the different forms are found.  Occur : in relaxed, indo-
 lent, constipated.  Exciting cause : pressure of uterus.  Period :
 in early months, or in last, and again after delivery.
    Attendant Phenomena.—Itching, weight;  if inflamed pain,
 throbbing,  heat, bearing  down, pain  in defecation, motion
 distresses, tenesmus, bloody discharge.
                              7 
82
MANUAL OF  OBSTETRICS.
  Rarely curable during pregnancy.
  Treatment.—Open  bowels; Sulphur, Bitart.  Tot., Confect.
Senn., Coloc., Mass. Hyd., Enemata.
  Diet: bland without stimulants.
  Anodyne lotions or ointment to external;  return if possible;
sometimes incision.
  If inflamed.—Poultices;  astringents; cold   lotions;  cold
semicupia.
  Avoid operations until after labor.
  02dema.—Is frequent.  Most in latter months.
  Extent: Feet, legs, thigh^ vulva, hips, face.
   Cause : Pressure upon veins.   Sometimes from renal con-
gestion, then albuminuria exists; such dropsy manifests itself be-
neath the eyelids and upper extremities, and should always ex-
cite apprehension lest convulsions should succeed.
  Effects: Are  mechanical, interfering with motion ;  or if in
labia, with labor.  Relieved by horizontal posture.   Sometimes
complicated with Eclampsia, Erysipelas, or even gangrene from
over-distension.   Always  examine urine if oedema  of face is
noticed.
   Treatment: Rest, salines, diuretics.
   If extreme.—Punctures, cold water,  saturnine lotions.
   If albuminuria.—Local depletion over kidneys, saline purga-
tives.
   Toothache.—Odontalgia ; not uncommon.
    Occurs .in early months.   Sometimes an  early sign  of preg-
nancy.
   May be continued  or paroxysmal.
    Causes :  Neuralgia ; Gingivitis ;  Catarrh ;  Carious  tooth ;
Constipation ; Breath is acid, reddens  litmus.
   Diagnosis: Whether from caries  or merely sympathetic;
pregnancy is  a presumptive proof of neuralgic character.
    Treatment: If neuralgic.—Oils of Cloves, Mint, or Cinnamon,
 &c.; Tannin, Kreasote, Stramonium,  Valerian, Blister.   Tine.
 Aconit. beneath ear is very  effectual.
   If inflamed gums,  scarify, leeches, warm water, purgative*. 
MANUAL OF OBSTETRICS.
83
  Main point of interest is as to extraction.  Authorities differ.
  Usually  will not do good,  and is likely to produce  abor-
tion.
  Dyspncea.—Occurs sometimes  in  early from sympathy; at
quickening ; more in latter months from plethora and mechani-
cal  cause ;  most in primiparae.   Also from cardiac or thoracic
disease, tumors,  &c.
  Treatment: In  early.—Antispasmodics ; Valer.; Ammon.;
Ether.   If from congestion,  VS. ;  purgatives ;  Ant.  Tart.;
Ipecac.   Mechanical;  position.   Attend  to bowels.   Avoid
flatulent food.
  Cough.—Occwrs sometimes in early months from sympathy ;
in latter, from pressure.   Thoracic diseases.
  In early:  No expectoration; pulse unaltered;  no feverish
symptoms; subsides spontaneously.
  In latter : The mechanical succussion may cause premature
labor;  shown markedly in influenza ; loss of rest and headache
also demand interference.
  Diagnosis: By stethoscope.
  Treatment: In  early.—Antispasmodics ; narcotics;  bowels
free.  In later.—Venesection; Ant. Tart.;  Ipecac.
  Diet: Avoid  flatus.
  Palpitation.—Very common, especially in hysterical.
  Occurs just after conception ; at quickening; towards close.
  Causes :  Sympathy ; pressure ; mental emotions ; disordered
stomach ; flatus  ; foetal motions.
  Treatment: In paroxysm.—Antispasmodics, Valer.,  &c.;
Ether;  Chloroform ;  Opiates ; Sinapism between shoulders. If
plethoric.—VS.
  In interval.—Iron ; antispasmodics ; posture ; exercise; dress
not to bind.
  Vertigo, and dimness  of vision, and faintings, are frequent.
  Arises from nervous  susceptibility or .from  plethora.   Some
women  easily affected by moral emotions, as joy, anger, odors,
unpleasant  sights, foetal motion.
  Syncope  attacks while standing, tinnitus, vertigo, dimness of 
84
MANUAL OF OBSTETRICS.
vision, weakness of knees.  Sometimes yawning, sense of heat,
chills, pulse and respiration nearly cease*.
  Relieve by Ammonia, cold water,  horizontal posture, wine
and water, &c.
  Incontinence of  Urine.—Enuresis.— Occurs early from
pelvic irritation.  In latter months, from pressure, especially in
ample pelvis.   Coughing causes expulsion.
   Treatment:  In early.—Fomentations ; leeches; Belladonna ;
Hyoscyamus ;  Lupuline ; astringents.
  In  latter.—But little  can  be effected;  cold  sponging; eva-
cuate bladder frequently to prevent involuntary expulsions.
  Dysuria.—Caused by irritation ; pressure;  paralysis; piles;
calculus ;  tumors ; displacements.
  Diagnosis :  By vaginal examination.
   Treatment:  If from irritation, leeches, anodynes, mucilagi-
nous  drinks, fomentations ; if from piles, leeches ;  from over-
distension, inf. Uva Ursi; if from  compression, position; too
pendulous belly, a bandage; catheter.
   Pruritus.—Sometimes excessively distressing.  Dewees found
a few cases to arise from aphthae.   Treatment:  Sol. Bibor.
Sod. 3j.—iij. to Oss.   If dry and red excoriations, dry Calomel;
Decoct. Papav.;  Acet. Plumb.; Sol. Alum ; Sol. Sulph. Zinc.;
cold  water; Sol.  Nit.  Argent, grs. v.—x.  to 3j.; Ung. Cor.
Sublim.; Sol.  diacet. Plumb, tepid.;  place compress wet with
solution between labia ; chloroform ointment.
   Internally.—Pil. Plummeri; Elix. Vitriol; Ilyoscy.; Cicuta.
   Icterus.—Jaundice usually in latter months from pressure.
Sometimes in early from sympathy.
   Sometimes preceded by digestive derangement;  vomiting;
weight in epigastrio.
   Treatment:  Keep stomach and bowels free.   Position on left
side.
   Insomnia.—Sleeplessness;  agrypnia; pervigilium.  Not un-
common.  Most in  hysterical.   Sometimes in  early, most in
latter months.
   Causes :  Nervous;  hot bed-room ;  too little exercise;  foetal
motion ; plethora. 
MANUAL OF  OBSTETRICS.
85
   Treatment: Cold bathing  to  head ;  pediluvia  (sometimes
cause abortion) ; laxatives ;  mild anodynes ; small venesection ;
avoid stimulants, tea and coffee ;  light diet.
   Free air and exercise ; sponging body at bed-time.
   Cramps.—Are frequent and annoying.  Most  at fourth and
fifth month, and at latter end.
   Causes:  Mechanical ;• muscular  distension;  stretching of
ligaments ;  constipation ; fatigue ; pressure on nerves.
   Situations: Along  crista ilii; in symphysis, from round
ligaments ;  in lumbar  muscles, coccyx, sacrum ;  in inferior ex-
tremities, anterior and inner part of thigh from anterior crural
nerve; in  sciatic, along calf, heel,  and sole; in large pelvis,
pains are severe ; interfere with walking;  cause falls.
   Treatment: Frictions ; position.
   Retroversion  of the Uterus.—Infrequent.   May  exist
also in  unimpregnated.  The os is close  behind  symphysis
pubis; fundus in hollow of  sacrum ; posterior wall  of vagina is
depressed, anterior carried forwards.
   Occurs in those a short time pregnant; while uterus is yet
in pelvis ;  before 18th week.   Either sudden  or gradually.
   Causes:  Large pelvis ; projecting promontory  of  sacrum ;
most in thin women ; moles;  tumors ;  scirrhus;  distended
bladder;  enlarged ovary.   Excited by violent efforts, vomiting,
defecation, falls, blows.
   Symptoms : One of most prominent and distressing is reten-
tion  of  urine  (hence  in dysuria of early pregnancy always
suspect retroversion) ;  difficulty in defecation ; both these are
aggravated by efforts; weight and fulness of pelvis; bearing
down ;  dragging pain in groins.   If not relieved, violent pain,
febrile symptoms, vomiting, peritonitis ; fatal by irritation, in-
flammation, or sloughing.  By examination vagina is directed
forwards, posterior wall  in folds, anterior stretched, a tumor
stretching across  pelvis.  Sometimes Retroflexion, i. e. the  os
in situ, but fundus depressed,  making uterus  " retort shaped ;"
not in pregnancy.
   Diagnosis: From  ascites,  by effect  of  catheterizing; from
                             7* 
86
MANUAL OF  OBSTETRICS.
ovarian enlargement, by suddenness and form of tumor; from
tumors, by shape, position of cervix.   Per rectum examination
valuable.
   Treatment: First, use catheter, male elastic preferable; if
silver,  direct backwards.  Second, open bowels; Chloroform.
Then begin with two  fingers in vagina to pull down cervix;
two in rectum to push up fundus.  The supine position failing,
place on hands and knees.   Insert a  bladder into rectum and
inflate  it  After  reduction, keep patient on her side for some
time;  evacuate bladder frequently, and always  stoop forwards
in  doing so.  When the uterus rises above the promontory,
this accident will not recur.
   If uterus continues unreduced, inflammation is excited, adhe-
sions form, and the attempts at restoration are hazardous.
   If reduction proves to be impossible, it has been proposed to
puncture membranes through os and procure abortion ; or even
through uterus.
   Gastrotomy proposed as a last resort.
   Anteversion.—Fundus at symphysis ;  cervix in sacrum.
   Is rarer and less serious than retroversion.
    Causes:  Empty bladder, relaxed  abdomen,  and  some sud-
denly  applied force;  faecal accumulations;  chronic metritis;
fibrous tumors ; fall; diarrhoea.
   Symptoms: Retention of urine rare; constipation occasional;
weight; pain.    Examination detects  position  of fundus and
cervix.
   Diagnosis:  From Stone  by  sound;   from  Retroversion,
tumors, and ovarian enlargement, by vaginal examination.
    Treatment: If slight, relieves itself.   Hook down cervix and
elevate fundus.
   Retroflexion and Anteflexion rarely concern  the pregnant
state.
   Anterior Obliquity of Uterus.—" Pendulous belly" is of
consequence in labor.
   Influence of Gestation on Disease.—Two aspects.—
Are pregnant women more  or less susceptible of epidemic dis- 
                  MANUAL  OF OBSTETRICS.               87

eases ?  Does pregnancy aggravate, accelerate, or retard existing
disease ?
  Pregnant women  are not generally so  subject to epidemic
diseases, but sometimes are more so, and  then the proportionate
mortality is greater.
   On existing disease.—On  acute diseases is unfavorable, for
1st.  The vascular system is additionally  excited.   2nd. The
foetus is liable to  be affected, and  then  abortion occurs under
most unfavorable circumstances.  3rd. The treatment required
to subdue inflammation is liable to  produce abortion.
. Hence,  in acute diseases, treatment must be moderate  but
decided.  Venesection should be used decidedly, but not re-
peatedly.   Emetics  are  hazardous.  Purgatives of a  drastic
character should be  avoided.
  On chronic, is not so prejudicial.  Phthisical women conceive
readily, and do not  abort proportionably.   Phthisis was  sup-
posed to be retarded by pregnancy.   Grisolle, however, proves
otherwise; the issue is precipitated; and  Dubois' experience
confirms this.   The children of  phthisical women are  not  im-
perfectly nourished.   Phthisical women go to full term.
  On aneurism and  cardiac disease  : Pregnancy is prejudicial;
dyspnoea is increased during pregnancy,  and  in  parturition
there is danger.
  Regimen of Pregnancy:  Diet should  always be  light, espe-
cially in the first and last  months;  flatulent food  should be
avoided.   Though no foolish  concessions  need  be  made to
" longings," a woman's dislikes should be regarded.
   Atmosphere : Low, damp, miasmatic situations to be avoided.
  Exercise to be regularly taken daily in open  air; walking best.
  Dress: Avoid all tight  dress, especially  over breasts and
around  waist.
  Changes in the Ovum.—The  ovum progresses  towards
the uterus, under the ciliary influence, together with the mus-
cular action of the tube, occupying seven or eight days at least
in transitu.  It  acquires in  the  tube  an  albuminous envelope,
which, uniting with  the zona pellucida, forms the Chorion. 
88
MANUAL OF  OBSTETRICS.
  The ovum  has  three envelopes, Chorion, Tunica Media,
Amnion ;  has  also  as  accessories  the Umbilical  Vesicle,
Allantois, Placenta, and Cord.
  CHORION.—Situation: The most external covering.  Cor-
responds to the membrane lining the egg-shell; evident soon
after reaching uterus.  Has two surfaces.   Inner smooth.  Ex-
ternal  covered with short cylindrical  villi spongioles;  these
are solid, and  frequently terminate in knobs.  At  about two
months these villi begin to disappear from the general surface,
and aggregate at the spot where the chorion  comes  in contact
with the uterus ; opposite to  this spot the cord  forms on the
inside, and here is the future  placental site.   Divided into two
laminae, which are well seen over placenta ; outer is exochorion,
inner endochorion ;  more properly into an indefinite number.
  Structure:  Is said to be destitute of vessels, nerves, or lym-
phatics.  Is  developed thick,  becomes thinner gradually, re-
maining thickest over placenta.  Is separated  from amnion by
a gelatinous layer, which condenses into a thin membrane called
Tunica Media.  Between these a fluid sometimes exists in con-
siderable quantities called "false waters ;" successive discharges
of this constitute " Hydrorrhcea."
  Abnormities: Inflammation; vascularity; thickening; false
membranes; " vesicular mole."
  UMBILICAL VESICLE.-VESICULA ALBA.—Situation :
In interspace between amnion and chorion.  Exists only before
third month.   Analogous to yelk, but unlike it is uot ultimately
inclosed in abdomen.    Communicates  with  intestinal  tube,
upon which  it lies.  Shape :  Rounded or oval.  Size of small
pea.   Progress: The small end  becomes narrow and forms a
canal; this gradually becomes impervious and  threadlike  at
about two months ; it shrinks, and remains flattened out along
cord.   Contains a yellowish, white fluid with granules and a few
globules.  Composition:  An  external  vascular layer and  an
inner  mucous.   Vessels:  Omphalo-mesenteric artery and vein.
Use: To  contain  nutriment  for embryo before placenta  is
formed. 
MANUAL OF OBSTETRICS.                89
   ALLANTOIS, is a delicate membranous sac of an elongated
form ; arising from caudal extremity of embryo; lies between
chorion and amnion.   It  is observed on 10th day, and grows
rapidly ; the base soon becomes applied  to the chorion.  As
the mucous layer is  closing  to form the intestine, the sac be-
comes constricted into two portions;  that within the body
contains the urinary bladder : the portion between it and the
umbilicus is the Urachus  ; the part beyond is the Allantois ;
through the urachus the urine in  early embryonic life can pass;
subsequently it becomes impervious.
   AMNION.—Amnios, the envelope nearest the foetus ;  " is
formed by the  inner lamina of the fold, of the cephalic and
caudal hoods which  constituted  the external serous layer of
the blastoderma around  the  embryo; is continuous with the
margins of the ventral opening; its internal surface  exhales a
fluid in which the embryo floats."  Structure, thin and  trans-
parent, but firm and resists laceration; externally flocculent,
internally  smooth; as yet vessels and nerves not  recognised.
Relation  to fatus, early  is  close, later separated  by liquor
amnii.  Is  continuous with  abdominal  integument of foetus.
From outer coat of cord.
   Abnormities.—Inflammation, thickening.
   Liquor  Amnii.—" The waters."  A fluid  contained within,
and secreted by, the amnion.  Quantity: at first proportionately
greater than foetus, afterwards exceeded by it;  at term  about
one pint,  may be  quarts.   Contains, water, albumen, albumi-
nate  of soda,  chloride of  sodium, phosphate  of  lime, lime,
extractive  matter.  Source:  some say  from mother, others
foetus, others  both.   Color: at first pellucid, becomes milky
from  intermixture with  epithelium of foetus, also viscid and
unctuous ; may be greenish, grey, yellowish, blackish.  Taste :
saltish.  Odor:  peculiar, disagreeable; sometimes  is  acrid.
 Uses : 1st, said to be for nutrition  during early months.   2nd,
preserves  an equable temperature to  foetus. " 3rd, diminishes
shocks, allows   motion to foetus.  4th,  prevents  pressure  on
cord.   5th, acts as wedge during labor and lubricates passages.
0 th, facilitates operations. 
90
MANUAL OF OBSTETRICS.
  Abnormities.—Scanty, excessive, and delays labor; " dropsy
of amnion."   Variety,  in  color, yellow,  brown,  red, green,
black.   From dead foetus offensive and sanguinolent
  PLACENTA.—(From irXaxug broad.)—The organ of hema-
tosis for the child ;  a  spongy vascular mass ; is a flattened
body, about 6 to 8 inches in diameter ; £ inches to 1^ thick at
centre; tapers to the edge.   Circumference: 18 to 24 inches.
Shape:  oval or  rounded, battledore.   Weight:  usually  a
pound or more.   Is  usually  single, very rarely  double for  a
single foetus.
   Two surfaces : Internal or Foetal, and External or Uterine,
or Maternal.  Internal or Foetal: is smooth, shining; marked
by radiations of vessels;  covered  by, 1st,  chorion  which is
firmly attached, and sends  processes  between lobules.   2nd, by
amnion nearest foetus, is loose.   Outer, Maternal: is uniform
but not smooth ; is covered by decidua serotina; when this is
separated are seen the lobules or  cotyledons, between which
the decidua  serotina  send  processes; the vessels of one lobule
do not communicate with those  of  another.   Situation:  any
part of uterus,  usually at fundus, mostly on left  side, anteri-
orly or  posteriorly;  can be   ascertained  by  stethoscope;
verified by observing  the part of  membranes ruptured.
   Period of development.—Does not begin till  end of  first
month.
   Structure.—The villi of the chorion that are in  contact with
the decidua increase,  develope, interlace, and become inclosed
by septa of  the developed decidua which receive them ; thus
are constituted the foetal and maternal portions of the placenta
which  form in the human subject an indivisible mass, while in
the bitch they are  separable.
   The two fcetal arteries, emerging from the umbilicus, subdi-
vide infinitely, and extend  as capillaries into the villi, and here
loop over and become venous  capillaries, which converge, and
form  the umbilical  vein.   By  examinations  from without
inwards, the  uterus at the site of the placenta is found to  con-
sist of large cells  or sinuses, which inter-communicate freely, 
MANUAL  OF OBSTETRICS.
91
but do  not pass beyond a membrane,  the  decidua serotina;
into  these cells, which are the uterine sinuses or veins, the
blood is poured  by the curling uterine arteries terminating in a
capillary extremity.   Into these cells  from the  placenta are
intruded  the  capillary vessels of  the foetus  covered by the
decidua  serotina, but  no vascular  inter-communication  exists
between the  mother and the foetus.   At this  part where the
capillaries  of  the foetus  and the maternal vessels are in close
contact, two sets of nucleated  cells are said to exist, one belong-
ing to the maternal portion of the  placenta, the  other to the
foetal; between  these two a space exists in which the materials
secreted by the  maternal cells are poured out and absorbed by
the fcetal cells.
   Abnormities.—Malformations, displacement.  May be seat of
congestion  into  substance, on  surfaces, between membranes.
Inflammation (placentitis), which   may  attack one  or more
lobes, resulting  in adhesion, pus, death of foetus, and  abortion.
Hypertrophy  of  part  or whole;  atrophy;  cartilaginous  or
calcareous deposits ; fatty degeneration ; vesicular mole.
   UMBILICAL CORD.—"  The cord," funis  umbilicalis, na-
vel-string.  Is  the connecting  medium  between  foetus and
placenta.  Composed  of two arteries,  one   vein, gelatine  of
Wharton, fine areolar tissue, a sheath of amnion externally; in
embryonic life the duct of umbilical vesicle,  urachus, omphalo-
mesenteric vessels, and a portion of intestine (hence umbilical
hernia).   Visible, about  end of first month;  at first is thin
and  cylindrical, the  vessels  straight;  between  3rd  and  9th
week appears like two vesicular swellings; after this the vessels
run  spirally,  the  arteries around  the vein  from left to right;
swellings like knots exist on  some cords, and sometimes com-
plete knots are formed.  Length, varies from  8 inches to  67
inches ; average 18 inches.   Some  cases on record of 5 or even
 2 inches.
   The vein has  no  valves; its calibre  equals that  of both
 arteries.  The arteries are branches of the fcetal internal iliacs;
doubt of existence of lymphatics and nerves.   Position, usually 
92
MANUAL  OF OBSTETRIC*.
above  head of child ;  variations, before head, around a limb,
around neck (one case in 9 or 10), sometimes causes delay in
labor, sometimes strangles child.  Continues to  pulsate  some-
times 15 or 20 minutes  after birth; even more; is weakest  3
or 4 inches from umbilicus.
  Abnormities.—1st, vessels may divide before reaching placen-
ta.   2nd, two veins and one artery ; one of each ; three arteries.
3rd, two cords and  one child.   4th, knots which  by  being
drawn during labor may stop circulation.   5th, vessels closed.
6th, absence of  funis  and umbilicus.  1th, insertion into some
other part  of foetus than umbilicus.  Sth, may contain a portion
of intestine.  9th, communication between two cords in  twins.
10^, inserted into wrong part of decidua.   11th, twists im-
pairing nutrition of foetus.  12th, varicose or hydatidic.  13th,
coats rupture and hemorrhage.  14th, torn by falls.
  In some cases a limb has been  found almost, in  some  quite,
amputated, by the  encircling cord.
  The  Embryo.—The  ovum  exists before impregnation;
then is called embryo till third month; fcetus, as long as in
utero;  child, or infant, after birth.
   Resuming the  account from  page 62,  " The  germinal
membrane consisting of a layer of epithelium-like cells, incloses
the yelk, lying in contact with the internal surface of the zona
pellucida.   Soon after its  formation  there is produced  on its
surface an  opaque spot, the germinal area, and here  the embryo
is first  developed.  About this time the germinal membrane
becomes divisible into two layers.   The superior  or external
lies next to the zona pellucida, and is called the serous  layer,
from  it are developed the organs  of  animal life, e. g.  bones,
muscles, and integument; the inferior  or  internal  division in
contact with the yelk itself is  called the mucous  layer, and
forms the viscera.   At first  the area  germinativa  is rounded,
but soon  becomes oval, then  pear-shaped, and  during this
change  there  appears the  area pellucida, and  between  the
mucous and serous layers, the area  vasculosa, from which the
blood-vessels are formed.  The first trace of the embryo  in the 
                  MANUAL OF  OBSTETRICS.                93'

centre  of  the  area  pellucida is a groove, the nota primitivaj
formed  in the serous layer, it is wider at  the anterior or
cephalic extremity, and  tapers  towards  the other extremity.
Coincidently with the primitive groove are formed two oval
masses of cells, one on each side of the groove, the lamince
dorsales ;  these rise into two prominent masses, turning their
edges inwards over the groove.  Their form changes from oval
to pyriform, and finally guitar shape.  The inner side of each
of these masses  adjoining  the groove  becomes' pellucid and
developes  into nervous substance.  The parts from the opposite
sides unite and form a tube, which is the central canal of  the
cerebro-spinal axis;  the nervous matter becomes  the rudi-
mental spinal cord, and these  are the first parts developed.
Three cerebral vesicles are formed  before the primitive groove
is closed  over;  the  upper dilating  into three pouches;  the
caudal  extremity of  the groove  dilates into a lancet-shaped
pouch corresponding to the cauda equina.   The closure of the
canal by the nervous layers begins at the  middle, and at  the
same time the other parts  of the laminae  dorsales unite  and
form the rudiments of the head and dorsal  part  of the body.
Immediately beneath the groove is seen a linear mass of cells,
the  chorda dorsalis, around which  the vertebral  column is
developed.  The earliest indications of vertebrae are in square
plates.  While the dorsal laminae  are closing thick prolonga-
tions of the serous layer  are  given off from the laminae ven-
trales ; these bend downwards and  inwards towards the cavity of
the yelk,  where they unite and form  the anterior walls of the
trunk.  During these changes  the area vasculosa forms, which
may be considered the third or middle layer of the germinal
membrane.  At the circumference  of  the area  isolated  red
spots are  seen, which soon unite and form vessels ; the margin
of the vascular layer is at first  circular, and bounded by vessels
united in the circulus venosus.   About the same time the heart
is formed by the  vascular layer bending  down  from  the
cephalic extremity so as to inclose the anterior part of  the
cavity  of the body.  The blood-vessels are developed from
                              8 
94
MANUAL OF OBSTETRICS.
nucleated cells,  which send processes, unite, and thus produce
a net-work.   From this net-work in the area vasculosa, vessels
extend into the area  pellucida and  join the incipient heart,
which is at first a tube, prolonged inferiorly into two venous
trunks, and superiorly  into three or more aortic arches, which
unite beneath the vertebral column and form the aorta.  At first
the  aorta divides  into two branches, the omphalo-mesenteric,
which terminate in the sinus terminalis, and thence the blood
is returned  by the  omphalo-mesenteric  veins.    Finally the
sinus terminalis disappears and vessels  cover  the yelk-bag.
Meanwhile  the embryo becomes  boat-shaped ;  the cephalic
end bends down and forwards, the germinal membrane follows,
and a fold is produced called  involucrum capitis.   Soon after
another fold of the membrane is formed at the caudal extremity
and presses from behind  forwards.   These  two  folds are
connected by that  part of the embryo which passes off from the
structures of the axis on each side into the expanded germinal
membrane.   Thus the embryo is  separated by a  construction
anteriorly,  posteriorly, and at sides, from the  rest of the
germinal  membrane;  the cavity is turned towards the  yelk.
The internal layer of the membrane forms the intestinal canal;
the external layer  subsequently developes into the walls of the
neck, chest, and abdomen.  Gradually the cephalic, caudal, and
lateral edges rise and extend over the body from the abdomen
to the back, meet, coalesce, and inclose the embryo in a sac—
the amnion. The inner of the two layers  forms  the amniotic
sac, the inner lines  the internal surface  of the chorion.   The
amnion is continuous with the skin at the umbilicus, which at
first is  wide, and gradually closes.  The inner  layer of the
germinal membrane remains continuous with  the intestinal
canal;  the  constricted part is  called the omphalo-mesenteric
duct; the inner layer  having  at this  period extended over the
whole  yelk has become  the  umbilical vesicle.   By the  con-
striction at the umbilicus the body of  the embryo becomes
mostly detached from the umbilical vesicle, though the cavity
of the intestine still communicates with it  through the duct. 
MANUAL  OF OBSTETRICS.
95
The yelk sac contains nutriment for the embryo, but its  func-
tion  ceases early.  On the walls of this sac the omphalo-me-
senteric vessels  ramify; an artery and two veins.  While the
vesicle is forming a pear-shaped mass  of cells projects from the
caudal extremity of the  embryo  and becomes the allantois,
upon the walls  of which the future umbilical arteries and vein
develope.   It grows  rapidly, reaches the chorion, in the villi of
which the umbilical vessels unite  in the  formation  of the
placenta.  As the abdominal cavity closes, the allantois becomes
constricted into two portions, the larger  proceeding to the
chorion, the less is retained in the abdomen, and becomes the
bladder ;  the constricted part between the two is the urachus.
   DIMENSIONS  OF EMBRYO.—About the third week, it is
oblong, swollen in the middle, obtuse  at one extremity, and
pointed at the other, somewhat curved forwards; color, greyish
white; consistence,  gelatinous;  length,  two  to  four lines;
weight, one to two grains.  The head  appears  as a  small
tubercle, separated from the body by  a notch.   No extremities
seen.  It  is  surrounded by the amnion.   The abdominal cavity
is open ;  the heart is beyond it, consisting  of a single auricle
and ventricle.
   At fifth week:  Head  has greatly  increased; eyes  seen as
two dark spots ; superior extremities seen like two obtuse  teats;
length, two-thirds of an  inch;  weight, 15 grs.   The funis can
be seen;  the inferior extremities seem  rounded pimples;  the
divisions of the vertebrae can  be seen.  Heart, interventricular
septum seen, but incomplete.  Lungs  seen as five or six lobules,
in which bronchi  terminate  in cul-de-sacs.   The  Wolffian
bodies, or temporary kidneys, constituted of  an excretory  canal,
are seen along the vertebral column, extending from the lung
to the pelvis.   Alongside of this canal  is  seen another tube,
which becomes either the oviduct or vas deferens.
   Early in life are seen on the neck four  fissures analogous to
branchiae, and  to these the aorta sends four branches, but they
become  obliterated, and the vessels  become  the arch of the
 aorta and  pulmonary artery.  One  branchial  fissure is con- 
. 96
MANUAL OF OBSTETRICS.
verted into the external ear.  The upper jaw  is composed of
two pieces, which close.  The nostrils are separate;  and if de-
velopment is arrested, hare-lip follows.
  At seventh week : Ossification seen in clavicle and lower jaw.
The intestine still extends into the funis.  The omphalo-mesen-
teric  canal  is almost  obliterated.  The  anus  remains  closed.
Kidneys and capsulae renal es begin to appear, and soon after the
sexual organs.  Bladder is seen as a tumor- continuous with
urachus.  Length of embryo, one inch.
  At two months :  Forearm and hand seen, but not the arm;
no fingers.  Funis  not spiral, four or five lines  long, inserted
low.   Organs of generation seen, but difficult to discriminate
from length of clitoris.  Embryo 1^ to 2 inches long; weight,
3 to 6 drachms ; head forms about one-third.   Eyes seen, not
covered by  lids ; nose an obtuse  eminence; nostrils  round and
separate ; mouth gaping.   Epidermis distinguishable.
   At tenth  week: Length,  1 \ to 2\ inches; weight  1 ounce to
\\.   Eyelids  cover eyes.   Lips  develope.  Parietes of thorax
seen, and heart no  longer visible.   Fingers distinct, but at first
are webbed.  Funis becoming spiral, still  contains intestine;
not inserted so low.
   At end, of third month :  Weight, 3 to 4 ounces; length, 5 to
7 inches.   Eye-ball  seen  through lids, membrana pupillaria
seen.  Forehead and nose seen ; lips well marked.   Funis con-
tains no intestine ;  spiral turns well seen.   Nails appear.  In-
tegument rosy.   Sex distinct.
   At fourth month : Embryo becomes foetus.   Length, 6 to 8
inches ;,weight, 7 to 8 ounces.   Fontanelles large, as also are
sutures.   Hair seen on head.   Eyes, nostrils, and  mouth are
closed.  Tongue and chin  seen.  Skin rosy, with down  on it.
Muscles capable of motion.   Cord inserted higher.
   At five months: Length, 8 to 10 inches; weight, 8 to 11 oz.
   At six months: Length,  11  to 12£  inches;  weight, 1 lb.
Hair  seen  longer and thicker.   Nails solid.   Scrotum small,
red, and empty.
   At seven  months : Length, 12$ to 14 inches.  All parts more 
                  MANUAL  OF OBSTETRICS.                97

developed.  Membrana pupillaris disappears.   Palpebrae partly
open.  Descent of testicles begins.
  At eight months : Length, 16 to 18 inches ;  weight, 4 to 5 lbs.
  At term:  Length,  19  to 23  inches;  weight, 6 lbs.  to 7
(average) ; 10, 11, 12, occur, and even 16  alleged.
  Secretion of Bile: Noticed at about five  months, and con-
tinues.
  Meconium : A dark green, semi-fluid  substance, existing in
the foetal intestines.   At  an early period  the intestinal canal
contains  but little fluid ; about  third month more abundant
secretion occurs.  Before  fifth month the  meconium exists in
small intestine only, and is greenish brown ;  after that it accu-
mulates in large intestine  and becomes darker.  It is a mixture
of bile with the products secreted by the mucous membrane;
said to be digested liquor  amnii.
   Urine : Never entirely  fills bladder at birth ; sometimes not
evacuated for several hours after birth.
  Characteristics  of Full Development.—Ability to cry ;
moves limbs readily ; body clear  red ; mouth, eyelids, nostrils,
and ears open ; cranial bones firm, and edges of fontanelles not
far  apart; hair,  eye-brows, and nails developed ; discharge of
meconium within a few hours after birth ; capability of sucking.
  Of Immaturity.—Small in size ; motions feeble ;  inability to
suck; skin intense red, with blue streaks; head  covered with
down; bones soft; fontanelles wide;  nails  not  formed; eye-
lids, nostrils, and mouth closed ;  stools and urination imperfect.
   Vernix Caseosa ; or Smegma : An unctuous yellowish white
substance that covers foetus more or less completely;  in some
almost absent; most about head, axillae,  and groins.
  Is the effete epidermis, with the secretion of sebaceous glands.
  Is insoluble in water, alcohol, and oil,  partially in potash.
  Position of child in  utero :  Formerly supposed to be sitting,
and that it revolved—not so.  It is usually unaltered through-
out gestation ; the arms are folded  on chest, knees drawn up,
feet crossed,  back curved, head  bent forwards.  In  first and
second position,  the  back  is partly forwards;  in  third and
                             8* 
98
MANUAL OF OBSTETRICS.
fourth, the chest is.  But  the  determinate  position is  not  as-
sumed till about the sixth  month, perhaps not till later.
  DIMENSIONS  OF  FCETUS  AT TERM—Length,  18,  22,
24 inches.   Weight, average 7 lbs.
  Diameters  of  Fcetal  Head.—Longitudinal or  Antero-
posterior, from forehead to occiput, 4—4^  inches ;  Transverse
or Bi-Parietal, between parietal bosses, 3{—4 ; Occipito-Mental
or Oblique, from posterior fontanelle to chin, 5 ; Cervico-Breg-
matic, perpendicularly from highest part of sagittal suture, 4—
4£;  Occipito-Bregmatic, from anterior  fontanelle to midway
between occipital  protuberance and foramen  magnum, 3$;
Inter-Auricular, 3; Fronto-Mental or  Facial,  from frontal
boss to point of chin, 3—3^.
   Circumferences  of Head.— Occipito-Frontal; Occipito-
Mental, the largest;   Sub-Occipito-Bregmatic, runs  through
extremities of bi-parietal and occipito-bregmatic diameters. This
and the preceding are the important ones.   Facial or Fronto-
Mental.
   The diameters  are  not  invariable.  The head in  difficult
 labors elongates in course of occipito-mental diameter, and flat-
 tens transversely.   By instruments, the bi-parietal may be re-
 duced one-third of an inch.
   Shoulders  Transverse, 4f—5£.   Hips  Transverse,  4—5.
 Thorax Antero.-Post. 4\.
COMPARATIVE VIEW OF PELVIC AND F03TAL DIAMETERS.					
•	Antero-Postbrior.	Transverse.		Oblique.	Sacro-Cotyloid.
Superior Strait, Inferior Strait, Excavation,	4 inches. 4—5. 41-5 J.	5i inches. 4 41		5 inches. 4|	3 ins. 10 lines.
LoNGITUDINi Occipito-Mental, Occipito-Frontal Sub-Occipito-Br	FCET IL DlAMKTEES. 5 inches. , 4-4*. egmatic, 3|.	AL	HEAD. Bi Parit Bi-Temj Trachec Fronto-	Transve tal, 3 inchei Doral, 2£. >-Bregmatic, Mental, 3}.	EtSE. ). H—4.
 
MANUAL OF OBSTETRICS.
99
  By comparing these  diameters, it will be seen that, in order
for  the  head to pass,  it must present either the occipital  or
mental end of the long diameter.
  Besides the diameters, the foetal skull possesses points of in-
terest in the fontanelles and sutures.
  Anterior  or Greater Fontanelle or Bregma.—Formed
at the junction of the sagittal, coronal, and frontal  sutures ; is
quadrilateral with  four angles, or lozenge-shaped; sometimes
prolonged down the frontal bone.
  Posterior or Occipital Fontanelle.—Smaller than pre-
ceding ; formed by union, of  the two limbs of the lambdoidal
suture with the sagittal; is  triangular with three  angles;  in
rare cases has four, from non-union of occipital bone; recog-
nise it by the acute angle of the lambdoidal suture.
  The Sutures, of interest, are sagittal, frontal, and lambdoi-
dal, because they indicate the position of the head.
  Advantages of Sutures, &c.:  To allow edges to ride over
during  labor; again it is thought that compression of fcetal
head causes insensibilityand prevents struggles.
  The heads of boys are larger than those of girls, J?th or J„th;
hence more males are still-born than females, 14 to  10.  Labors
with males are severer.
  More males than females are born, 106—100.  A country
life seems to favor the  production of males.
  The relative age of the parents exerts an influence.   Upon a
mean number of births, the sex of the child is that of the parent
whose age is  in excess.
  By Emerson in Philad., it was found that the maximum of
conceptions occurred in winter and spring, especially the latter;
the smallest number in summer and autumn, the minimum in
summer.  Abundance of food seems to favor male conceptions.
Scarcity, female.  The occurrence of epidemics  induces female
births.
  Sources  of Foetal Nutrition.—At first by imbibition
through villi  of chorion.  The  umbilical vesicle is  thought' to
contribute.  Liquor amnii most probable source.  It is absorbed 
100
manual of obstetrics.
by cutaneous surface, for a foetus has been found without pla-
centa,  funis,  mouth, or anus.  It  is also swallowed, for hairs
have  been found in  it  and epithelium.   The  meconium is
thought  to be  the  result of digestion.  Calves  have been
nourished for two weeks  upon it.   (How is  nutrition effected
in cases where liq. amnii  is evacuated weeks before delivery ?)
The placenta is rather an organ of hematosis than of nutrition.
   Other sources are  said to be milky juice of utricular glands,
gelatine of cord, allantois.
   Fcetal Circulation.—The peculiarities are the ductus
venosus, foramen ovale,  ductus arteriosus, umbilical arteries,
umbilical vein.
   Ductus Venosus.—Communicates between umbilical  vein
and inferior cava.  Just at the point where the two fissures of
the liver intersect, the umbilical  vein divides;  the  posterior
branch, called the ductus  venosus, goes  sometimes to the vena
cava, sometimes, though  rarely, to one of the hepatic veins, and
then empties  into the cava ; the other branch  unites  with the
vena porta, and ramifies through the liver, subsequently going
to the cava.
   Foramen Ovale.—Foramen of  Botal: Exists  in the inter-
auricular septum.
   Ductus Arteriosus.—Communicates  between  pulmonary
artery and aorta, entering aorta on  its transverse arch.
   Umbilical  Arteries.—Two in number.  Branches of inter-
nal iliac or hypogastric arteries ;  pass to sides of bladder, ascend
through the umbilicus and along the cord.
  Course  of Blood.—Satatier's, or figure of eight theory.—
Blood enters by umbilical vein; part goes to vena cava through
ductus venosus,  part to liver and through portal  circulation,
thence through hepatic veins to cava, thence into right auricle,
thence through foramen ovale into left auricle, thence into left
ventricle, thence through  aorta and  its various branches, &c.;
the major part returning  by the umbilical arteries.  The blood
of the superior cava  returns into right auricle,  thence to right
ventricle, thence to pulmonary artery, a little to the lungs, the 
MANUAL OF OBSTETRICS.
101
main  stream through  ductus arteriosus, where  all the blood
commingles.
   Winslow's theory.—The blood passes into right auricle as in
adult; thence a part through  the right ventricle; pulmonary
artery, and ductus arteriosus,  into  the aorta;  another  and
larger part through foramen ovale into left auricle, thence to
left ventricle, thence through aorta and its branches.
   The foetal pulse is not synchronous with maternal;  it beats
120 to 150.
   State of lungs before birth.—Small, unaerated, dense and
firm,  small branches pass from  pulmonary artery  for  their
nutrition ; function not yet required.
   Immediately upon respiration,  the  current of blood is di-
verted to the lungs, the ductus arteriosus is useless, the foramen
ovale is closed by the valve developed for that purpose,  and the
usual mode of circulation  obtains.
   The umbilical arteries close on the 2nd day, and in three weeks
are coaverted into a cord.
   The umbilical vein and ductus venosus are contracted on the
4th day, and closed on the 7th.
   The ductus arteriosus andforamen ovale rarely persist beyond
eight or nine days, but sometimes the foramen ovale is persis-
tent through life;  sometimes causes one form.of the  morbid
state known as morbus coeruleus.
   The ductus arteriosus and umbilical arteries become oblite-
rated by hypertrophy  of the walls; the ductus venosus and
umbilical vein simply because no blood traverses them.
   Pathology of Foetus.—May be affected with  numerous
diseases  in  utero;  either coincidently, or independently of
mother.   Instances  known of  Intermittent  Fever, Variola,
Rubeola, various cutaneous eruptions, Hydrocephalus, Pleurisy,
Abscesses, OZdema, Tubercle,  Peritonitis,  Enteritis,  Hyper-
trophy, Atrophy, Syphilis, Worms, Rickets, Caries, Necrosis,
Pertussis.
   Death of Foetus.—A knowledge of  it  is frequently  of
importance, especially in reference to obstetric  operations. 
102.
MANUAL  OF OBSTETRICS.
  It is difficult to ascertain the fact.
  Signs.—1. Cessation of motion.  2. Subsidence and flaccidity
of abdomen.   3.  Recession  of umbilicus.  4. Loose feel of
uterine  tumor.  5. Sensations  of rolling  in  abdomen, also
weight  and coldness.  6. Breasts becoming flaccid and milk
suppressed.   7. Health  deteriorated.   8.  Appetite  bad.  9.
Countenance sunk, areola around eyes.  10. Fetid breath. 11.
Rigors.  12. Loss of auscultatory phenomena.
  Separately these signs are not reliable;  a number conjoined
makes death probable.
  Fallacies.—Motion is frequently  suspended without  cause;
woman's account not to be trusted.   Sense of coldness no value.
Sense of rolling may occur and yet foetus alive; may proceed from
loss of tone of abdominal muscles.  General health deteriorated
by other causes.  Breasts seldom become flaccid after being
tense without death.
  A dead foetus may be retained for months without these signs;
or may be retained and motion  fancied.  Auscultation may
not give information,  for practical  tact may be  deficient,  or
sound inaudible.
  After rupture of membrane, liq. amnii  may be dark, thick,
bloody, or even fetid, and child alive.   More certain signs are
—1. Emphysematous feel of scalp.  2. Peeling of cuticle.  3.
Loose overlapping of bones.   4. A peculiar sharpness of edges
of bones.
  In face presentations, lips flabby, tongue flaccid and motion-
less.
  In breech, sphincter ani readily admits finger;  discharge of
meconium in no presentation a sign of death.
  In arm presentation pulse may cease, arm be discolored, and
yet alive; but if cuticle peel,  child is dead.
  In funis  presentations, absence of pulsation not  always a
sign of death.
  Superfoetation.—Def.  A second impregnation while the
uterus contains an embryo or foetus.
  Much doubt as to its possibility. 
                 MANUAL OF OBSTETRICS.                103

   Cases giving rise to this opinion are—1.  A full grown foetus
and a blighted ovum delivered together.   2. A twin birth, one
fully developed, the other immature.   3. Twins  of  different
colors.  4. Cases in which a mature child is  born and some
months after it a second mature child ; instances of 4J months
interval, 3 months.
   First and  second classes prove nothing, only a blighting  of
one ovum in a twin conception, or else a difference of  develop-
ment ; in such cases the living child is usually vigorous. Third
class requires a speedy succession of coitions.   Fourth class—
one case explained by existence of double uterus.
   Obstacles to second impregnation are decidua, plug of mucus
in cervix uteri.
   Extra Uterine  Pregnancy.—Three  forms  said   to
exist.
   Ovarian, Tubal, and Interstitial; some recognise  a fourth,
Ventral.
   Ovarian ; doubted by some.
   Tubal  most common form, for  impregnation occurs in the
tube.
   Interstitial very  rare.
   Causes conjectural only.
   Symptoms.—Sometimes resemble disease of uterus or ovaries.
Usually  much  suffering from  an  early  period.   Not easily
made out before 3d month.  Certain signs of pregnancy may
be present, but irregular ; thus, menstruation may be regular or
suppressed,  absent, profuse; the mammary changes  occur;
nausea may occur; foetal motion  early perceived;  abdomen
increases on one side and pain localized in the tumor; sense of
weight and uneasiness in kidneys and pelvis ;  per vaginam os
is high or depressed, but not dilated; cervix undeveloped;  a
constant circumscribed pain in groin.
   When  cyst ruptures (which is ordinary termination) great
uneasiness or  pain suddenly occurs, languor,  debility, extreme
exhaustion, sometimes bloody discharge from vagina, dysuria,
tenesmus, irritable  stomach, collapse from loss of blood. 
104
MANUAL OF OBSTETRICS.
  These  symptoms more sudden in tubal;  interstitial  also
rapidly;  the crisis accelerated  by  violent motions,  shocks,
blows, coughing, vomiting.
  Termination.—Commonly  terminates  before  fifth month;
sudden by shock, hemorrhage, inflammation;  or survive  and
recover a measure of health ; may even conceive again, instances
one to seven times.
  Foetus may be retained from. 3  months to 56 years.   Mont-
gomery,  an instance, woman lived till 94, had foetus in abdo-
men for  46 years, and during this time bore two children.  A
pseudo-bony cyst may form ;  abscess may form and foetus be
evacuated piecemeal through  abdominal  integuments,  groin,
umbilicus,  epigastrium,  colon, rectum, vagina, or  bladder, in
which last sometime^ fragments have  formed the nucleus of
a calculus.
  Foetus may live till 9 months, rarely, however, beyond 3rd
or 4th.   The development proceeds as usual, and even a quasi
decidua is formed.  At term  a pseudo labor may occur.
  Treatment.—First indication is to retard rupture of cyst;
avoid exertion,  uterine irritation and  pressure; if uneasiness
occurs, VS. leeches, and opium.
  If rupture occur, the indication will be to moderate effusion
and  to support  strength.  Hard  bed,  head  low, binder to
abdomen, ice, acet. plumb., broths, stimulants.
  If inflammation set in, use opium as  for peritonitis, VS.,
cal. et opium, blisters.*
  After rupture, foetus dies ;  keep quiet, bowels open, leeches
and anodynes for renewed pain.
  If abscess forms, caution is requisite in opening, lest hemor-
rhage ensue.
  Gastrotomy has saved a few cases.
  Abortion.—Def.  Expulsion  of  the embryo before it is '
viable.  Foetus  is  viable at 7 months or  64- months.  Every
foetus that moves at birth is  not viable—instances of children
reared, born at beginning of 6th month, at 6 months and 10
days. 
MANUAL OF OBSTETRICS.
105
  A case by Dr. Barrows of Hartford in Amer. Jour, of Med.
Sciences for April, 1853, gives  an example of a female child,
born before the completion of the fifth month, 10 inches long,
weight 14 ounces; evinced respiration, pulse, voluntary motion,
and utterance of sound for forty-five minutes.  The particulars
are given with minute fidelity.
  Premature delivery is applied  to  expulsion after viability.
Miscarriage is the popular term for all immature expulsion.
  Danger, popularly lightly esteemed.   Ingleby records 4 fatal
cases from hemorrhage, Denman 2, Whitehead 3.
  Frequency, 1 in 78£; is the most frequent form in which
hemorrhage  presents.   Few women  pass  through menstrual
life without aborting, 8 only in 64.  Thought that first preg-
nancies most liable; doubtful, if the cases produced designedly
are thrown out of consideration.  Male conceptions supposed
most liable, but it is difficult to determine sex.
   Divisions.—Spontaneous, arising without obvious cause.
   Accidental, produced by injury, &c.  Designed.
   Class  of Society.—Most frequent in extremes.
   Kind of Women.—Plethoric, nervous and irritable, indolent,
 dissipated.  Constitutionally diseased, ex. gr. syphilis.  Organic
 uterine  disease.  Polypus; tumors,  especially  of  os.  Ad-
 hesions ;  displacements; acute diseases, as  variola, scarlatina,
 rubeola, typhus.
    Occurs at.—About third month most common, coincidently
 with menstrual  period ; many women  can recognise  the cata-
 menial period by  an imperfect nisus  for first three  months,
 some throughout gestation. Reason, irritation of ovarian nerves
 causes a nisus, afflux of blood, separation of recently formed
 placenta, hemorrhage, and abortion.
    Causes, Predisposing and Exciting ;  or better, Ovuline
 —Uterine—Constitutional—Accidental.
    Ovuline, very common.   Still-born in Europe 1 in 22 births
 —of 935 cases analysed, 71 occurred or 12| per cent, nearly.
 Hydrocephalus; pleuritis ;  peritonitis; variola  even without
 affecting  mother.   Syphilis; Convulsions and  Intermittent
                                9 
106
manual of  obstetrics.
said to occur in utero ; plurality of ova; placentitis ;  placen-
tary congestion;  fatty placenta; rupture of umbilical  vein—
diseases of chorion, of cord.
  Easy to understand why death of foetus  gives rise to expul-
sion,  a foreign  body excites  contraction.  But  considerable
time may elapse between death and expulsion.
  Uterine Causes.—One said to be irritability  of  uterine
fibre (a phrase  to conceal ignorance).  Retroversion  ;  ante-
version ;   adhesions;   fibrous   tumors;   polypus;   cancer;
cauliflower  excrescence ;  corroding ulcer ;  placenta praevia ;
ulcerations  of cervix  in various forms;   endo-uteritis;  dys-
menorrhcea.
  Constitutional  Causes.—Syphilis—Tuberculous  disease
(phthisical women  are peculiarly susceptible of impregnation),
variola and other acute diseases. Uraemia said to be ; miasmatic
residence; Scorbutic diathesis.  Tight-lacing ; and analogously,
abdominal  tumors.  Irritation of dens sapientiae and  extrac-
tion ;  protracted  lactation; women advanced  in life with first
pregnancy said often  to be the subjects of  abortion.  Cystitis;
diarrhoea; dysentery ; ascarides ; constipation ;  piles ;  stran-
gury.
   Mechanical Causes.—Coitus ;  plugging vagina for hemor-
rhage ; puncturing membranes ; violent exercise, as horseback,
jolting over rough roads ; carrying heavy weights ; blows; falls;
sudden efforts ; vomiting ;  dancing.  The strong compression
in convulsions, hysteria, or epilepsy ; operations.
   Certain  Medicines.—Emetics ;   emmenagogues,  savine,
ergot, tansy; mercury ; bleeding;  opium.
   Emotional Causes.—Terror, <fec.
   Sometimes abortion seems epidemic.
   Assigned  Causes.—Odors ;   sights ;   laughter ;  crying;
itching; sneezing ; hot rooms ; hot baths ; pediluvia.
   Of these some are trivial, some mere coincidences.   Some
apparently likely to cause  abortion fail  in  this issue.  Strong
examples by Lachapelle, Mauriceau, Davis, Whitehead, Meigs,
and Lever. 
manual  of obstetrics.               107
  The truth is, if the ovum  is healthy, abortion is difficult to
produce; if diseased, the ovum is shed, as decayed fruit falls.
  The " habit of aborting " often assigned—a loose  phrase—
women will repeat these expulsions to a very considerable num-
ber ; 10—20—22 repetitions are recorded.
  [Tyler Smith's arrangement of causes. Eccentric, Centric,
and Emotional.
  Eccentric.—1st.  Irritation  of  mammary  nerves—pro-
longed lactation.
  2nd. Irritation  of trifacial nerves . by dens  sapientiae and
extraction.
  3rd. Irritation of vesical nerves by  calculus.
  4th.  Irritation of ovarian nerves, seen at menstrual period.
  5th.  Irritation of rectal nerves, piles, ascarides, purgatives,
enemata, diarrhoea, dysentery, constipation.
  6th.  Irritation of vaginal nerves, coitus, tampon.
  1th.  Irritation of uterine  nerves, separation of membranes,
disease of placenta, puncture of membranes, horse or carriage
exercise, coitus, tampon, vascular irritation and inflammation,
ulceration  of os, uterine displacements, placenta  praevia, tu-
mors, injuries.
  Centric, are exanthemata, inflammatory condition of blood,
as in fevers, syphilis, carbonic acid, albuminuria, savine, ergot.
  Emotional.  Terror, joy, &c]
  It  is important  to remember that usually several causes act
together, and also that some space of time may elapse between
the application of  the cause and  the production of the effect.
  The  application  of some cause coinciding  with a menstrual
period is more  likely to  produce.
  SYMPTOMS are modified, 1st, according to period of gesta-
tion ;  2nd, whether preceded or not by death of foetus; 3rd,
whether caused by violence.  In proportion  as near term the
ordinary phenomena of labor will present,  serious  or other-
wise,  according to complications.
  In  early months, especially if preceded by death of foetus,
but little noticed ; it may seem merely a deferred catamenial 
108
manual of obstetrics.
period, more pain and a greater discharge; such cases often seen
in dysmenorrhoeic women.
   If pregnancy  be somewhat advanced, fcetal death will  be
discovered by Signs (as  at page 101): death  may occur and
fcetus be retained till term.
   From violence, either accidental or designed; symptoms are
more severe, legal medicine  records many fatal cases.  Some-
times  a sharp pain  occurs at the time of an  accident, passes
away, and pains are renewed after some days.   Occasionally
an injury produces an immediate effect, ex. gr. a fall, and a large
issue of blood ;  this occurs in early abortions.
   Ordinary history is, some cause specified; and then pain
in back, followed by hemorrhage, increase of pain extending
into hypogastrium, expulsion.  To these are often added rigors,
lassitude, hot skin, accelerated pulse, thirst, palpitation, sense of
weight in pelvis, loins, and about anus, vesical tenesmus.
   The pains of abortion are often very severe, in fact are said
at times to be more intolerable than those of labor.
   Vaginal examination  detects hemorrhage more or less pro-
fuse, clots, dilatation of cervix and os, protrusion of membranes,
expulsion of ovum entire, rupture of  membranes and escape of
liquor  amnii, expulsion  of  embryo or fcetus,  subsequently of
secundines.
   PROGNOSIS.—By far the  majority of abortions do not
jeopardize life  immediately.  A few  cases  are fatal  at  once.
More secondarily.
   The question of most immediate interest is, will  expulsion
occur.  Consider,  1st, the  amount  of hemorrhage, and  see
personally the clothes.   2nd, if bleeding is continuing; (and to
decide  it, place a fresh  napkin to vulva, having previously
placed dry clothes beneath the hips.)   If  the hemorrhage is
profuse, abortion will usually occur;  but it may be very great
and repeated, and yet pregnancy continue.  It has been thought
that  if the bleeding  commences at fundus, abortion is  more
likely, for more extensive separation occurs  during the passage
down of the blood;  if near os, it readily escapes and uterus is 
MANUAL of obstetrics.
109
not distended.   If pains are regular, if they dilate os, if mem-
branes protrude,  abortion  almost inevitable.   If membranes
ruptured, is unavoidable.
   As  regards  the fatality, hemorrhage  is  the most  serious
circumstance;  phlebitis occasionally follows.
   Occurring during acute disease, abortion adds to the gravity
of prognosis.  Few deliveries  during variola recover.   Same
may  be said also of scarlatina,  rubeola, erysipelas, visceral
inflammation.   In typhus I have seen several instances of safe
issue; in one case of acute rheumatism, abortion was followed
by death.  " When acute diseases are not intense enough to
produce  abortiou, the patients are not in a worse condition for
treatment  than women who  are  not pregnant; but when
abortion takes place before the disease is cured it is  generally
fatal."   " Abortion or premature labor following acute disease
is rather a measure  of the violence  of that disease than an
active cause of the fatal result which may ensue."
   Accidental  is  more  serious   than  spontaneous.  Produced
abortion is dangerous,  from hemorrhage, metritis, peritonitis.
Difference  of opinion as to comparative  danger  of early and
later months.
   DIAGNOSIS.—Principally from dysmenorrhcea. Resembles
it in seat of pain, in effects, both are intermittent, and symptoms
cease  on expulsion.  Pains of dysmenorrhcea are said to precede
hemorrhage and mitigate in progress.    Shape of clot said to be
triano-ular in  dys.; not so in abortion, but pressure alters shape.
If a  clot can be  felt in os  uteri, it  may be confounded with
membranes,  but a clot does not  become tense  with pains.
Attend to history, .whether previous dys.; also to  causes likely
to produce abortion.  Finally if regular previously, and then a
cessation, if pains continued  and severe, abortion is in  progress.
Later in  pregnancy other signs  will throw light.
   Examine all  substances expelled.
   Mode of  Expulsion.—Sometimes in early months entire;
more  usually separately ; first  liq. amnii, embryo, placenta;
often  a fleshy mass with membrane attached to edge forming
                             9* 
110
manual  of obstetrics.
a  cavity;  embryo  sometimes  dissolved, leaving  a cavity;
placenta may pass in lochia, sometimes requiring a long time,
keeping  up  hemorrhage, and causing mistakes  for polypus
uteri.
   " Fleshy moles " occur from effusion of blood into placenta,
and  becoming organized.   Moles are always a  product of
conception.
   Sequelae.—Irritative fever, Phlebitis,  Peritonitis,  Metritis,
Ulceration of cervix,  Organic  disease  of  uterus, Anemia,
Menorrhagia, Dysmenorrhcea, Phthisis, Sterility.
   TREATMENT.—Preventive,  adapted to threatened or com-
menced.  That for hemorrhage.   That for sequelcs.
   Preventive : For ovuline  causes, for intrauterine diseases,
no remedial means avail.   For uterine causes, as malpositions,
restoration must be effected;  uterine sound inadmissible.  For
tumors, no remedy.   For ulceration of cervix, resort  to specu-
lum and nit.  argent., but avoid injections ;  rest; salines.  For
plethora,  regulate  diet  and exercise;   a  small  venesection
especially at  menstrual period;   avoid  coitus.  For  anemic
state, use tonic  regimen,  mineral and  vegetable  tonics.   Of
constitutional causes, syphilis alone is remediable; give mer-
cury.  Remove from miasmatic district.   Avoid  all  emotional
causes  and  all those called  accidental.  Stop lactation.  For
vesical and rectal irritation, use anodyne enemata  or supposi-
tories.   For  piles,  use laxatives, enemata,  diet, and  avoid
operations.    Constipation, diet,  enemata,  laxatives;  avoid
retention of  urine ;  avoid coitus strictly in  habitual, even  per-
haps for  a  year ; avoid active medicines and bleeding ; avoid
opium and mercury, unless for syphilis.
   In regard to rest, opinions differ, but at menstrual period, a
recumbent  position  should  be  maintained if  abortion  is
threatened ;  long walks, severe  exertion, and fatigue obviously
should be avoided.
   In Threatened Abortion :  If os is dilated  and yields to
pain, membranes  protrude, and there is much  hemorrhage,
expulsion will  seldom be prevented;  but if  os is closed, and 
MANUAL OF OBSTETRICS.
Ill
any chance left, give embryo the benefit of the doubt.  Indica-
tions  are,  1st, to  allay pain, by stopping uterine contractions.
2nd, to -control hemorrhage, by preventing- farther detachment
of ovum.   Place patient on a mattress, lightly covered ; but a
single attendant;  ensure perfect  tranquillity; diet, cold arrow-
root, jellies, gruel, crackers ;  drinks, lemonade, cream of tartar,
barley water, iced water.  Use blood-letting if strength permits,
and opiates  freely; opiates  by mouth  or rectum; excellent is
starch and laudanum enema ; opiate suppository; acet. plumb.
et opii grs. v  to gr. \ varying the proportions every two hours
pro re nata;  Tine. Cannabis Indica, 5 to 10 drops;  nauseants,
ant. tart, or ipecac.  Use opiates freely, and when pains have
 ceased, open bowels by enema or ol. ricini; not too early.
   If expulsion is inevitable, an active purge aided by an enema
 of-turpentine will often accomplish it.
    For the hemorrhage, if not severe, cold, by cloths or ice to
 hypogastrium and pubes, or ice in vagina, or cold enema, aided
 by rest, &c, will  often suffice.  These failing, pass a piece of
 alum close against os uteri; if bleeding continues, add a vaginal
 tampon, of pieces of muslin, tow, silk-kerchief, sponge, or com-
 pressed  sponge in cervix.  A  tampon must  not  be left too
 long, twenty-four hours  usually sufficient;  sometimes causes
 retention of urine;  requires catheter.  Ergot in  tincture or
 infusion.
    Sometimes  vomiting  will   produce expulsion  and  stop
 hemorrhage.
    In very  early  abortions the hemorrhage seldom requires
 interference;  as pregnancy  advances  and vessels are larger, of
 course  more discharge  occurs;  later still, however, though
 bleeding be severe  when abortion takes  place, there is less
 chance of flooding.   Nevertheless even before four months,
 much blood may be lost.  Ingleby says six quarts in one case.
- With dead foetuses there is usually but little hemorrhage.  If
 pregnancy be advanced  to six months, and bleeding is profuse,
  rupture membranes; and if urgent, deliver manually.  Rupture
  of membranes in early abortions is at no time to be  practised. 
112
MANUAL OF  OBSTETRICS.
If a part  of  embryo  is expelled and  placenta remains, there
may  occur a  draining  hemorrhage  lasting  for  weeks, or
phlebitis,  <fec.  Such  cases  may  extend  over  weeks or even
months.   Examine os carefully with  finger, and if ovum  is
partly within  and partly  without os,  detach and  remove it.
If hemorrhage is threatening, press firmly with  left  hand over
fundus uteri,  and  pass one or more fingers into vagina, and
with one finger detach and remove.  Instruments used for this
purpose, such as Dewees' wire-crotchet, Bond placental forceps.
Ergot rarely  succeeds.   Try  turpentine  enema.   If cannot
remove, use vaginal injections of tepid water, and if offensive
odor, a dilute solution of chloride of soda.
   In the  exhaustion from  loss  of  blood the diet  must be
improved and even stimulant  allowed, as hereafter in uterine
hemorrhage.   A bandage and rest are proper, as after ordinary
labor.  Milk is secreted, and lochia discharged,  as usual, if the
gestation has advanced.
   Parturition ; the function by which the product of con-
ception is expelled from the  mother.
   Occurs, at 9 calendar months,  and  one week;  10 lunar
months ;  40  weeks ;  280 days ;  (Variations, see Duration of
Pregnancy.)
   To calculate : Naegele says, note the last day of  menstrua-
tion, reckon back three months, and add 7 days, this fixes the
day—thus, menstruated June 10, 3 months backwards March
10th, add 7 days March 17th.
   Meigs computes 3 months backwards from last day of cata-
menia.
   Determining  Cause  of  Labor,  not  known—various
theories.   Most popular the coincidence of  labor  with 10th
menstrual period—but some  women menstruate  every 3 weeks,
others  6.
   Efficient  Cause, in first  stage, uterus—in second stage ab-
dominal muscles aid.
   Evidences of uterine agency :  Strong contractions in version 
MANUAL OF OBSTETRICS.
113
 —foetus expelled  in case of paralysis, of prolapsus, after death
 of mother, during syncope, asphyxia, convulsions.
   " Labor may occur in cerebral paralysis where volition only
 is withdrawn—in  coma, where volition and emotion are both
 withdrawn—in paraplegia, where volition, emotion, and respi-
 ratory reflex action are cut off. Sometimes, though rarely, where
 nothing but peristaltic action only remains."
   Evidence of action  of abdominal muscles—affected by voli-
 tion.  Baudelocque's case.
   Anger, fear, surprise, will suspend labor.
   Mechanism  of Labor.—-Presentations of the vertex
 in different positions are by far the most common.   According
 to  Merriman  1664 in  1800; Bland 1792 in  1897 ; Boivin
 19,730 in 20,357 ; Lachapelle 14,677 in 15,652, and 20,698 in
 22,243; Naegele  1210  in 1296 ;  Lovati  61 in 67; Velpeau
 392 in 400 ; Smellie 920 in 1000 ; Siebold 132 in 137 ; Kluge
 257 in 298 ; Mazzini  439 in 452 ; Ramoux 266 in 275 ; Pa-
 cord 49 in 53; P.  Dubois 10,262  in 10,742 ; Riecke 214,134
 in 219,258.
   Of the vertex, there are two fundamental presentations—the
 occiput either  anterior or posterior to the transverse diameter,
 hence  divisions  OCCIPITO-ANTERIOR  and OCCIPITO-
 POSTERIOR.  Of these the Occip.-Anter. are much the most
 frequent.
  Each of these presentations admits of three positions, or more
 simply two.   They are, 1st,  Left Occipito-Anterior ; 2nd,
 Right Occipito-Anterior, and  3rd,  Occipito-Pubic ;  4th,
 Left Occipito-Posterior ; 5th, Right Occipito-Posterior ;
 6th, Occipito-Sacral.  Of these  the  3rd and  6th  occur so
 rarely as to be believed impossible by some.  Other designa-
 tions are given  as, 1st, Left Occipito-Cotyloid or Acetabular ;
 4th, is Left Fronto-Acetabular ; 6th, is Fronto-Pubic,
  OCCIPITO-ANTERIOR POSITION, frequency supposed to
depend on the weight of occiput inclining to the most dependent
part of uterus, which is  anterior by  reason of the  inclination
of pelvis. Includes three varieties, 1st, Occipito-Anterior Posi- 
114
MANUAL  OF OBSTETRICS.
tion.  Frequency 69 per cent. (Naegele), supposed to depend
on rectum  pressing  the face towards  right  side.  Position of
child is back towards front and left of mother's abdomen—fcetal
abdomen towards back and right—occciput behind ilio-pectineal
eminence—anterior-fontanelle towards right sacro-iliac symphy-
sis.  Sagittal  suture is  in right oblique diameter, trace it for-
wards  and find  posterior fontanelle ; trace backwards towards
anterior fontanelle.  On examination the finger touches the
right parietal boss.
   To be expelled, the head requires three motions. 1st, Flexion,
2nd, Rotation,  3rd, Extension.  After expulsion, it executes
another, 4th, Restitution.
   Flexion.—The child's chin normally is close to the chest, but
uterine contraction acting on the foetus and resisted by the cer-
vix, causes  increased flexion ; by  this the occiput is depressed,
the occipito-bregmatic diameter becomes parallel to one oblique
diameter, and the bi-parietal  to the other, the occipito-mental
diameter parallel to axis of pelvic circle, the occipito-bregmatic
circumference corresponds to plane of superior strait.  Urged
by contraction, the head now descends  till checked by sciatic
ligaments  and anterior inclined plane, and a second  motion is
given,  Rotation.  The occiput slides on the  left anterior plane
of ischium in order to place itself behind the pubes—the fore-
head slides on  right plane towards hollow of sacrum.  This
motion is not completed till head emerges from bones. During
it the sacral plexuses are compressed and cramps occuri
   Extension.—Hitherto flexion has  increased, but now the chin
quits the chest,  and the head is slowly extended backwards;
the object is that occipito-mental diameter may be parallel with
axis of outlet, while  the rest of body still follows central line of
superior strait.   The bi-parietal diameter corresponds to bis-is-
chiatic—occipito-bregmatic to  coccy-pubal. The maximum dia-
meters correspond.  At this time straining and tenesmus occur
—the  perineum  dilates.   The  transverse  diameter of the
shoulders still occupies the oblique diameter.  The head now
distends vulva, and slides along  coccygeal and perineal plane, 
MANUAL  OF OBSTETRICS.
115
labia majora are effaced, nymphae  pressed  up, skin of thighs
sometimes yields, parietal bosses pass the bis-ischiatic diameter,
and head is soon expelled.   Meanwhile occiput rests under arch
of pubes, and the rest  of  head emerges in following order;
sagittal suture,  parietal bosses, anterior fontanelle, os frontis,
orbits, mouth, chin.
   Restitution.—Free  now from any force, the head resumes
its  relation to trunk,  and face  looks towards right thigh of
mother.   Shoulders follow head  upon  the  planes—the great
diameter corresponding to  oblique of pelvis, the right rotates
towards pubes and remains as a pivot, the trunk bends, and left
shoulder emerges first.
   The rest of fcetus  usually follows immediately.
   2nd. Right Occipito-Anterior.—Frequency.  Naegele says
.07 as an original position, though more cases terminate in this
position.
   Posterior  fontanelle lies to  right  ilio-pectineal eminence.
Occipito-bregmatic diameter in oblique diameter  from  right to
left.
   Flexion is as before.   Rotation from right to left.  Extension
as  before.   Restitution towards left thigh.   Shoulders the
counterpart of preceding.   Thought not to be so favorable  as
first.
   3rd. Occipito-Pubic.—Rarity. Boivin 6 in 20.517.  Dewees
3 cases.   Bi-parietal diameter is in transverse.   Occipito-breg-
matic in the antero-posterior.  Rotation is not necessary.  Re-
stitution doubtful which way.
   OCCIPITO-POSTERIOR POSITIONS.—Frequency.  Nae-
gele 29  per cent.  Are less favorable  than Occipito-Anterior.
Reasons, 1st.   Occiput must pass over an extent of seven inches
instead of two.    2nd. Head is driven continually  against the
posterior wall of the pelvis  at a right angle.  3rd. Vertex can-
not present at vulva until a considerable  portion  of chest is
driven into pelvis, hence the antero-posterior diameter corres-
ponds to a line  drawn  from anterior fontanelle to posterior part
of thorax.  4th. Part of the expulsive force is lost by  the great 
116
MANUAL  OF OBSTETRICS.
curving of the  spine.  5th. Forehead is too  broad for  pubic
arch, and hence coccy-pubal diameter loses half an inch.
   Causes : Unknown.   Occurs in succession to same woman.
   Varieties :  Three.   Left Occipito-Posterior.   Right  Occi-
pito-Posterior.  Occipito-Sacral, or Fronto-Pubic.
   4th.  Left Occipito-Posterior.—The most common.  Most
favorable.   Back of foetus is backwards and to right. Abdo-
men to front and left, left side to  front inclining to right.
   Occipito-mental diameter to one oblique; bi-parietal to other;
anterior fontanelle behind ilio-pectineal eminence.
   So far as favorable as first position.  But after os is dilated,
occiput passes rapidly along sacrum to perineum;  now instead
of extending, head must flex more;  chest enters  pelvis from
right to left, and force lost by flexion of head.  Rotation occurs.
Forehead does not fit sub-pubic arch.   Occiput presses strongly
on posterior  commissure of vulva.   Posterior fontanelle first
appears,  then sagittal suture,  ant. fontanelle, parietal bosses,
frontal  bosses,  face.  Restitution,  face  to left thigh.   Left
shoulder under pubic arch ;  right first delivered.
   5th.  Right  Occipito-Posterior.—Rarity.  .03  per cent.
Back of fcetus towards left and backwards; right shoulder
towards left and forwards.   Bi-parietal diameter is in left  an-
terior oblique.  Occipito-bregmatic in right oblique diameter.
Rotation, reverse of preceding.  Restitution, also reverse.  This
position may be,  and Naegele thinks generally is, converted
into 2nd, or right occipito-anterior position.
   6th.  Occipito-Sacral.—Very  rare.
   No rotation.   Restitution uncertain.
   The presentations of the  vertex may then be practically con-
sidered as only four; the 3rd and 6th from their rarity maybe
omitted.  Of the 3rd I have seen but a single instance.
   Classification of Labors.—First element  is part pre-
senting.
   Presentation.—That part of the fcetus on  which the  finger
impinges while it is still at the brim.  May have several posi-
tions. 
MANUAL OF  OBSTETRICS.
117
  Position.—The relation of presenting part to acetabulum
and sacro-iliac symphysis.
  Errors in diagnosis rectified by the position of caput succe-
daneum;  i. e.  the swelling  of scalp where not covered by
uterus.
  Foetus may present by Head.   Breech, including hips and
loins.  Inferior Extremities, including knees and feet.  Su-
perior Extremities, including shoulder, elbow, hand.   Besides
these are presentations of various parts of Trunk ; of two  or
MORE PARTS ; of FUNIS *, of PLACENTA.
  Diagnosis of Head.—Presentation determined by hardness;
sutures ; fontanelles.  Easy at first, difficult after long delay.
  Fallacies : Intercostal spaces mistaken for sutures.
  Of Breech.—By softness; cleft between nates; anus; coccyx;
genitals.  Difficult when swollen.
  Fallacies: Cleft  mistaken for  sagittal suture;  coccyx for
occipital angle ;  ischia for parietal bosses; female genitals for
mouth.
  Of Knee.—By roundness and hardness.
  Fallacies : Mistaken for elbows ; but never have two elbows.
  Of Foot.—By length; at right angles with leg; equal length
of toes; narrow heel.
  Fallacies: Mistaken for elbow.
  Of Elbow.—By sharp olecranon.
  Of Hand.—Short; unequal fingers;  thumb opposite.
  Fallacies: From foot.
  Of Face.—By eyes;  eyelids ;  nose and lips ;  tongue; chin;
ears.
  Fallacies: Chin  mistaken for  heel, knee, or elbow ;  mouth
for anus ; nose  for genitals; cheeks for tubera ischii.
  Labor is divided into THREE STAGES.
  First Stage extends from commencement of dilatation  of os
to its full dilatation.
  Second Stage terminates with birth of child.
  Third  Stage ends with expulsion of placenta.
  Is also divided into Regular, Irregular, and Complex.
                            10 
118
MANUAL OF OBSTETRICS.
  Regular Labor.—Head presents, and  no circumstances
occur essentially modifying or requiring treatment.
  Irregular.—When some other  part than head presents,
but otherwise as before.
  Complex.—When some  complication  exists  requiring
treatment.
  EASY.—When no more than ordinary difficulty occurs.
  DIFFICULT.—When more than ordinary difficulty occurs.
  Regular  Labor includes EASY and DIFFICULT.
  Irregular Labor includes BREECH; KNEES ; FEET;
SHOULDER  or ARM ; TRUNK; TWO or MORE PARTS.
  Complex Labor  includes CONVULSIONS;  HEMOR-
RHAGE;  PLACENTA  PREVIA;   RETAINED  PLA-
CENTA ; PROLAPSUS OF CORD; PLURALITY; RUP-
TURE OF UTERUS; INVERSION OF UTERUS.
  Regular  Labor,  or Natural.—Head presents and no
complication exists requiring interference ; terminated within 24
hours with  safety to  mother and child; secundines expelled
normally.  Authors differ in  defining.  Frequency: Smellie
says  900 in 1000;  Bland, 1792 in 1897;  Clark, 9748 in
10,199 ; Merriman, 2607 in 2735 ; Lever, 4266 in 4666 ; Assa-
lini, 205 in 269.
  Ushered in by certain  PREMONITORY SYMPTOMS;
PRODROMATA.   1st.  Subsidence of  Abdomen.  During
last fortnight of gestation fundus sinks from  epigastrium  and
tilts forward.
   Caused by partial  absorption of liq. amnii;  relaxation of
uterine tissue, also of ligaments and vagina.  Effects: Woman
feels better ; moves more readily; relieves dyspnoea, digestion,
vomiting.  Sometimes  said to be quite sudden, as in  one night;
usually gradual.   Is an evidence of roomy pelvis.
  2nd. Micturition.   Caused by pressure  diminishing  ca-
pacity of bladder;  also sympathetic  irritation. Is not amena-
ble to  treatment.  (Dysuria  relieved by urinating while upon
hands and knees.)
  3rd. Griping, Tenesmus, Diarrhoea, all result from sympa- 
                 MANUAL  OF OBSTETRICS.               119

thy; but  diarrhoea not inconsistent with fecal  accumulation.
As a sign of approaching delivery it is uncertain.  Relieved by
demulcent enemata with* opiates.
  4th. Painless Uterine  or Fibrillar Contractions.  Oc-
cur from one to three weeks before delivery ; are sooner mani-
fest in primiparae than in multiparae.   Sensation of squeezing,
momentary, without pain ;  uterus feels harder.   Are of service
to produce  gradual  changes in neck, and even to dilate  os
measurably before  labor sets in.   Such are the  cases in which
delivery  said to occur in  three or four pains.   Ould thought
they  directed  head  to  superior  strait and  thus influenced
presentation.  (In  premature  and forced labors mal-presenta-
tions are most frequent.)
  5th. "Show," an increase of mucous  secretion of vagina
together with the  plug of  mucus  that  has been in  cervix; is
sometimes mixed  with blood;  sometimes considerable blood
is discharged.
  Source of  blood: Small  vessels in  vicinity of os, most
noticed at time of full dilation.  Occurs  about twenty-four
hours  before labor.   Object,  to lubricate passages.   Quantity,
varies, profuse  or  scanty.   Quality, thin, or viscid almost like
albumen, the latter most favorable. Value, the best test of near
approach of labor.
  6th. Relaxation of Pelvic Symphyses, said to occur, but
is doubtful; does  in lower animals.
   1th. Uterine Contractions.—Labor Pains.  The periodi-
cal contractions of uterus.   Commence in cervix (probably at
first without pain).  First noticed in loins, and then to  extend
around  abdomen  and  down  thighs.    Early  pains  called
" cutting," or " grinding."    Action  of woman  under them :
stops speaking, compresses mouth, grasps and  squeezes some
near object; as it passes off resumes ordinary behavior, or else
complains and frets with  short cry.   In second  stage  are
called "forcing,"  or "bearing  down."    Cause of suffering.
1st, forcible distension of  cervix (Mad. Boivin, who ought to
know, says cervix  is seat of  pain).  2nd, pressure on nervous 
120               MANUAL OF OBSTETRICS.
filaments  during  contraction.   3rd,  distension  of  passages.
Great variety as to apparent suffering and mode of  enduring.
Pains  are  not uniform;  gradually increase; then  stationary
and  decrease; are periodical; interval of  ease  diminishes in
progress of labor.   Pulse  at first increases, stationary, subsides.
  False Pains.—Sometimes mislead woman and practitioners.
   Caused by,  over fatigue, affecting lumbar and iliac muscles;
by indigestion, constipation,  diarrhoea, cold, motions of child,
organic disease of kidney, prolapsus of bladder, rheumatism of
uterus.  Are  not unfrequently attended with  feverish  symp-
toms.   May occur at any time during gestation ;  frequently at
night; most in primiparae.

   Diagnosis.—True, commence    False, commence  at  fun-
in  hypogastrium,  felt first  in  dus; extent limited ; erratic;
back, extend round in front; re-  recur irregularly.
cur regularly.
   Dilate  os;  protrude bag of    No show.   Do  not dilate
waters; contraction  felt  exter-  os.  Do not be deceived by
nally.                           contraction of muscles.

   Insist on vaginal examination.   Saves anxiety, time, watch-
ing, and accoucheur's character.
   Treatment.—Rest; bowels must be opened ; aromatic  pur-
gatives ; then follow with opiates; opiated  liniment to abdo-
men ; for diarrhoea, ol. ricin. and laudanum ; opiate suppository
or  enema. If plethora,  VS. reduces temperature, relaxes soft
parts, increases mucus.   If rheumatic, laxatives, diaphoretics,
warm bath, VS. if necessary.
   Cases occasionally  met with where sharp pains  occur and
dilatation takes place to some extent;  labor seems imminent, but
pains cease, and  delivery does not ensue  for days, and  even
two or three weeks.
   Symptoms  and evidences of labor vary in different stages.
   First Stage.—Pains  are " cutting," " grinding," short, se-
 vere, not very frequent, intervals  decrease;  oblige  patient to 
                 MANUAL  OF OBSTETRICS.               121

suspend occupation ; do not induce bearing down;  seat usually
in back ; extend round;  cause much suffering ; cry short and
fretful; pain in back  sometimes  relieved by pressure;  some-
times not.   Sometimes  each pain  commences with  nervous
shudder  resembling a chill;  it varies in duration; seems to
relieve pain : faintness and  nausea occur at  times: vomiting
occurs and is useful, relaxes os and  removes indigestible mat-
ters ;  state of mind irritable, restless, low-spirited, fearful; as
labor advances, courage improves.  Roberton mentions a case of
suicide in despondency of first stage.  Great  varieties  in forti-
tude and resignation ; efforts at restraint objectionable.  Surface
of usual temperature ; no sweat; pulse not quickened till second
stage ;  considerable variations noticed.   Uterus hardens, tilts
forwards to bring axis  into axis of superior strait; then relaxes 5
by auscultation the uterine pulsations are stronger; a rushing
sound  is heard from liq. amnii, or perhaps from muscular con-
tractions of uterus ; at height of pain  sounds  become dull and
return as declines.   Vaginal examination detects  os high  up
and towards sacrum; in  various  degrees of dilatation  and
tension ; vagina in various states of heat and  moisture.
   Os dilates slowly at first;  more rapidly after size of a half-
dollar from wedge-like action of " bag  of waters;" does not
always dilate equably ; anterior lip often  longer than posterior,
and this delays advance of labor; show becomes more sangui-
neous  near full dilatation ; pains longer ;  membranes rupture;
second stage sets in.   Os now recedes up to top of sacrum and
pelvis, encircling the neck  of foetus.
   " Bag of Waters " is  technical  name for the  segment  of
membranes  protruding  from os  distended by the liq. amnii.
Its shape varies from round to elliptical or elongated according
to presentation.  Is hard  and tense during  pain; in interval
wrinkled ; usually ruptures  at dependent extremity, and then
discharge is. complete until head descending stops  the  egress ;
if higher up liquor drains  away at each  pain, and in this form
sometimes covers face as it emerges, and  child said to be "born
 with a caul."  Great variations as to  time of rupturing;  if it
                            10* 
122
MANUAL  OF OBSTETRICS.
occurs early labor is  delayed; is sometimes extended  from
vulva before the head;  sometimes  even a  foetus at term  is
born  enveloped in membranes; not always possible to tell if
membranes are ruptured ; examine for it during a pain.
   Duration of First Stage.—Varies greatly;  average six
hours ;  is the longest part of process ;  labor may be suspended
after os one-quarter dollar in size.
   [In this stage "the ovarian nerves and the nerves of the os
and cervix uteri are  acting as spinal excitors ; the only motor
nerves involved are the uterine;  the portion of spinal  centre
involved  is the  lower medulla ;  the medulla oblongata being
not at all affected."—T. Smithy
   Second Stage.—A lull succeeds rupture oftentimes; but on
recurrence, pains are longer and oftener;  intervals shorter;
suffering  greater but better  borne;  pains are " bearing down"
Woman breathes deep, closes glottis, grasps  something firmly,
braces  her feet, contracts abdominal muscles, strains violently
until pain ceases, or she is compelled to cry out and the period
of tension passes.  Outcry  is no longer fretful, but a straining,
terminating sometimes in short cry and gasping for breath.
   Appearance.—Skin florid, purple;  veins turgid ; eyes suf-
fused ;  perspiration  free;  surface warm;  pulse accelerated.
Vomiting frequently occurs; its import varies with concomi-
tant symptoms ; if simply bilious or mere contents of stomach
is useful; if dark, greenish, foetid, with abdomen  tender, fever,
uterine action suspended, it is unfavorable.
   Tendency to sleep  between pains often noticed, especially in
protracted ; generally useful, but if head aches and especially in
primiparae, guard against convulsions.
   Cramps in  calves  noticed; result  of pressure;  relieved by
 friction.   Rectal tenesmus occurs, bladder cannot be evacuated
 until pressure  is relieved.   Vaginal  examination  defines the
 head, its sutures overlapping ;  also the " caput succedaneum,"
 a swelling more  distinct if labor  is delayed and  membranes
 have  ruptured  early (it is  the scalp distended  by a  local
 effusion of serum); sometimes the scalp is much corrugated. 
MANUAL OF OBSTETRICS.                123
  Head passes bones and distends perineum, but as contraction
diminishes, again recedes;  recession beneficial in relieving dis-
tension ;   gradually  distends  more  and more.   Perineum
becomes  thin, tense,  elongated,  and  widened.  Contractions
become " double  pains," and with  an  all absorbing  effort and
sharp shrill outcry, the head passes the vulva, and relief ensues,
with panting and sobbing.
  At the moment of extreme distension sometimes a transitory
insanity is noticed ; result of excessive suffering or else cerebral
congestion.
   ["The excitor nerves are  the ovarian, uterine, vaginal, and
nerves of ostium vaginae;  the  motor are the uterine, vaginal,
and respiratory, and of the sphincters ani and vesicae."]
   An interval of ease almost invariably follows  the  expulsion
of  head; abdomen  sinks; uterus  diminishes.  Pains  soon
recur, expulsive but not so violent, and shoulders followed  by
rest of child  are expelled.
   Third Stage.—Detachment and Expulsion of Placen-
ta.—Usually last pains also detach placenta ;  uterus contracts
itself away from surface of the uncontractile placenta; sometimes
it is expelled simultaneously with foetus;  oftener is expelled
into superior part of vagina; often is partly within and  partly
without   uterus; much depends  on previous energy of con-
 tractions ; where  instruments  requisite, more delay; vagina is
 an active  agent in expulsion.   Time varies;  average ten mi-
 nutes ;  if delayed over  one  hour there is abnormal  cause.
 Emerges edgewise; with  maternal surface first, if  cord is  not
 touched;  but if it is pulled, the foetal surface tends to emerge,
 accompanied and assisted by voluntary expulsive efforts; by
 examining the  rent of membranes, the placental site may be
 estimated.
   Following the placenta  is a  gush   of blood of variable
 amount;  not  abnormal  unless excessive;  more than a pint
 abnormal.
    Frequently a nervous shudder succeeds;  teeth chatter and
 tremulousness, but this is not  from cold. 
124             MANUAL OF OBSTETRICS.
  [During this stage the vaginal surface is intensely excito-
motor.  " The nerves involved are the ovarian, uterine, vaginal,
mammary, and gastric."]
  DURATION OF LABOR.—All varieties, from five minutes,
or " two or three  pains," to a week.  Authors average it at
four hours.  Longest time is  occupied in dilating os.
  More births occur during night, 1*31 to 1  for day.
  MANAGEMENT OF  NATURAL  LABOR;   or,  DU-
TIES OF THE ACCOUCHEUR.—The cardinal rule is, that
it is not to a case of sickness  the summons is; but to superin-
tend the exercise of a natural function.
  DIRECTIONS.—When  summoned  go at  once and with
" obstetric haste."   Provide a flexible  male catheter,  lancet,
perhaps tine, opii and chloroform if  at a distance.
  See the nurse first, and  inquire of her, as to number of pre-
vious labors, whether  easy or .not, age,  general health, show,
waters, bowels, urine.  Then enter lying-in room, avoid appear-
ance of hurry.  Inquire of patient as to general health, pulse,
tongue, skin, previous labors.  Then direct  attention to pains,
frequency, character, force, regularity,  situation felt.   Judge
somewhat from outcry and effort.  If woman is in bed, turn
attention to vaginal examination,  " taking a pain ;" for a primi-
para request it through the nurse, and  perform it in the pre-
sence of a third person always.  Always make  it  as early as
practicable with decorum—and invariably make an examina-
tion as soon as membranes rupture, in order to verify diagnosis
of presentation, or to rectify  untoward  occurrences.  Position
of woman, generally on left  side with   knees drawn up and  a
little  separated—varieties, right side, or  supine " on broad of
back"—the last preferable,  must be near edge of bed.  Hand
to be  used, either one according  to  position.   An  accoucheur
should accustom himself to have no choice of hands.  Smear in-
dex and second finger with lard, sweet-oil, or pomatum, to faci-
litate  introduction, and to guard against contraction of disease.
Arm  enveloped in a towel or  covered with oil silk sleeves. .Pass
index along cleft of nates to vulva, and  insert during a pain— 
MANUAL OF OBSTETRICS.               125
follow curve of sacrum and bring finger a little forward to find
os—then wait till pain ceases to get information—if one finger
will not answer, use two. By vaginal examination you ascertain
six points, 1st. Is woman pregnant ? 2nd. Is she in labor ? 3rd.
State of membranes; 4th.  Presentation;  5th.  How  far ad-
vanced ; 6th.  Size of pelvis, state of os, vagina, and perineum.
  Examinations are to be  repeated seldom—once  an  hour  is
sufficient.  Too frequent cause dryness, heat, and tumefaction.
  Having examined,  wipe the finger  under bed-clothes on a
napkin  provided—ascertain  the  nature  of discharge.   Then
turn attention to room, &c, temperature cool, rather than warm,
66°—ventilation to be free—attendants, two sufficient.
  Examine " the things" for child, a string to tie cord,  of linen
or cotton thread doubled three or four times.   Scissors to cut
cord ; pins : for woman binder, a stout towel or unbleached mus-
lin at least a foot wide and three feet long; strong and long pins.
  Attention may be requisite in " making the bed."   Choose
a cot or single bedstead, on it a mattress, over  that a  piece of
india-rubber cloth, or thin oil-cloth, over it a  folded blanket,
then a sheet.
   Woman's dress—chemise and ordinary nightdress—gathered
above hips.  Covering to patient to be light.
   As to  confinement to bed, it  is to depend  on  advance of
labor;  if just commenced, sitting in a chair or walking about
relieves  tedium,  useful  in  primiparae.  If os  is considerably
dilated, the woman should lie in bed, in just that position that
suits her feelings and wishes best, without regard to the accou-
cheur's tastes or  convenience.   Accoucheur should not stay in
the room during the first stage, that  all freedom  as  to usual
evacuations may be enjoyed.  Conversation to be  cheerful.
Avoid  all  prognosis as to termination  to the woman and
attendants, but for self you mustTorm some opinion. Judge by,
1st. What is presentation ?  Should be determined  at first exa-
mination.   Head known by hardness,  fontanelles,  and sutures.
2nd.  What  position—known  by situation  of anterior fonta-
nelle, should certainly be made out when membranes rupture. 
126                MANUAL OF  OBSTETRICS.

3rd. As to number of labors—primiparae more tedious.  4th.
Size of pelvis. 5th. State of vagina. 6th. And  especially  the
state of os.  Most favorable s.tate of vagina is cool; moist, and
relaxed, with  abundance of thick  tenacious  mucus; unfavor-
able if dry, hot,  narrow, and constricted.
   States of Os.—If lax, soft, thick, moist, cool, and not tender,
may expect speedy termination.  If thin,  hard, unyklding, dry,
tender, and as if bound with wire, expect - protracted.  Cervix
thin, allowing presentation  to be made out,  and low in pelvis
before dilating, usually denotes tedious labor.
   Return  home, to be governed by state  of os, vagina, and
perineum ; if  os size of a dollar and yielding,  avoid any con-
siderable absence.  Before going direct diet  to  be light, toast
and tea, crackers, <fec, avoiding meat. Drinks,  cold water or tea,
avoid stimulants.   If labor is protracted,  better diet will be
requisite.
   Also attend to state of bowels.   If labor  is  advanced and
constipation exists,  direct an enema; if in an early stage  order
castor oil, for it acts readily arid quickly.
   Attend to state of bladder; if it  is stated that " the urine is
continually dribbling away" pass the hand  over  hypogastrium,
and if a tumor distinct from the uterus  is  felt, percuss it, and
when satisfied pass catheter.  If a  male  flexible catheter is
used,  there will  be no difficulty in  reaching  the bladder, but
when the  head  is  far down and compresses the  urethra, the
thumb should be placed against the head and pressed up ; the
male  catheter will take the proper direction.  The female silver
instrument is .less efficient,  more difficult to  pass  in obstruc-
tions, and less  reliable for relief  when passed.  Repress all
attempts to encourage " bearing down" in first stage.
   Avoid any attempts to dilate os manually—except where
anterior lip forms an obstruction.   " Meddlesome Midwifery is
bad."
   Avoid rupturing membranes,  unless the os be fully dilated,
and  the  presentation  is ascertained.—Premature  rupture re-
tards  labor. 
MANUAL OF OBSTETRICS.
127
   Duties of Second Stage.—Patient to be in bed in the posi-
 tion most comfortable to her.  Principal duty of accoucheur said
 to be supporting perineum.   Most ruptured perinea are particu-
 larly " well supported."  Object is to prolong curve of sacrum
 and coccyx, and prevent laceration.  Not to be commenced until
 perineum  is thinned out,  and vertex is  separating labia.  A
 towel is to be placed in palm, and pressed moderately during
 a pain, merely to sustain structure.  Strong bearing down to
 be  discouraged when  perineum  greatly distended.  Avoid
 retracting skin over head.  On the whole it seems questionable
 whether this part of  duty would not be better honored in the
 breach than in the  observance; many, perhaps, most primi-
 parae lose their fourchette in the first labor, but the loss is
 scarcely appreciated.   Estimate the advance of  head, not by
 examining at the pubic arch, but at the perineum.  Sometimes
 at this period pains fail,  and may  be renewed by pressing
 firmly on end of sacrum.
   As soon as head is delivered support it in  palm, and feel for
 the funis ; if it encircle the neck, loose it and  slip over shoulder.
 (In rare instances it may delay advance of shoulders, and may
 require to be divided.)   This  done, support the head with one
 hand, and place the other  over fundus uteri, and press firmly
 and  steadily, following the uterus as it expels the child.   Keep
 'hat hand on  the uterus until the cord is to be tied.  Strenu-
 ously avoid pulling the shoulders, unless the child's life is jeo-
 pardized ; for the risk of hemorrhage is great, irregular contrac-
  on, and retained placenta  also result.  If  much  delay occurs,
 ? child seems inanimate, or after a few attempts  at respiration
. eases to breathe, assistance is to be given.  Keeping one hand
pressing on abdomen, insert the index of the other into the
axilla nearest the perineum, and pull in  the axis of inferior
strait; the delivery of one  shoulder usually suffices, and child
is soon expelled.  Some support perineum during" expulsion of
shoulders.  Place  the child  with abdomen  towards mother,
close to her, and with its mouth away from the discharges, that
its struggles may not pull on the cord.
  Now the uterus is to  be compressed by an  assistant. 
128               MANUAL OF OBSTETRICS.
   Of Tying Cord.—Wait till child cries  freely, and pulsation
ceases six inches from umbilicus; then tie the cord twice, and
divide between the knots.   Some use no ligature, some use a
single tie.  Tie at least 2"- inches from abdomen that no fold
of intestine, abnormally in  cord, be encircled if  tied too close.
Tie firmly, and leave a space of % of an inch beyond the liga-
ture, that the gelatine of Warthon escaping from a thick funis
may not loosen the ligature.  Always see when the cut is made,
lest the " penis"  or " a finger" be amputated.  Generally no
hemorrhage  from placental end of cord, but it may possibly
occur.   Chevreul  relates three cases; source of exit the umbilical
vein.   Child to be taken by ankles in  one hand and arms in
the other, suffering the head to rest in the palm.  (Accidents
occur from carelessness.)   To be received in flannel, and laid
away till the nurse is  no  longer  useful to  the accoucheur's
requirements.
   Next step is to ascertain if there is a second foetus—examine
per vaginam for membranes.  A large placenta may cause sus-
picion of the existence of a twin.
   Duties in Third Stage ;  Delivery of Placenta.—Never to
be delivered unless the uterus is contracted.—Place one hand on
uterus, and if the woman is lying on her side direct her to turn
on the back; grasp the  uterus steadily, but without violence,
to ascertain its contraction, and then with other hand trace up
the cord.   If the insertion of the cord can be felt  in the vagina,
it is generally, not always, safe to assist delivery.   Feel for the
rough  or maternal surface of the placenta,  with two fingers
push it back towards sacrum, and at same time towards vulva;
if these tractive efforts depress the fundus  uteri as felt by the
other hand, cease, for the placenta is still attached in utero,
and its delivery  is  not to  be hastened  unless required  by
hemorrhage, <fec.   The effect of  traction a better guide than
mere lapse of time.   If the  placenta is felt per vaginam to be
still in utero, and  hemorrhage is not occurring, grasp and knead
the uterus, and  wait for  the  recurrence of contractions.   If
the placenta  be  pulled away before the  uterus  is contracted, 
MANUAL OF OBSTETRICS.
129
there is danger of hemorrhage, of inversion, of rupturing pla-
centa.
   Direction of traction to be, first, in axis of brim, finally in
axis of outlet.  When about  to emerge,  rotate the placenta
several times in order to gather up membranes; if portions or
shreds be left, they may cause fetor, hemorrhage, irritative fever,
or merely alarm by subsequent expulsion.  Place placenta in
some vessel, and  subsequently examine it,  to see  if  entire;
for this  purpose  put it  upon  a  plain surface maternal  side
upwards.
   Application of Binder.—Some think unnecessary, others
highly useful in preventing hemorrhage, in relieving sense of
vacuity,  in  preventing pendulous belly; comfort to woman a
sufficient plea.  Not to be  relied on to  check hemorrhage.
Still keeping one hand upon the uterus, have the dress raised
towards  the face, and place the bandage, previously rolled up,
next the skin;  adjust it so as to cover  the hips, request  the
patient to  raise the  hips,  and rapidly encircle  her with  the
bandage;  now fold  one  or more  napkins,  place  them  over
fundus uteri, and secure the bandage with strong pins, com-
mencing over the epigastrium ; (if there seems a disposition of
the uterus  to enlarge, envelope a small  duodecimo volume in
one of the napkins.)   These manipulations to be executed under
the bed-clothes, without exposure.   Next  direct the  nurse to
withdraw soiled clothes, and to  place a dry  blanket beneath the
hips, without suffering the patient to rise,  and then to place a
folded napkin to vulva ; see that napkin before leaving the house,
that the mind may be at ease as to hemorrhage.
   Next duty will be to dress cord ; by taking a piece of linen
about 7 inches  square, cutting  a  hole in middle, and drawing
the funis through ;  fold it  and place upwards  along abdomen
and have it secured by a roller.
   Stay in  the house at  least an hour—better two.   Before
leaving, direct patient " to be changed ;" not, however, for two
hours, and  insist that she  shall not assist  herself, or be raised
to semi-erect posture, for there  is  great danger  of hemorrhage,
                            11 
130
MANUAL  OF OBSTETRICS.
which may be speedily fatal.  Also direct diet, the simplest—
toast and tea, gruel, &c.
   Difficult  or  Delayed Labor.—Head  presents;  not
completed within 24 hours ; more  than ordinary difficulty.—
Frequency, 1 in 36.  Most  in primiparae, but multiparae with
large families not  unfrequently have delay.  Is more serious
than natural labor, for mere protraction increases danger. The
hazard is not in first stage,  for as long as the membranes are
unbroken, provided the normal quantity of liq. amnii is present,
delay is of little consequence; but in second stage much  less
time produces  much more serious consequences.   Hence, in
estimating necessity of interference, less attention is to be paid
to the interval that has elapsed since first access of pain, than
to length of  time  since  discharge  of liq. amnii.  With some
families  there seems a  transmitted  disposition to  protracted
labors;  with others the reverse.   Women  of  delicate  habit,
those with deranged digestion, depressed  mentally, debilitated
by discharges, are  all  liable ; yet even grave disease does not
always protract labor inordinately, ex. gr.  Phthisis.
   The two  great  causes of  delay are, deficiency of expulsive
power, i. e. Inertia  of the Uterus ; and too great resistance, i. e.
Rigidity of Soft Parts ; other causes are of minor importance.
   Deficient Contraction.—Cases  of  this  kind  are seen
mostly in the delicate or exhausted;  in primiparae usually.
   They  may usually, with  proper  hygienic  means, be left to
nature,  for  if  the expulsive  force  is small, the  resistance is
equally  so.   Regimen a primary  consideration.   Apartment
cool, an  occasional cup  of  tea or  some warm liquid, or light
nourishment as a  bowl  of  gruel;  cheerful  conversation, with
special avoidance of bearing  down ; changes of posture from
side   to side, or walking about, ordinarily  suffice  to  worry
through.  In some cases the moderate  use of stimulants, as
wine and water, or in gruel or arrow-root, <fec,  may be  of ser-
vice  ; requires caution as to use.   If pulse  is weak and slow,
surface cool, uterine contractions powerless, and no hemorrhage,
they may be used. 
MANUAL OF OBSTETRICS.
131
  The great remedy is Opium, to be given as near as possible
to time of natural  rest, and in efficient doses.  Various forms.
Laudanum best,  at least  40 drops,  sometimes 3j ; an over-
powering dose suspends action completely.   Oftentimes, when
the pains are short, teasing, inefficient, giving the  sensation of
mere griping in abdomen, a dose of 40 drops will procure a few
hours' rest, and patient will awake to  renewed and effectual
efforts.   (Experience  has taught me  to stay for a little  time
after a dose of laudanum, for in some cases the beneficial effects
have been manifested in a short time, in a change  of pain, effi-
cient action, and steady progress towards  completion.)
  Chloroform, by regulating nervous action, may be  of service.
  If on awaking, contraction is not resumed, or opium proves of no
use, give an enema of salt and water, or Spts. Tereb., or Decoct.
Senna, and  these, or simple enemata, may  be  repeated  from
time to  time.  An active cathartic will  be of service if the
bowels are  costive; black  draught.  These failing, the  next
medicinal means is Ergot, which may be given in fresh powder,
in infusion or saturated tincture.
   Rules for Ergot.—Not  to be given: 1. To  relieve your-
self.   2. Not unless os uteri is fully dilated.  3.  Not in con-
tracted pelvis.   4. Not if presentation is beyond reach.   5. Not
in  mal-presentation.   6. Not if obstruction  in soft  parts.  7.
Not if fcetal head  is relatively too  large, ex. gr. Hydrocephalus.
8.  Not if head symptoms present.   9.  Not in  over  excite-
ment of vascular or nervous system.  10. Seldom in primiparae.
   May be given:  1.  If  labor ceases simply from  want of con-
tractions.   2. If head or breech presents.   3. If  os is dilated.
4.  Pelvis ample.   5. Parts relatively of correct  size.  6. No
excitement.
   The use of forceps should be practicable before using Ergot,
in  order that if  delay ensues, instruments  may be used  before
child  is poisoned  in its  blood.   Examine the foetal heart re-
peatedly, and if lessened in frequency,  depressed  in strength,
and if irregular, or intermittent, lose no time in terminating the
labor.  When reduced below 110, and at same time intermit- 
132
MANUAL  OF OBSTETRICS.
tent, the child is  rarely, if ever, saved; depression without in-
termission is no  certain ground for apprehension.  Children
born  two hours  after Ergot  has acted are  usually still-born.
Ergotised children are resuscitated with difficulty.
  If Tincture is used, give 3j. every fifteen minutes until  four
doses are taken ; if this does not act, either abandon the remedy,
or send for another sample.   Of powder, give 15 grs. of freshly
powdered every ten  minutes till 3j. is taken.  Infusion, 3ij. to
§iv., take £.  Ergot  is very apt  to  spoil.  Formula, R  Ergot
3j. to 3ij.; Bibor. Sod. grs. x.;  Aq. Cinnam. §iss.  The  cha-
racter of an "  Ergot pain" differs from  ordinary uterine  con-
traction ; it is energetic, continuous, and expulsive ; it lasts till
delivery is  effected or effect of remedy passes off;  child  does
not  recede  as  in ordinary labor, but advances continually.
Bad effects on  child,  by compression, asphyxia, toxemia.   On
woman, fistulae from pressure,  rupture  of uterus or vagina,
cerebral disturbance, delirium, coma, retention of placenta from
irregular contraction.  Galvanism has been  tried as a remedy
for inertia.   If Ergot fails, delivery must be instrumental.
   Cannab. Indica, Indian Hemp, is said to be oxytoccic; Tine.
10 to 30 drops, said  to be more speedy than Ergot, more  eva-
nescent, but more energetic and certain.   Borax also has repu-
tation.
  Irregular  and Spasmodic Pains delay labor by want of
consentaneous  action of muscles;  some parts rigid and con-
tracted, some soft and yielding, with no distinct interval of  con-
traction.  If not treated, patient becomes exhausted ; presenta-
tion may even  become changed.  Opium by mouth or rectum
relieves.  Chloroform meets the indication precisely.
  Premature Rupture of Membranes delays, by substituting
for the elasticity  and wedge-like action of the bag of  waters,
the rigid and  irritating hardness of the head upon the sensi-
tive os.   Children are oftener still-born, and instruments oftener
requisite, when membranes are ruptured early.
  Lee thinks premature rupture almost always indicates preter-
natural presentation. 
MANUAL OF  OBSTETRICS.
133
  From Excess of Liq. Amnii.—Contraction may be enfeebled,
like as in over-distended bladder; but caution is necessary in
assuming this as a cause of delay.
  Remedy:  Rupturing membranes.  Not until,  1st. Os fully
dilated.  2nd. Presentation  made out.   3rd. No mechanical
obstruction.   To  be done in  interval  of pain lest funis be
washed down;  puncture as high as possible.
  Toughness  of Membranes.—An  analogous cause.   Arises
from disease of amnion ; patches of lymph found.
  Remedy :  Rupturing membranes ;  sharpened finger nail or
quill, probe.
  Obliquity of Uterus.—Retards ;  either anterior or lateral;
left lateral the more common of the lateral varieties.  Anterior
exists in multiparae with " pendulous abdomen ;"  os is high up
towards sacrum.   [Such cases mistaken for imperforate os.
(Dewees.)]
  Remedy :  Change of position according to form.  If position
on back does not remedy " pendulous belly," support  it  with
towel.   Avoid manual attempts to draw os into centre of strait,
nature will accomplish it.
  Mental Excitement or Depression influences labor.
  Such sources of delay  are combated by  judicious  moral
measures or Chloroform.
  Second principal cause is too great resistance.
  Rigidity of Os.— Occurs: Most in primiparae, especially in
advanced life, of rigid fibre, and vigorous ; in  multiparae, when
severe  labors.
  Causes.—Premature  rupture  of  membranes; stimulants ;
repeated examinations ; excitement;  plethora  ; full bladder or
rectum ;  scirrhus ; disease of os, as in dysmenorrhcea.
  It makes a material difference in difficulty arising from rup-  .
ture of membranes, if labor does not  come on for two or three
days after the  rupture;  the  ill effects seeming to result from
the mechanical irritation produced by uterine  contraction.
  Advanced  age is usually  a source  of delay, not always;
maximum of resistance between 30 and 38 years.
                         11* 
134
MANUAL OF obstetrics.
     Sometimes the os sensibly contracts during a  pain, and re-
  mains rigid even in interval; in such cases rupture of uterus is
  to be feared.  Sometimes undilatability is so great that os has
  been torn off, and has come away like a ring.
     Treatment.—Regimen:  Very free use of drinks, cool; no
  stimulants ; avoid bearing down ;  cool temperature ;  mental
  quiet.  Bowels  freed by saline laxatives  or enemata.  Watch
  bladder  in all tedious labors;  every six  hours examine hypo-
  gastrium.
     Most potent remedy is Venesection ; especially in plethoric,
  with severe pains, hot and tender vagina, and full strong pulse ;
  os thin and hard,  head pressing it not only during a pain, but
  continuing after.   Great objection to its use is  woman must
  lose blood in later stage of labor, and then becomes prostrated.
     As to quantity, must not be too great; for, if it diminishes
  rigidity, so does it the expelling force.  Average, 16 oz.  Only
  to affect pulse.
     Chloroform acts well; adapted to cases where VS. unadvis-
  able.  Ant. Tart, in nauseating doses.  Before using, be  cer-
  tain that  os  has dilated somewhat.  Objection is harshness.
  Emetics also used, as Ipecac.  Belladonna ointment by Chaus-
   sier, 3j. to 3ij. to §j. applied to os ; is liable to produce faintness
   and vertigo; not  to  be used in debilitated or head affections;
   used in local  soreness.   Warm baths advised ;  liable to pro-
   duce hemorrhage; warm douche has been advised to os in  a
   continuous stream for an hour or more.   Fomentations.  Large
   and repeated enemata of warm water.  Opiate enemata in dys-
   menorrhoeic os,  useful.   Tobacco enemata  too  dangerous.
   Sponge in vagina with  some emollient.  Lard freely introduced
   into vagina is of some service.   Opium  by  mouth is of
#  questionable utility.   Manual dilatation  advised by Scotch
   school; condemned, and justly so, by Irish and English.   One
   form of delayed dilatation is relieved by  it, i. e. cases in which
   the anterior lip is caught between head and pubes; here the
   maintenance of the lip  above the pubes for two or three pains
   expedites  labor, but even this caD be  dispensed with.  Where 
MANUAL OF  OBSTETRICS.
135
rigidity is insuperable, incisions have been recommended.  The
use of instruments in rigid os not advisable.
   Rigidity  of Vagina  and  Perineum.—Sometimes delays,
in connexion with rigidity of sacro-ischiatic and coccygeal liga-
ments.   Pressure may contuse;  and inflammation, or  even
sloughing, result.
   Treatment:  VS.; opiate  or simple enemata ; fomentations;
lard; sitting over warm water.   Avoid frequent examinations.
Avoid Ergot.   Avoid stimulants.   Chloroform.
   Cicatrices or Bands in  Vagina.—The result of sloughing
in  a previous  protracted labor or instrumental delivery; are
found  in various situations and of varying  extent.
   Treatment:  Dewees used VS. ad deliq.;  propriety doubt-
ful. Patience  and  time.  These failing, notch the edges with
a guarded scalpel or  bistoury, avoiding bladder,  rectum, and
large vessels.
   Morbidly Thick Hymen.—Occasionally delays.   Treat as a
cicatrix.
   Male  children are of more tedious delivery than  females,
from the greater size of head.  Circumference fths inch larger ;
transverse diameter, ^th ; bi-parietal, fths.   More women die
with  male  births.    More  complications occur  with  males.
Fewer females  are still-born.  More males suffer  injury during
parturition.  More males die in early childhood.   Deaths in
utero are equal in both sexes.  First labors are more dangerous
to both mother and child than subsequent.  Duration of labor
is longer with males.
   LABOR  DIFFICULT FROM  DISPROPORTION.   May
arise,  1st,  from  too small  a  pelvis ;  2nd, too  large  a
head.
   Two classes, 1st. Those in which natural efforts will suffice
to expel; 2nd.  Those in which they are insufficient.         •
   If the antero-posterior diameter is less than three inches, a
living child at  term cannot  pass.  If less  than 3h laterally, by
l£th antero-posterior, delivery cannot be  effected per vias na-
turales. 
136
MANUAL  OF OBSTETRICS.
   Rules for Action.—Wait patiently to see effect of pain, and
afford  ample  time, if there is a  prospect of natural delivery.
Avoid examinations.   VS. may prove  of service  where febrile
excitement  obtains, abstract  as  little  as possible.   Ergot in-
admissible.  Opium will effect nothing.   Various  modes  of
instrumental delivery  become requisite according  to  the de-
grees of deformity.—See Instrumental Delivery.
   Tumors of various kinds diminish pelvic capacity ;  fibrous,
osseous, adipose, steatomatous, sarcomatous, or scirrhous. Situa-
tions behind rectum, in recto-vaginal space, or in vagina.   The
amount of obstruction will depend upon  size, mobility, and com-
pressibility.  If large,  they may require instrumental  aid.   If
mobile, may be  pushed out  of the way.   Polypus may be
detached, or expelled still adhering.  Examinations should be
made in intervals of pains, and recto-vaginal touch practised.
   Surgical aid by scalpel, trocar, or ligature, may be necessary,
and to effect delivery may require instruments, or even in very
rare cases the Caesarean section.
   Diseased Ovary may interfere.  If it cannot rise with the
uterus, either by reason of size or from  adhesions, it may pro-
trude before the head.
   Treatment.—If it cannot  be raised  beyond brim,  use the
trocar ; if too solid for evacuation, embryotomy will probably
be requisite.
  Protrusion of Bladder, or Vaginal  Cystocele.—From relax-
ation of vagina the bladder may get below the brim,  and  be
pushed down into pelvic cavity.  The most serious consequence
is the danger of incautious puncture for supposed bag of waters ;
(this has occurred).  Patient complains of fulness and  tension, -
with desire and  inability  to  urinate.  In  pelvis is found  a
tumor, elastic, covering the head anteriorly, but not posteriorly,
aatheter passes backwards.
   Treatment.—Introduce an  elastic  male catheter—push up
the head if necessary.
  Calculus very rarely has  been known  to  obstruct labor. 
MANUAL OF OBSTETRICS.
137
If it can be raised and kept above brim nothing else is requisite.
Failing in this, vaginal lithotomy.
  Vaginal hernia may occur in recto-vaginal  space, not of
moment unless filled with scybala.
   Treatment.—Reduce hernia early.  Forceps.
  Faecal accumulation in rectum very often occurs, but should
be  obviated  before labor.  Enemata, or scoop,  if at time of
labor.
  Preternatural size  of the  head, arising either from ad-
vanced ossification, or from distension by fluid. At times head
is firmly ossified,  and the usual " moulding" is prevented.   In
such cases patience must be  exercised,  and  if aid becomes
necessary symptoms will guide as to the mode, by forceps, or
craniotomy.
  Hydrocephalus  before birth is not very rare.   Amount of
fluid three or four pints—circumference of head as high as
24£th  inches.   Left  to  nature such cases terminate, by, 1st,
slow and tedious expulsion ;  2nd, bursting of head and  scalp ;
3rd, rupture  of uterus; 4th, death  without delivery.  Most
usually require aid.
  Danger  is  from pressure, which is powerful and universal,
and is  very liable to eventuate in sloughing and fistulae.
  Diagnosis, by great volume of head, bones wide apart, fon-
tanelles and  sutures  opened widely,  fluctuation (but this may
be  absent).   Imperfect  ossification  with tedious labor  might
deceive a careless  observer.                                  4
   Treatment.—Ordinary principles  must  be modified.   The
delay that in natural labor is requisite and advisable, is in
these cases hazardous to mother, without corresponding benefit
to child.  If  natural  efforts cannot  overcome, perforation is
the  alternative;   though forceps may be tried,  usually they
slip.  But it  is necessary to be absolutely sure of  the nature of
the case before using the scissors.
  Reason for such decision.  1st.  Danger of contusion, in-
flammation, laceration,  sloughing.   2nd.  Exhaustion.   3rd.
If born alive, child is likely to die.   4th. If alive, the disease 
138
MANUAL of  obstetrics.
  is likely to go on.  5th.  Child's value to society likely to be
  null.  6th. Mother's life of paramount importance when life is
  at issue against life.
    Ascites and  Tympanites may occur, the first as the result
  of inflammation,  the second  from putrefaction.  Delay  takes
  place after passage of  shoulders.  Ascertain  cause  by digital
  examination.   Child usually dead in, first, either from disease,
  or later from  pressure on cord.
     Treatment.—Labor to be assisted with  fingers, blunt-hook,
  or perforator.
     Short Cord.—Cords of six or seven inches are on record.
  Such may cause delay.   After head has passed, complete ex-
  pulsion may be prevented  by actual brevity, or from twisting
  around the neck.
     [A case where a cord  was so shortened by being twice around
  the neck,  that foetus was strangled in utero, and the child be-
  came putrid.   On delay occurring, the cord  was severed, and
  the body expelled with tremendous force.  Amer. Jour. Med.
  Science, 1852.]
     Treatment.—Give uterus time  to  contract.   After  head is
  expelled, if delay becomes  hazardous, cut the cord.
    Face Presentations.—Frequency 1 in  212£, or Cazeaux
  1 in 250 to 300.  Arneth 1 in 165, and also in 144,694 births,
  732 face  cases, 1 in 197|.  Mortality to  woman 1 in 50, to
  child 1 in 7 ; and more fatality has been  noticed  in  assisted
leases.  Lachapelle in 72 found 42 safe to mother and child.
    Mechanism.—Four positions.   1st.  Right mento-iliac. 2nd.
  Left mento-iliac.  3rd.  Mento-sacral.   4th. Mento-pubic.
     Mechanism.—1st.  Right mento-iliac, most common.  Face
  comes down transversely, but the length  of the neck is  not
  sufficient to  allow the chin to get as  low as the tuber ischii
  without engaging  the thorax in the superior strait, throwing
  the occiput back  on the chest, causing a  line through vertex
  and sternum to  take  the place of fronto-mental diameter;
  hence when rotation occurs, chin and front of neck slide from
  behind forwards on the anterior inclined plane ; the bregma 
MANUAL OF OBSTETRICS.
139
slides on posterior inclined  plane into the anterior surface of
the sacrum.  The right cheek is at first  lower, and  engages
first at the superior strait, and remains behind left pubes while
the left rotates  from above downwards, and from right to  left.
The chin appears under pubic arch, and gradually rises, while
the sagittal suture, &c, sweep the sacrum and perineum.
   2nd. Left mento-iliac, differs from previous, in that the chin
slides on the left anterior inclined plane, and the bregma on the
right posterior one; the  left cheek comes down, and remains
behind the right  pubal ramus, while  the right cheek  descends
from right to left; the left cheek  presents first under the ramus
of the arch, and continues its motion till it reaches the leftside
of the strait.   The chin under the symphysis tends slightly to
the left.
   3rd. Mento-sacral.—Very rare.   Because,  1st, the  occipito-
pubic position which gives rise to it is rare ;  2nd, it must soon
become transverse, even if presenting in  this position at first;
3rd, if the chin was retained on the sacro-vertebral  angle, it
would  cause the  occiput to descend; 4th, the chin could not
descend to the perineum in this position  unless in an immature
fcetus.
   4 th. Mento-pubic.—Rare at the beginning  of labor, but it is
the position in which the two principal positions terminate.
   " When the face presents at  the superior strait with  chin
to pubes, and forehead to  sacrum, the fronto-mental  diameter
three inches is  parallel to sacro-pubic  four and  a half inches;
so  far  there is no disadvantage;  but later, when the  head
descends, the  chin  gets below the  pubes before  the occiput
reaches the  excavation, and the  breast is still at the superior
strait while the face is engaging  in  the pelvic circle,  then the
front of the neck being  stopped by the lower edge of the
symphysis, compels the vertebral column to react upon the
posterior part of the head, which it urges from behind forwards
so as to force it through the vulva by presenting to that open-
ing a series of  circles whose principal chords  are measured by
the vertical diameter of the head." 
140
MANUAL OF OBSTETRICS.
   Causes.—Unknown.
   The  face does not always  present full; the forehead often
 sinks lower than the chin; in some  cases one cheek descends
 foremost; if face cases end speedily the child is not in danger;
 but prolonged pressure on the neck may cause intra-cranial
 effusion.  Children are  born  greatly distorted; mouth pulled
 upwards, eye down, alae of nose tumefied, and this should be
 told to  attendants previously to the end of labor.
   Diagnosis  by eyes,  nostrils,  mouth,  chin ;  may  be con-
 founded with breech.
   Care is requisite in examining that eyes be not injured.
   Treatment.—Most cases do wellif  left  to nature; special
 care to preserve membranes for sake of child's face; patience
 and time.  Forceps or perforator may become necessary.
   For child after delivery, leave swollen face  alone or some
 evaporating lotion.
   Irregular Labors include, 1st. PRESENTATIONS OF
 THE PELVIC EXTREMITY of the fcetal oval.  2nd.  OF SU-
 PERIOR EXTREMITIES.   3rd. LATERAL  presentations.
 4th. OF TWO OR MORE parts.
   OF PELVIC EXTREMITY.—Includes Breech, Knees, and
 Feet.
   Frequency: Of breech, 1 in 52 ;  (Arneth, 1 in 58; in 159,
 593 births, 3000 breech cases, 1 in 53 ;) knees rare, 1 in 3445 ;
 feet, 1  in 92£ ;  Arneth, 1 in 112  and 1  in 104.  Are less
 common in primiparae.   Some  women have  a succession.
   Mechanism.—Two presentations.  1st. Sacro-anterior (more
 frequent).  2nd. S aero-posterior.  Positions, either hip, mak-
 ing 4 varieties.  Originally all  the varieties of feet, knees, &c,
 are simple breech presentations.
   Mechanism.—The nates present transversely in  one of the
 oblique diameters;  the anterior one being lowest, and becomes
 fixed under the pubes, and while the  other buttock sweeps the
sacrum and perineum ; the arms, if no traction is used, remain
folded  on the  chest, and  are so delivered;  the shoulders
descend, and are extruded obliquely ;  the chin becomes strongly 
MANUAL OF OBSTETRICS.
141
flexed, and the head corresponds in its diameter to the vertex
presentation,  the  face  following  the  sacral curve.   Either
buttock may present, the left more commonly.
  In  the sacro-posterior position  either buttock may present,
the left more frequently ; as soon as the ischia are delivered, if
no interference occurs, the anterior surface of the child sponta-
neously becomes directed  backwards, and  delivery occurs as
before.   Sometimes the chin departs from the breast and the
occiput presses on the nape of the neck ; gradually the vertex
turns more  backwards, and  gets  into  the concavity of the
sacrum; the inferior surface of the lower jaw presses the pubic
arch,  while the occiput sweeps over the perineum.
   Symptoms.—Pains not  so  powerful,  intervals  longer; less
reflex stimulation of vagina causes weaker pains.  Auscultation
finds fcetal heat  higher up than normal.  Meconium covers fin-
ger, but is not diagnostic, as  it occurs in  other  presentations.
Digital  examination finds a smooth, moderately soft  tumor, in
which by pressure is discovered the tuber ischii.
   Breech may be confounded with head, tuber ischii with malar
bone  or shoulder;  make diagnosis  by softness, pulpiness, no
sutures, no fontanelles,  cleft  between  nates, genitals.  Coccyx
declares not only that the breech presents, but also its position.
   Knees confounded with elbow, diagnosticate by size.
   Feet to be distinguished from hand by heel, toes  short and
equal in length,  no thumb ; difference in articulation, the foot
being  at a right angle; phalanges of fingers may be  readily
followed ;  inner border  of foot thicker than outer.
   Prognosis.—No danger to  mother, only more  tedious; but
to child fatal 1 in 3£;  1 in 7 ; 1 in 11; according to various
authorities.
   Causes  of Danger to  Child.—1st.  Cerebral circulation
impeded by pressure  on  body.   2nd.  Circulation of  funis
stopped.   3rd. Placenta detached before respiration established.
   Organs  of generation have been known to slough away.
   Management.—Inform  some  friend  that a  "cross birth"
exists, and prepare  for  an  asphyxiated foetus;  especially in a
                             12 
142
MANUAL OF OBSTETRICS.
primipara.  Meigs recommends to have forceps ready.  Brandy,
cold water, and a warm bath should be accessible.  Ergot may
be at hand.
  Indication is to diminish the continuance  of the stage of
danger, which is after the umbilicus reaches the vulva.
  Keep patient in bed to retard the rupture of membranes and
avoid straining.  Be careful in examining not to injure genitals.
Allow the breech to come slowly, and avoid drawing down the
feet, for as long as the legs are extended by the side of the cord
they are a protection against pressure, and again the doubled
breech prepares for the exit of head; again if  brought rapidly
down the chin leaves the breast,  the arms  are extended by the
side  of the head, and the occipito-mental diameter is brought
into  apposition with the transverse ; delivery becomes difficult,
and death of child is ensured.   As soon  as cord can be felt
pull down a loop ; if it pulsates  strongly there  is  no need of
haste;  if putrid, of course leave to nature;  if its  beats are
feeble,  irregular, or intermittent, do  not  delay assistance;  if
convulsive attempts at respiration are noticed, hasten delivery,
either by hand or by forceps.  If delay occurs, pass two fingers
up to the mouth and thus allow  air to enter, or a  tube might
be used, ex. gr. a catheter.  Again it is advised to draw child's
head away from the  perineum,  and thus allow mouth to be
extruded.  The arms, by slipping  up beside the head, cause
delay;  deliver either arm first by passing  the  finger Over the
shoulder and sweeping the arm across  the anterior surface of
the chest; a blunt hook is not advisable.
   To deliver the head, have the uterus strongly compressed by
both hands  of an assistant, pass the right arm between the
child's  legs and  let  its body  rest on  the forearm,  pass  two
fingers up to the child's superior maxillary bones on each  side
the nose, at the same  time  press two fingers of the left hand
firmly on the occiput; draw steadily with the right hand, at
the same time forcibly elevating the child's body towards the
mother's abdomen, the left hand  meanwhile assisting by push-
ing up the occiput.  Bear in mind  the axis of the pelvis. 
MANUAL OF OBSTETRICS.
143
  If the presentation be sacrum to sacrum, the conduct of the
case may, in the majority  of cases, be safely left  entirely to
nature ; nevertheless if the face does not rotate into the sacrum
aid may be given gradually, even  after  the  body is delivered;
moderate  and repeated efforts will suffice.   If,  as  sometimes
occurs, a hydrocephalic child  presents by the breech, perfora-
tion may  be resorted to, with  less hesitation as the absence of
pulsation  of the cord evidences death.  Instances occur where
the body  is pulled off from the head, and  difficulty takes place
in extraction.  Pass the fingers into the mouth, and then apply
forceps ;  have them held by  an  assistant while perforation  is
effected, and the craniotomy forceps applied.  Before leaving  a
breech, case examine the limbs and genitals of the child;  if the
latter have been injured apply a leech or  simply a  poultice or
evaporating lotion.
   PRESENTATIONS OF THE ARM include those of shoul-
der, elbow,  and hand.   Originally are all shoulder.  Fre-
quency 1  in  260|.  Danger, fatal to child one-half, to mother
1 in 9.
   Causes.—1st. Excess of liq. amnii;  2d,  faulty alteration of
the shape of uterus by  early contractions.  Again, a hand
coming down by the side of head may push it to one side.
   Positions, Four.—Either right or left hand, and either with
foetal back towards maternal abdomen (2  to 1 in frequency)  or
with back to  spine of mother.   The right  arm presents more
frequently than left.
   1st Anterior Dorsal Position;  right arm  and  shoulder
occupy the brim, occiput lying forwards,  the head  rests in left
iliac fossa, back lies obliquely across  lower segment of uterus,
breech upwards and to right side, legs and other  arm at the
back of uterus.
   2d Anterior Dorsal Position:  left shoulder at the brim, head
in right iliac fossa, breech to left  side, feet and arms at back of
uterus.
   1st Posterior Dorsal:  left shoulder  and  arm at brim, head
 with the  face forwards in left iliac fossa, abdomen and limbs 
144               MANUAL OF  OBSTETRICS.
obliquely  across  anterior  wall  of  uterus, breech  to  right
side.
  2d Posterior Darsal:  right shoulder and arm in pelvis, head
in right iliac fossa, breech to left of uterus.
  Symptoms.—If high up it is difficult to feel a presenting part.
If in a primipara the presentation  cannot be felt, suspect mal-
presentation.  Shape of Uterus is irregular, larger diameter,
transverse, and if parietes flabby, the head can often be felt in
iliac region.  Auscultation  finds  the heart  above iliac region.
 Vaginal Examination may find a " pocket of membrane" or a
hand.   (Cases known where a hand has been touched and  yet
withdrawn, and head presented.)   Hand sometimes felt beside
head.  Make the knowledge of the presentation certain, and
that early.
  Diagnosis.—Hand may be confounded with foot; but no
prominent heel and round  instep, fingers unequal, thumb, bend
the phalanges of fingers.   Elbow confounded with knee, patella
flat and movable, olecranon sharp ; and if there is doubt it is
permissible to bring down  the limb to assure the presentation,
but never  to draw subsequently if an arm.  Bringing down a
hand is of use  to decide the position of the child, and also to
fix which  hand it is  proper to employ in version.   Shoulder
mistaken for nates or head, not so  large  or so fleshy as nates,
no arms or genitals, not so large or bony as head, no sutures
or fontanelles,  known by  clavicle,  ribs, spine of scapula, and
acromion.  Main point to  be decided is  position, whether back
to abdomen or vice versA.  The  palm of  fcetus corresponds to
abdomen  and limbs of child, the thumb points to the position
of head.
  Treatment.—Arm presentations require interference.  If  left
to nature  uterus inflames  or ruptures,  exhaustion  and death
take place, or, in a  few  instances, "spontaneous expulsion"
occurs.  First step is to tell friends  of " cross-birth" and possi-
ble  death  of fcetus.   Keep  membranes entire as long as possi-
ble.  Confine patient to bed.  Be assured of presentation, and
then avoid examinations.  Avoid straining. 
MANUAL OF OBSTETRICS.
145
  Cases  present under four aspects—1st.  Membranes  entire
and os dilated.  2d. Membranes ruptured and os dilated.  3d.
Membranes ruptured and os not dilated-  4th.  Membranes rup-
tured, pains violent, presenting part closely impacted.
   Object of interference is to substitute some other for the pre-
senting part by which the progress of labor can be controlled.
Version is the resource.   Is to be attempted even before com-
plete dilatation of os, size of half a dollar is sufficient.  Prepa-
rations.—Empty bladder certainly, and rectum if there is time.
Chloroform by all means.  Accoucheur to take off his coat, to
have an apron or sheet over his dress, to oil his arm or to fill
vagina with lard.   Woman to be close to edge  of bed on the
side, or  preferably on her  back with  an attendant supporting
each knee.   An assistant steadies the  uterus.  Choice of hand
to be determined according to which fcetal hand is presenting,
i. e. right to right; ascertain this by grasping it as in  " shaking
hands."  Some always use right, some the hand corresponding
to the side on which the woman is lying.   If there is no assist-
ant place one hand upon the uterus to fix it firmly, and mani-
pulate with the other;  but if assistance is procurable, hold the
presenting  arm in one hand, and pass  the other into  the vagina
during a pain, the  fingers being in a conical form ; into uterus
during an interval; rest the bag of  waters on  the hand, and
pass up if possible some distance before rupturing membranes;
rupture them ; pass along anterior aspect of child, which is
ascertained by clavicle;  pass to umbilicus, feel funis, and usu-
ally near it is a foot.  If it is the  foot opposite to the hand in
vagina it is sufficient to turn  by ; ascertain this by great toe;
if it is not, secure it between two fingers and search  for other.
During a contraction keep quiet.   Get as much of the limb as
possible in  grasp.   During a  lull  of  contraction draw on  the
foot, being specially careful that version is attempted over the
anterior and not posterior aspect  of child.   Cease during con-
traction, and straighten out the hand.  Turn toes towards sacro-
iliac synchondrosis.  (Where version was delayed I have found
it of service to pass the hand over  the breech and at the same
                            12* 
146               MANUAL OF  OBSTETRICS.

time to draw on  the  foot in  the  vagina with other hand.)
Draw gently.  Deliver hips, sweep arms over the face.  Place
fingers on maxillary bones  and occiput, and complete delivery
as in breech cases.  Attendant must  compress uterus firmly.
If membranes ruptured  and os dilated, lose no time.  Early
action finds more liq. amnii and corresponding  ease in version.
If membranes ruptured and os not dilated, rule  is never to force
the hand in.  Chloroform or VS. and Antimony.   If membranes
ruptured and pains  violent, if  passages are hot and tender, os
swollen and painful, uterus hard, intolerant of pressure,  and
irregular, pulse frequent, dry tongue and thirst, pains strong,
and contraction about body firm, bleed; to 16 or 20 ounces;
or give Chloroform freely before turning.  Formerly Laudanum
was given in doses 60  to 100 drops; also Sol. Antim. Tart., and
after about an hour's delay  commence.  In such cases, child
rarely saved.  If  hand does not recede as it  should, place a
fillet on  the foot in vagina, and press  up axilla, observing the
intervals of pains.  If impracticable to push  up, or  as some-
 times occurs to pass hand in, never amputate arm, for children
 have been  born  alive and even lived to maturity thus muti-
 lated.  Determine child's death by auscultation, and eviscerate
 if necessary.  Delivery of placenta requires care, pressure, cold,
 Ergot.
   Spontaneous  Evolution, is the recession of the  arm  and
 substitution of the breech.   This was Denman's idea in 1772.
 Said to occur, but very rare.
   Spontaneous  Expulsion,  described  by  Douglas,  1811.
 Shoulder rests under pubic arch,  powerful pains press down
 successively the thorax, abdomen, and  nates, which  sweep the
 perineum while the shoulder remains  stationary.  More  cases
 occur thus, but most usually  happens with premature.  Is dan-
 gerous to mother, almost certainly fatal to child.  (An instance
 of favorable issue  to a second twin and also to mother, recorded
 in Charleston Journal, 1850.)
    Trust to "spontaneous expulsion"  only in premature labors.
    Turning by  External  Manipulation  has been  recom-
 mended ; is rarely of service. 
MANUAL OF OBSTETRICS.
147
  PRESENTATIONS OF CENTRES.—Are rare.  Diagnosis:
By exclusion.
  Of Back.—Uncommon.  Known  by spines and origin  of
ribs.   Version.
  Of Umbilicus.—Rarest.   Known by large, soft abdomen,
and no osseous prominence ; funis felt.  Version.
  Of Sternum.—A bony plane ; cartilages of ribs; intercostal
spaces.  Version.
  Of Side.—No round, firm  head, sutures, or fontanelles; no
rotund, fleshy  breech, with  genitals  and anus; ribs and inter-
costal spaces.   A single intercostal space  might be taken for
sagittal suture.  Version.
  PRESENTATION OF TWO OR MORE PARTS.—Hand
and Head.—Not very unfrequent.  Occurs usually  in wide
pelvis.
  Treatment: Watch carefully, and as soon as  membranes
rupture, press  it upwards.   But if too far advanced, avoid med-
dling, for its presence merely delays labor.  It has been said
that the sharp olecranon tends to rupture perineum.
  Arm and Hand.—Rare.
  Head and  Foot.—May  occur in unskilful turning.
  Put a fillet  on foot,  and  press up the head.
  Hand and  Foot.—When they occur, such cases terminate
by nates or shoulders.   Traction of Foot.
  Feet, Hand, and  Breech.   Head,  Foot,  and Hand.
Hand, Foot, and Cord.—These three require  merely traction
of foot.
  Complex  Labors include  CONVULSIONS, 'HEMOR-
RHAGES, PLACENTA PREVIA, RETAINED PLACEN-
TA, PROLAPSUS OF CORD, PLURAL BIRTHS, RUP-
TURE OF  UTERUS, INVERSION OF  UTERUS.
  PUERPERAL CONVULSIONS.  (Eclampsiapuerperalis).
  Def. " Violent and  involuntary contractions of a part, or of
the whole of  the body, sometimes  with rigidity and tension
(tonic convulsions); but more frequently with tumultuous agi-
tations, consisting of alternating shocks (clonic convulsions); 
148
MANUAL OF OBSTETRICS.
that come on suddenly,  in  recurring  paroxysms," " accom-
panied or followed with more or less suspension  of  sensorial
and intellectual faculties for a variable period ;" occurring be-
fore, during, or after labor.  By some are considered analogous
to infantile convulsions.
   Frequency: 1 in 602.   1 in 485.  Arneth, 1 in 502.
   Fatality: To mother, 1 in  4.   To child, usually still-born,
not always.
   Occur: Mostly in primiparae ;  most in  male labors ; strong
and plethoric.   (Instance of multipara with twelfth child ; fatal
issue.—Amer.  Jour. Med. Sciences, Jan. 1851.  With tenth
child.—Lancet, July, 1851.)
   Varieties.—1st.  Before Labor.   2nd. During Labor.
3rd. After Labor.—First is the  least frequent; very rare be-
fore six months ; if at  all, about seven or eight months.  (Ca-
zeaux records a case in which in two successive pregnancies con-
vulsions  occurred  at six weeks.)  Second  is most common.
Third not so common,  and more favorable.
   Divisions.—Epileptiform ; Hysterical ;  Apoplectic.
   Causes.—Divided into Predisposing and Exciting.
   Predisposing  may  also be arranged  under the heads of
Hyperemia, Anemia ox Spanemia, and Toxemia.
   Predisposing.—First  labors ;  plethora ; pressure on aorta;
nervous temperament; atmospheric  causes, as highly charged
electrical state; damp,  moist, and foggy weather;  mental  ex-
citement,  as in unmarried; plurality;  dead child  ; excess of
liq. amnii; disorder of primae viae ; contractions of uterus ;  re-
tention of urine; albuminuria ;  few cases  unconnected  with
constipation;  previous  injuries of head.   Epileptics are  not
more liable than others.  Of all these asserted causes, probably
no  one plays  a  part so  important as the non-elimination of
urea,  and its  consequent circulation, causing toxemia.   Dr.
Lever, in 1843, called  the attention of the  profession to the
frequent coincidence of convulsions and  albuminous urine,  and
in but comparatively few instances since, where albumen  has
been carefully sought for, has it  been absent.  The converse, 
MANUAL OF OBSTETRICS.
149
however, is hardly true to the  extent claimed for it by Dr. L.
In some cases, where circumstances have induced me to examine
the urine, I have  found albumen, but  convulsions have  not
occurred.   Dr. L. found in more  than fifty analyses that albu-
men was detected only in cases that were  attacked with eclamp-
sia.  Perhaps future investigations may prove that in some
cases the  convulsions occurring during  labor are merely con-
vulsions symptomatic of the retention of  urea that occurs either
in Morbus Brightii or from a temporary  congestion of the kid-
ney, and consequent non-elimination of urea, arising from pres-
sure upon the emulgent veins, as  stated by Cormack. ■
  Exciting  Causes.—Loaded stomach ; indigestible food;
labor pains ; rigidity of os and whatever opposes the action of
uterus; straining during labor ; irritation to the uterine nerves
by introducing hand.
  [T. Smith makes two divisions of causes.   Centric and Eccen-
tric.—" 1st. Causes acting on  the central organ ;  as pressure
on the medulla  oblongata by congestion, coagula, serous effu-
sion ;  loss of blood;  morbid elements in the blood ; the influ-
ence of emotion.   2nd. Causes acting on the extremities of ex-
citor nerves ; as irritation of the  incident spinal nerves of  the
uterus  and uterine passages ; irritation of excitor nerves within
the cranium ; irritation of the incident  spinal  nerves  of  the
rectum ; irritation of the ovarian nerves; irritation of the gastric
and intestinal branches of the pneumogastric nerve; irritation
of the  incident spinal nerves  of the bladder.   As probable
causes, may be enumerated irritation  of  the  cutaneous nerves,
of the nerves of the mammae, and of the hepatic and renal
branches of the pneumogastric."]
  Epileptiform  Variety.—Symptoms.—Some  premonition
seldom absent; as agitation; malaise; irritability;dyspnoea ; pain,
splitting, dull, sharp, beating increased by stooping; on one side
of head, or one coronal boss, or in back  of head, refractory to
treatment; pain like a nail driven in; nausea; vertigo ; dimness;
tinnitus; pain in epigastrio; muscae volitantes; temporary blind-
ness, drowsiness; face flushed; twitching  of muscles; oedema of 
150               MANUAL OF OBSTETRICS.

face ; extreme restlessness at each pain ; change of manner, dull,
heavy, stupid, abstracted, loss  of consciousness, impeded utter-
ance ; rigors ; pulse  slow or  quickened ;  horripilation ; furred
tongue; constipation of bowels;  tenderness of uterus.   Some of
these may precede for  some days; some a few hours.
  While in  labor, patient may suddenly complain,  " I  can't
see," or " is  dazzled,"  &c, or  violent " splitting pain in head"
or stomach, and then  become convulsed ; face is bloated and
livid, throat  swelled, carotids  throb, jugulars prominent; eyes
seem to start, while  the  cornea  may be drawn  beyond sight,
sometimes one outwards and one inwards, pupils usually dilated,
sometimes contracted,  sometimes expand on  approach of  light
during interval; lips in  continual  motion, mouth  drawn  spas-
modically upwards or to one side, jaws at first  depressed and
then firmly closed, frequently  biting tongue ; bloody foam on
lips; respiration at first rapid  but heavy, thorax heaves, deep,
irregular, labored, hissing; all the voluntary  muscles in violent
spasms, arms and  legs in rapid and violent  contortion; pulse
at beginning full, slow,  and oppressed, afterwards rapid and
small; bladder and  rectum sometimes expel  contents ;  so also
uterus  may contract  and expel foetus during unconscious state.
  Continues  five minutes to half  an hour;  gradually spasms
less violent, face less livid, breathes easier, foaming ceases, eye-
lids close, and deep sleep  ensues with stertorous breathing more
or less, rolls and moans, sometimes yawning;  pulse quick (and
if slow, indicates a repetition) ; skin hot and dry, becomes per-
spirable.   Awakes unconscious of  what has occurred,  and sur-
prised at confusion, &c.;  is dull and heavy;  suffers from pain
and soreness from exertion ;  voice hoarse and rough.  May
recover consciousness, and recognise friends without ability to
express herself clearly.   Intelligence without recollection, may
remain till next attack,  with weakness, headache, and confusion.
If continue to recur, coma is continuous.  As  many as eighteen
paroxysms noticed in twenty-four hours.
  A single convulsion  rarely proves fatal.
   Convalescence is  sometimes  tedious and  uncertain; for  a 
MANUAL  OF OBSTETRICS.
151
long time the  gait may be unsteady, memory  perverted, and
sight  abnormal.  Frequently  on  recovery  of memory, the
period of perfect recollection extends  much  further back than
the access of the paroxysm.  Mania sometimes remains.   Sub-
sequent pregnancies are not necessarily liable to recurrence. A
proclivity to abdominal inflammation is noticed after labors with
convulsions.
   Hysterical  form.  Cases  merge  into each  other.  This
form occurs in weak and debilitated.  During gestation usually,
or in first week after labor, while milk is in early secretion.
   Is caused  by want of. sleep, fatigue, disordered digestion.
   Symptoms.—Sensation  of tightness about throat, choking,
globus, hands  carried to throat, oppression  in  epigastrio, sob-
bing.  Face pale or flushed, hot  not livid, not  distorted, no
twitching, no foam, no hissing respiration, no convulsive move-
ment of jaw.  Muscles of back contract, and  form an arch ;
opisthotonos,  screams, sobs, sighs, weeping.   Does not lose
senses.  Urine limpid and profuse.
   Diagnosis.—From epilepsy.  Puerperal eclampsia is similar
in  violence  of convulsions,  in  total  loss of consciousness,  in
lividity from  apncea, in  coma.  Differ—in epilepsy an aura,
fits return at long intervals,  paroxysms seldom fatal, some pre-
existing derangement, while in Puer. convulsions cerebral con-
 gestion precedes, hissing characteristic, rapid succession of fits,
often fatal, attacks healthy.
   From Hysteria.—In H. never total abolition of intellect; no
Jsoma subsequent, limbs flexed forcibly and writhing, globus, no
  rothing.  Cold dash  produces sobbing.  Resists vaginal exa-
 mination.
   From Coma of Apoplexy.—In A. no convulsive phenomena
 precede coma,  extremities have lost  sensibility and mobility,
 hemiplegia.   History essential to diagnosis.
   From  Concussion, by history and marks of injury.
   From Intoxication, by odor  of  breath and  vomiting of al-
 cohol.
   Prognosis.—Average  fatality one  fourth.  Collins 5 in 30. 
152
MANUAL OF OBSTETRICS.
Velpeau 8 in 21. To child, generally, but not invariably fatal,
34 in 51 Merriman.   Apoplectic  form worst.   Hysteric by no
means dangerous, unless they are  the result of some great men-
tal shock, and then they are so.  In primiparae more fatal.
  Convulsions after labor are less dangerous than early.  Early
in labor are  more  fatal, or during pregnancy.   If labor does
not permit completion, are dangerous.   If in interval coma is
continuous, and no consciousness occurs, unfavorable.
  Quickness, or slowness of the return of consciousness, is a
better test of danger than violence of fits.   If remission is
long,  and  second  spasm   shorter  and   milder,  favorable.
Children are said to be liable  to  convulsions, and die in a few
days after birth.
  Pathology.—Hitherto no characteristic lesion, and the post-
mortem appearances  are thought to be  the effects rather than
causes  of  convulsions.  Cerebral congestion,  or effusion  of
senasn,  and in apoplectic cases a clot may be found, pulmonary
congestion,  or peritonitis.  The true pathology of P.  convul-
sions is yet unwritten, but may it not be  because little or no
attention has been paid to the investigation of renal pathology
in this affection ? How many cases of epileptiform convulsions
do Hospital physicians examine, and find no cerebral lesion at
all characteristic ? and is not this because organic kidney  disease
is not looked for, and still more obscure  functional disease  un-
suspected ?  Were  the urine, as  found  in the bladder of such
cases, invariably tested, how much light might be shed on P.
eclampsia.   With the light the microscope is shedding  on this
branch  of morbid anatomy in the well known form of Morbus
Brightii, and more recently in  the almost  unexplored   aberra-
tions  of fatty deposit, may we not hope to read this   disease
aright,  at first by  its autopsic  revelations, subsequently by
being taught to look for such changes ?   Impurity of the blood
plays the most important part in  P. convulsions; whether the
result of hyperemia, anemia, or toxemia ;  and  how striking is
the analogy that prevails between the  symptoms of Morbus
Brightii and of incipient eclampsia, in  the  headache, oedema, 
MANUAL  OF OBSTETRICS.
153
coma, convulsions, muscae volitantes, amaurosis, and albuminu-
ria  of the two diseases.
  Treatment.—Prophylaxis ; regular exercise ;  bowels free ;
calomel et pulv. antim., followed by senna draught; venesection,
10 to 14 ounces ;  cups or leeches to lumbar region ;  open air;
unstimulating diet;  loose dress ; pulv. antimonialis in increas-
ing doses ;  tartar emetic ;  attend to renal secretion ; digitalis
and soda.
  During  fit.—A roll  of muslin  between  teeth, about six
inches long;  prevent from injuring  herself,  but not restrain
her; dash  cold water on face  with a whisk.
  As soon as violence  abates, bleed; bleed freely ; Denman,
40 oz., Blundell 70;  take 32  oz., and if pulse  not affected, 16
more, one or both arms.  Cold to head by stream or ice-cap ;
enema  of  turpentine  or salt, and repeat it; sinapisms to legs
and feet;  examine state of bladder; if full,  catheter;  make
frequent vaginal examinations lest child be  expelled uncon-
sciously.  Watch if  she is uneasy, gropes  and writhes  about,
and moans ; and if these signs occur periodically, the uterus is
contracting ; if head  on perineum she  strains.   Give a cathartic
early ; calomel 3j. mixed with butter  and placed on tongue;
ol. Tiglii gtt. ij. with  butter ; follow with senna draught; some
give camphor with  calomel..-  Repetition of venesection to 2nd
or 3rd, depend  on pulse; depend on state of circulation  in
interval, rather  than  on violence  of  attacks.   Sol. ant. tart.
grs. ij.  to  5iv.; dose £ss. every 15 minutes, ad nauseam.  If
pulse thready and convulsions recur,  chloroform, CC, or dry
cups, leeches ;  shave head except front locks ;  ice-cap.
   Shall labor be terminated artificially.—" It  is not proper in
all cases to deliver;  other circumstances must be taken into
account, as the situation of the head, state of os; is better to
leave a patient to her own resources  than to  kill  her  by an
operation."   In 200  cases, one-half were delivered  by natural
efforts,  22  died, 1 in 4£ nearly; by forceps,  35  deliveries, 13
deaths,  1 in 3 ;  by crotchet, 43 deliveries, 12  deaths, 1  in 4;
by version, 14 deliveries, 8 deaths, 1 in 2.'
                           13 
164             manual of obstetrics.

  Forceps or version if  design to save child ;  Ergot proposed;
Crotchet for  mother's safety;  Os not to be forcibly dilated ;
Sol. Ant. Tart.;  not use Ung. Bellad.;  Convulsions will  con-
tinue  after  labor;  look  to  bladder and rectum;  retained
placenta.
   When recur after delivery.—Chloroform, Opium, Hyosc. et
Camph., Sol. Antim.
  For Coma.—Leeches or cups, ice-cap, blister.
  " Opium to control hyperemic convulsions  is improper, but
for the convulsions of  debility it  acts as a  stimulant to an
exhausted nervous  system,  and arrests  the  fits."  Enema a
good  mode.   Camphor,  ammonia, wine, brandy,  &c,  are
useful on the same principle; for inanition, nutritious diet is of
more  service than medicines.
  Treatment of Hysterical Form.—As soon as patient can
swallow, give Spts. Ammon. Foetid, in cold water.  Chloroform,
Camphor, ./Ether, Assafetida, Ammonia, Valerian, Cold dash.
   If  disposed to vomit, use warm  water freely.  Bowels often
irregular  and  costive,  with  dark evacuations  and  scybala.
Give  Enemata of Assafetida or Turpentine; and, after relieved,
give diffusible stimulants with Opium.
  Of Apoplectic Form.—Not different from ordinary apoplexy.
Is seldom seen, and usually fatal.  Caesarian section to save
child  after death of mother.   Forceps.
  ' After Treatment.—Head cool; bowels soluble;  diet light;
apply child to breast; if these are flaccid, apply sinapisms.
   Sequelae.—Paralysis said to be  rare.  Eclampsia  seldom
recurs subsequently.  Unsteady gait. . Headache.

   HEMORRHAGES  IN  GENERAL.—Difficult  to  deter-
mine frequency, much depends on  accoucheur.
   Said to occur 1 in 146 J.  Collins, 1 in 125.   Arneth, 1 in 41.
   Fatality.—To mother,  1 in 5 \ ;  to child, 1 in 4.
   Not  every effusion of blood  after  labpr is  hemorrhage, but
rather  that which affects patient.   Before term, any except a
trifling loss, is styled Hemorrhage or Flooding. 
MANUAL  OF OBSTETRICS.
155
  Amount.—May be ounces, or quarts.
  Danger is proportionate to amount of blood lost, but rather
to effect; to  state- of patient  at the time;  some patients
affected by a few ounces, others hardly by a quart or more;  to
suddenness  of loss; sometimes, though rarely,  a single gush
proves fatal.  A draining hemorrhage may continue a long
time, the  loss being supplied by  new blood, but even here a
single gush may terminate life.
  Symptoms.—Countenance  pale, ghastly;  pulse  feeble, fre-
quent, fluttering, sometimes intermittent; weariness, weio-ht of
limbs, fainting,  sighing, vomiting, tinnitus;  more  aggravated
signs are, surface damp and chilly ; breath cool; pulse intermits
or imperceptible; intolerable restlessness and tossing; involuntary
jactitation ; insists on getting up ; deep, convulsive, gasping sobs ;
inability to see ;  syncope in  reiterated, attacks ; convulsions;
death.
  Modes.—By profuse gushes, as  seen in placenta praevia.
Source  the  denuded maternal sinuses and ruptured  placental
vessels.  By draining, or passive exudation, from partly closed
vessels, as seen in secondary hemorrhages.
  Means of Suppressing Hemorrhage.
  Nature's  Modes.—1st. Syncope,  by  allowing coagulation
during imperfect action of heart.
  2d. Vomiting, from sympathy between stomach and uterus;
caused  by loss  of  nervous  energy  from anemic condition of
brain.  Value is  uncertain;  if it does no  good it produces
positive harm by favoring exhaustion!  Of service as  a symptom
in concealed hemorrhage.
  3d. Coagulation.—A divided artery retracts within its sheath,
and allows fibrinous particles to  become entangled ;  clots form;
moreover the vessel diminishes  its calibre  by circular contrac-
tion.  As bleeding goes on,  blood is more disposed to coagu-
late.  Syncope favors coagulation.
  Fibrin is  poured out and  closes vessel,  becomes organized,
and permanent closure occurs.
  In the uterus an analogous process to ligation occurs.  The 
156
MANUAL  OF OBSTETRICS.
uterine sinuses do not retract or contract per se, but the system
of " living ligatures," formed by the uterine fibres contracting,
effectually secures  the open  mouths  of the sinuses.   If  the
existence of utero-placental vessels be admitted, their retraction
may be of some service.  Coagulation  also occurs, but is of
inferior moment; the  only reliable means for suppressing ute-
rine hemorrhage is contraction of the uterine tissue.   Clots
may increase flooding.
   The danger of Syncope in  flooding is its duration.   But it
also impairs nervous energy, and  thus  diminishes contractile
irritability, our only reliance.
   Position, &c.—If hemorrhage is sparing, the supineposture
will be of service  and is essential.  Patient should  be on a
mattress,  lightly  covered.   The apartment cool  and  dark.
Body and mind  to be at  perfect rest.  Attendants to be  few
and quiet.
   Regimen Essential.—Drinks cool;  iced water, lemonade,
Cream of Tartar,  Infus. Rosar. with  Acid. Sulph.  Aromat.
Nitr. Potass. largely*diluted.
   If flooding be long continued the drain must be supplied by
food, either in broths, soups, jellies, or solids ; solids preferable,
the lighter  meats, eggs, &c.; fluids cause flatulence, and diar-
rhoea may succeed,  which is prejudicial.
   To judge of continuance is of importance.  Clear blood away
from genitals.   Spread between hips and bed a sheet, or better
a blanket; place a clean napkin  to vulva.  If  bleeding  has
ceased napkin will  be slightly stained;  if continuing, clots, or
a stain more or less extensive.   If quantity is large the color
will be bright, if pale  the  exudation is  small, but when long
continued the color may be  pale.
   Venesection.—Used in threatened abortion.  In strong  and
plethoric, in early and middle months.
   Beware of collapse.  The usual loss  at  time of labor  may
prove serious if venesection of much amount has preceded.
   Medicines.—A. Aperients.—Useful if constipation.  Avoid
medicines acting on lower part of intestinal canal.  01. Ricini, 
MANUAL OF OBSTETRICS.
157
Sulph. Magnes., Cal.  Magnes.,  Seidlitz Powder, Rhubarb and
Magnes., Cool Enemata best.
  B.  Astringents.—Kino,  Catechu,  Hematoxylon,  Tannin,
Gallic Acid, Matico, Alum, Acet. Plumb.
  With the exception of Acetate of Lead, astringents are of but
little service.  Lead should be given boldly, and in combination
with opium.   Five or three grains of lead hourly, with one or
less of Opium, may be used for  three doses, and then the quan-
tity lessened.
  C.  Opium.—Great diversity of opinion  as  to its  power to
arrest;  of  its use in controlling the effects of loss  of blood,
restlessness, &c,  there is no difference.
  " After severe  hemorrhage, when countenance is sunk, eye
hollow  and glassy, lips blanched, skin cold, the whole person
corpse-like, pulse gone  at  wrist, beat of heart slightly heard,
stimulants vomited  or uninfluential, there remains  yet one
remedy capable of restoring patient to life, and that is Opium ;
acts by producing cerebral  congestion."  Use Laudanum in
teaspoonful doses.  If vomited, use solid Opium, or Enemata
with Laudanum or Black-drop.
  Applicable to  flooding after delivery; as a stimulant  when
nervous irritability of uterus is almost gone.
  Used in abortion to allay uterine action ; usually combined
with Acet. Plumb.
  D. Digitalis.—rRecommended  by Burns.  But it is uncer-
tain,  capricious,  requires  too  much time,  depresses nervous
system.
   C. Turpentine.—Advised by Denman ; useful in passive.
   D. Ipecac, by  its emetic effect produces contraction of  abdo-
minal muscles and compresses uterus.
   Antimony, as  a nauseant.
   E. Tine. Cannabis Indica, useful in menorrhagia.
   F. Ergot.—Useful whenever uterine contraction is admissi-
ble.  Not  in  all  forms of hemorrhage.  Not if desire to save
child.  Hazardous where great exhaustion of vital energy ; for
it is inefficient as a nervous stimulant, and even seems to have
                            13* 
158              MANUAL OF OBSTETRICS.
a sedative effect on  the  heart  May be given for floodings at
three periods;  1st, when head is on perineum and about to
be  expelled;  2d, between  passage  of head  and shoulders;
3d, and  most beneficial,  when insertion of funis can  be felt;
acts through the blood ; not to be used before version.
  Compared with Opium, Ergot is  useful to  prevent hemor-
rhage, Opium to save patients from the consequences of extreme
flooding.
  G. Stimulants.—Not  to be hastily given, for Syncope is of
advantage in restraining the flow, and to promote coagulation,
though not of reliable value.
  If system  sinks, instead of rallying, use stimulants.  Sustain
nerve force, and thus ensure contraction.  Alcoholic preferable,
brandy and  water, sometimes brandy per  se  less liable to be
ejected.
  Attend less to quantity than effect; give a teaspoonful, watch
effect, and repeat.  Mist. Camph. and Carb. Ammon.   Beef
tea in small quantities.  Arrow-root  and brandy.
  External  Stimulants.—Hot bottles, bricks, irons, &c.; Sina-
pisms, Capsicum.   If cold douche has been used  and patient
chilled, insinuate  a warmed blanket under.
  Mechanical Remedies. Cold.—As a refrigerant is not useful
in Ut. Hem. but as a stimulant it is invaluable.  When dis-
charge is moderate the powerful application  of cold  is unne-
cessary ;  cloths wet in cold or iced water may be applied over
hypogastrium; sprinkling not to be continued too long;  chilli-
ness depresses.
  More powerful mode is  ice in vagina,  over pubes,  or into
uterus if demanded.  Long continued use may freeze the  parts
and destroy  vitality.
  Most powerful  is a cold douche from a pitcher held high and
poured in full stream on naked hypogastrium.  Cold injections
into uterus are very efficient, somewhat hazardous secondarily.
Cold Enemata useful.  Evaporation  of Sulphuric Ether is an-
other mode  of refrigeration.
  If patient be much reduced, heat may be applied to extremi- 
MANUAL OF OBSTETRICS.               159
ties and praecordial region, and cold locally.   By some, sina-
pisms advised between shoulders or to breasts; to the latter
some object, as likely to stimulate uterus.
   Plug or Tampon: Applicable, 1st. To early miscarriages, if
there is no hope of  saving ovum ; 2nd. To accidental hemor-
rhage, as a temporary expedient;  also, 3rd. To placenta praevia,
but only pro tem.; 4th.  To menorrhagia in married.  Not to
floodings immediately after delivery.
   Object  is to prevent exit, and -allow accumulation of blood,
and so clog up vessels.
   Material.—Best is made of several pieces of muslin about four
inches square, silk handkerchief, tow, sponge..
   Must crowd fully up to os, and make vagina fullj and  then
secure with T bandage.
   Not to be left over twenty-four hours.   Retention of urine
will require catheter ; and, on  account of retention, it is better
to have the  tampon made up of several pieces, that a portion
may be removed without disturbing the whole.
   Alum Plug:  A piece of alum, about three inches long and
 one thick, crowded  up to os;  will  often restrain hemorrhage.
 Not to be left over twenty-four hours ;  coagula become putrid.
   Discharge of Liq. Amnii : by rupturing membranes, is a very
 useful remedy in latter months, in accidental hemorrhage, and
 partial placental presentation.
   Not difficult  to accomplish ; .catheter, stilet.  Uterine con-
 traction usually soon commences.  Has- been objected to as in-
 sufficient ; but the operator, who has attempted the version in
 an uterus where the liq. amnii has  been  long evacuated, will
 concede the capacity of the uterus to contract.  Rigby had 64
 cases successful without necessity of version in accidental hemor-
 rhage ; Merriman, 30 ; Ramsbotham, 23 but of 25.
    Emptying Uterus : When  discharge of liq. amnii has failed,
 the only resource is to empty uterus.   According to position of
 child and its life, the choice will lie between version, forceps, or
 crotchet.
    In earlier months, a finger  only is applicable;  before sixth 
160              MANUAL OF OBSTETRICS.

month,  the whole  hand  should never  be  introduced  into
uterus.
  Introducing hand, and irritating uterus with ends of fingers,
is applicable after expulsion of child ;  is useful.  Also if uterus
is in semi-contractile state.  Not  in great exhaustion.  Some
disapprove in toto.
  ■Kneading and  grasping with hand over the fundus uteri is
perhaps the most certain means of securing contraction.   Pres-
sure frequently is requisite even for  hours ; and it is better, in
cases of emergency, to be  done by the accoucheur himself.
  Pressure on the Aorta : Is spoken of as useful.
  Tight Bandaging of Arms and  Legs :  Proposed by Mau-
riceau, is of service in maintaining vitality in extreme cases.
  Bandage or Binder: Is much relied on to prevent flooding;
but if bleeding has occurred, it is  better not to trust to it  until
contraction is made certain by the hand.
  A small block or book should then be enveloped in a napkin,
and bound firmly over fundus uteri.
  Galvanism : Proposed  by Ramsbotham in, 1834, has found
an advocate in  Radford ; for inertia.   Simpson's trials  of it
resulted in no definite conclusions.
  Nursing the Infant : Is highly praised by Rigby, because of
the well known effect of nursing upon after-pains.
  Transfusion:  Highly lauded by Blundell in extreme cases ;
is seldom  applicable; still  less frequently useful.


               Forms  of Hemorrhage.

  MENSTRUATION  DURING  PREGNANCY.—Dewees
records the case of a woman who had menstruated but  twice ;
she became pregnant, and, after  a suppression of six months,
the menses returned,  and  continued  monthly  till  delivery.
Subsequently a return of catamenia proved the accompaniment
of pregnancy.
  Whitehead relates seven cases, three of which recurred up to 
MANUAL OF  OBSTETRICS.              161
termination of gestation; and by speculum found it to exude
from ulcerated cervix.
   (One instance  of menstruation in early gestation has  pre-
sented itself to me.   The lady had an abraded cervix; in three
successive pregnancies she menstruated the tfe*ee-first months.
Leucorrhoea exists during intervals.)
   The interest of this abnormity is, that one may be deceived
as to the existence  of pregnancy.   A concurrence of signs is
necessary for diagnosis.
   Treatment;—Cauterization of os.

   HEMORRHAGE IN CONNEXION  WITH ABORTION.
—Flooding may prove fatal in expulsion before fcetus is viable.
Ingleby relates  four cases fatal before four months ;  Denman,
2 ; Whitehead, 3 fatal in 602.  I knew a case which occurred
a few years since, fatal at fifth month  from  repeated  hemor-
rhages ; and, more recently, one fatal between second and third
months.
   Frequency : The  most common variety of hemorrhage.
   Causes.—(See Abortion.)
   Treatment.—Rest;  cool  bed;  cold  drinks;  Lead  and
Opium ; Antimony  ; Ipecac.; Tannin ; Matico ; Cold ; Alum
Plug ;  Tampon ;  Ergot.  Remove ovum by finger or placental
forceps.

   HEMORRHAGE WITH "HYDATIDS," may occur in 3rd
to 8th month of apparent pregnancy.
   Nature.—" Uterine Hydatids " are not acephalocysts,  but
the degenerated  and exaggerated villi  of chorion.  Are  the
result of successful  coitus.  More  correctly termed  vesicular
mole.
   The usual course  is that  flooding occurs, a portion of the
mass is expelled, hemorrhage is  repeated, and health becomes
affected.
   History.—Symptoms  of pregnancy  exist, but  with some
peculiarities;  uterus disproportionately large for time of preg- 
162
MANUAL OF OBSTETRICS.
nancy;  more  elastic;  not firm ;  no  quickening;  no stetho-
scopic signs;  per  vaginam,  cervix is found  not  developed;
ballotement cannot be  produced; expulsion makes diagnosis
evident.
  Appearance.—A mass of vesicles like white currants floating
in a pinkish  fluid;  amount, half pint to a quart; size, from
pin's head to* size of grape; attached  by a  pedicle; shape
round or elongated.
  Described as  having three coats;  the external, serous, thin,
transparent;   middle fibrous; internal mucous.  Both white
and  red vessels  seen on surface; contained fluid,  in small is
transparent;  in  larger, straw color or pink ; not coagulable by
heat.
  Acephalocysts have been said to exist in utero.
  While in utero the vesicular mole is said to be contained  in
decidua, and floating free, or' attached  to  ovum, according  to
amount of fluid.
  Hemorrhage  usually attends expulsion, and may endanger
life from  profusion  and  repetition.    If much  developed the
uterus  may expel  its contents en masse,  but  if small, a  por-
tion is expelled  with bleeding, and symptoms recur.
  Rather copious  watery discharge is a frequent occurrence.
  Vesicular moles may remain long in utero, five or six years,
and may attain  even  15 lbs. weight;  from the fact  of this long
persistence hydatids  are not always a  proof of criminality when
occurring under suspicious circumstances.
  Prognosis.—Usually, though not always, favorable.
  Varies with age;  continuance of discharge ; effect on consti-
tution : anemia  and  phthisis  induced.
   Treatment.—Before 7th month no  manual interference per-
missible.   If  hemorrhage  threatens  exhaustion,  use tampon ;
cold; ergot.   After  7th month introduce hand and scoop  out
contents of uterus.
  Subsequently  bandage and compresses.
  Lochia and milk will appear as usual.
  To prevent return, use tonics, iron,  zinc, and regimen. 
MANUAL  OF OBSTETRICS.
163
  " Fleshy Moles."—The expulsion is attended with hemor-
rhage.
  They result from  blight of ovum, and infiltration  of the
placenta or membranes  with blood.
  Occasionally a single large  cyst  is expelled.   Some years
since I saw one capable of containing at least a quart.

  ACCIDENTAL  HEMORRHAGE.—Before delivery;  after
6th month.
   Occurred, in 68,962 cases, 85 times.
  Fatality, of 85, 24 were fatal, 1 in 3£ nearly.
   Cause of Hem.—Separation  of placenta.
  Amount of blood lost is in proportion  to  extent  of  surface
denuded, but may be fatal from a single inch.
  Causes.—Shocks,  blows,  falls,  laughter, fatigue,  mental
emotion, straining  at stool, lifting weights, plethora, irregular
action of  uterus at placental attachment, morbid state  of  pla-
centa, coiling of funis around neck.
   Symptoms.—Sometimes as  soon  as cause acts hemorrhage
appears;  sometimes much blood is  poured out,  and  but  little
apparent externally.
   Faintness,  sinking, vomiting, cold extremities, rapid feeble
pulse, hurried respiration, sense of  d it tension.  (The quantity
of blood  discharged, less a measure of the danger than the
effect produced.)
   Pain, i. e. uterine contraction  may accompany bleeding or
not; acts  as a means of restraining by closing bleeding mouths.
   Rarely fatal at once;  syncope occurs, patient rallies ; syncope
recurs, surface blanched, cold sweat, countenance sunken,  pulse
quick, weak, fluttering.  If  not arrested, sight becomes dim,
ringing in ears, sighing, intolerable restlessness, death preceded
by syncope or convulsions.
   Examine to satisfy as to state of parts, os, cervix, source of
bleeding, whether placenta presents or not.
   Diagnosis.—Mainly  from placenta praevia.  Occurs  ind.e-
pendent of period  of gestation, and usually from an assignable 
 164               MANUAL OF OBSTETRICS.

 cause.  In accidental uterine, contractions  diminish  bleeding;
 in placenta praevia  increase.
   Examination finds no edge or surface of placenta, or thick-
 ened cervix.
   Treatment.—If  no pain attends, os  not dilated, bleeding
 not profuse, allow time;  horizontal posture on cool bed; cold
 cloths or ice.  Elixir Vitriol  and Infus. Rosar.;  cold  water,
 lemonade, cream of tartar, nitrate of potash largely diluted.
   For nervous excitement use Opium Tincture, Acet. Plumbi
 and Opium.
   Cold enemata for bowels.
   Alum plug.   Tampon.
   If hemorrhage is serious, rupture membranes; successful in
.most cases.   Difference of  opinion  among  authors.   Ergot
 useful.
   If  hemorrhage is alarming, version or forceps, according to
 situation of child.   Perforation.
   Tampon, as a  means  of ultimate reliance, unsafe; permits
 internal hemorrhage.
   Artificial dilatation of os is dangerous.
   If asphyxia occurs and threatens death, use means to rally
 before delivery.   Transfusion.
   Great care as to bandage.

  EXCESSIVE  "SHOW."—Usually show  is  but slight;
 sometimes |j. to ^ij.
  Appears early in labor.   Arises from laceration of small
vessels of membranes in vicinity of cervix.
  May  be mistaken  for placenta praevia;  determine  it by
vaginal examination.
  Remedies.—Rest.  Cold.

  PLACENTARY  APOPLEXY.—Def. An internal hemor-
rhage between  the  uterus  and placenta, the latter continuing
attached  by its  margin; liquor amnii colorless.   May  burst
through placenta and appear externally.  Amount, of  blood 
                 MANUAL  OF OBSTETRICS.               165

17 ounces—5 lbs.—121 ounces ; fatal from 4 ounces; is very
dangerous.  Fatal as early  as six months.
  Occurs during gestation,  or in labor.
  Is rare.
  Symptoms.—Sickness,  faintness, paleness, cold extremities,
pulse rapid and feeble, tossing, feeling of distension, " of burst-
ing," gasping; no external  bleeding.
  Locally, a swelling at placental site, elastic, conical.
  Treatment.—Rupture membranes.  Ergot..  If contraction
not rapid or sufficient, introduce hand and turn.
  Tampon objectionable.

   PLACENTA  PREVIA.—UNAVOIDABLE  HEMOR-
RHAGE.—PLACENTAL   PRESENTATION.—(See  Turn-
ing, described under Shoulder Presentation.)—Not  known to
ancients as an original presentation, but Hippocrates recognised
the  danger of placenta  coming first.   Guillemeau, in 1609,
advised prompt delivery in such cases, but without  assigning
reasons.  Mauriceau thought the after-birth to have  fallen
down.  So also La Motte.   Portal, in 1672, described it as an
original presentation, and  advocates speedy delivery.  Giffard,
in  1731, describes  a case.  Smellie, in 1745, alludes to-the
possibility of this  implantation.   Rcederer, in 1759, was" the
first to give  a distinct and  complete  description.  Levret, in
 1761, describes  it,  and  suggests delivery by version.  Rigby,
in 1775, published  his classical essay on the subject, and since
this  treatise, the subject has always claimed much attention.
In  1845, the views of Radford, Kinder Wood,  and Simpson,
were published, and attracted much notice, and gave rise to
 much controversy.
   Frequency.—About 1 in 50*0.
   Cases occur in groups.   Sometimes  in  succession  to same
 patient.
   Fatality.—To mothers,  1 in 3 ; to child, more than  half—
 65 per cent.
    Varieties.—Partially or completely over os;  no proportion
                              14 
166
MANUAL  of obstetrics.
obtains between amount of blood lost and extent of implanta-
tion.
  Hemorrhage is a necessary and almost invariable attendant,
and occurs on an average three weeks before labor ; variety, as
early as sixth month, seldom before; as late as commencement
of labor.
   Cause of hemorrhage.—Is  the withdrawal  of uterine walls
from a portion of  the  surface of placenta, and both uterine
sinuses and placental vessels bleed.
  Prognosis.—-If left to nature usually fatal; not invariably,
for strong pains have been known to force away placenta, and
subsequently fcetus.
   Symptoms.—Hemorrhage  during  gestation without known
cause, as exertion,  &c.;  usually  without  pain  at first,  but
distinctly increased by each uterine contraction subsequently.
   Amount may be  slight, or  enough  to produce  syncope.
Rarely.a first attack fatal.   (Lee records one.)
   Diagnosis.—Resort at once, if hemorrhage is in  progress, to
vaginal examination ; if it has ceased, take care to be immedi1
ately summoned on  recurrence.  Avoid relying on "no pain"
as a test of labor, and of danger.
   Examination will produce bleeding, hence let it be sure,  and
introduce two fingers, or whole hand if necessary, for os most
probably will be high up.
   A clot may give the sensation of the placenta, or may cover
and obscure its surface;  but a coagulum can be broken down ;
if in doubt hook it off if practicable, and examine it in water;
cervix has thick spongy feeling.  If centrically implanted no
membranes can  be  felt;  in partial cases they may be  dis-
tinguished.               <
   In early gestation  ballotement is interfered with, if placenta
involves anterior lip.
   Rigby thinks amount  of  attachment influences  time of
hemorrhage; occurring early when partial, late when central
implantation. 
MANUAL  OF OBSTETRICS.
167
  Labor pains increase the  hemorrhage, but it  may occur
without pain.
  Treatment.— Varies with actual existence  of hemorrhage;
period of pregnancy; amount of attachment; state of os.
  Indications in early :  to restrain  bleeding by temporary
expedients;  if  in  labor,  to promote evacuation of  uterine
contents and contraction of uterus.
  In  early, use rest in  horizontal position, light  covering,
cooling regimen, saline  aperients, cold enemata; avoid purging.
  One or more such occasions will  occur; leave special direc-
tions to be sent for on recurrence.
  Generally at sixth month, nature will effect delivery unaided.
Perforation of membranes with  a stilet and elastic catheter has
been advised.  If attachment be  partial,  rupture  membranes
and give ergot.   (Objection to ergot—difficulty in  version if
required.)
  If os is dilated and hemorrhage profuse, version  at once.
  But if os not dilated, must wait, but only till dilatable.
  Hand not to be thrust through os before some  yielding, for
dribbling hemorrhage may follow delivery.
   Size of os not  to  guide,  but its dilatability, for death may
occur and os be but little dilated ;  sometimes placenta itself
may prevent dilatation.
   Occurring early, say  at  7th month, os  is not only not dilated,
but cervix is unprepared to dilate.
   Time of interference :  to be guided  by amount, frequency,
and suddenness of hemorrhage, but  especially by  its 'effect  on
system ; by dilatability of os.
   Better be too early than too  late.
   If not dilatable, push an alum  plug to  os, and on this use a
full grown tampon to vagina ;  but watch carefully, for hemor-
rhage is in progress internally, and delay is to be practised only
till  os-is dilatable.   Watch surface,  countenance, and pulse;
if a " sensation of bursting " is complained  of, hemorrhage is
occurring and is serious ;  not to be left  longer than  24 hours ;
catheter requisite. 
168
MANUAL  OF OBSTETRICS.
  If great general relaxation occurs may be sure of dilatability
of os ;  then it is time to interfere.
  Be ready to  turn on withdrawing tampon.  (Directions for
version, page 145.)  Use left hand ; feet in  9 of 10 cases are
found posteriorly on the right side of mother.
  Avoid perforating placenta  if possible; if  vitality is low
choose the easiest mode of passing.
  Dewees objects to passing through placenta,  because, 1st. It
loses time.   2nd. It augments  flooding by detaching more of
placenta.  3rd. The aperture made is too small  for foetus.  4th.
The opening made by child's  body will  not permit head to
pass.  5th. This increases  hemorrhage.  6th. Destroys vessels
on which child's  life depends.   1th. Is sometimes impossible in
centrical cases.
  As soon as feet are brought down, give Ergot.  May expect
hemorrhage to moderate as soon as breech engages.  Secure
contraction  by pressure, cold, and  gradual delivery.  Deliver
placenta if delayed.
  Sometimes patient is exceedingly reduced, has even fainted, and
then bleeding has ceased, to be renewed on recovery.  Danger
is, if hand is introduced to deliver, flooding may be reproduced,
and patient die;  or if  undelivered,  will die on  recurrence.   In
such a case, use stimulants freely, externally and internally, but
avoid delivery, unless hemorrhage is severe.  Wait for reaction.
As  soon  as flooding   recurs,   proceed.   Material difference
whether syncope is the result of sudden  gush or  a draining
hemorrhage.
   Of Detaching Placenta and Leaving to  Nature.—Pro-
posed  by Kinder Wood of Manchester, in  1822 ; advocated in
1845 by Radford and  Simpson; founded  on the fact that pla-
centa is sometimes  expelled before  fcetus, and in  such  cases
flooding ceases.    Simpson brings  141  cases;  of these,  10
women died, 1 in 14.   By old practice, 1  in 3.   In 110 cases,
73 children were dead, 69 per  cent., and 33 alive, 1 in 3.  S.
says in 19 in 20 cases, bleeding diminishes or is  arrested on
detaching the placenta. 
MANUAL  OF OBSTETRICS.              169
  Applied to cases where hemorrhage is  great, puncturing
membrane insufficient, and turning inapplicable, from undilated
os or contracted pelvis ;  again, when fcetus is  not viable, and
version  not  applicable or demanded;  when  too much  re-
duced to admit of version;  when  child is dead;  in primi-
parae ; child  is not to be  extracted  unless a mal-presentation
requires version;  the operation doubles the hazard.
   Objections : 1st. Not applicable to that severe form which
occurs about seventh month, when  cervix not  developed, and
unwarrantable violence would be requisite to detach placenta.
2nd.  Ordinarily as much violence is required for detaching as
for version.   3rd.  If left to nature, some days  may elapse be-
fore expulsion, and irritative fever may arise, besides anxiety to
accoucheur, patient, and  friends.   4th. Fcetus dead, unless in
exceptional  cases.  5th.  Loss of maternal life is not lessened,
for though hemorrhage is relieved, irritation of nervous system
is increased.  6th. Affords opportunity for  indolent practice,
and screening culpable inability.  1th.  Increases difficulty in
malpresentations.

   Summary  of  Treatment.—1st. If no exhaustion,  or it is
just commencing,  turn and deliver  as  soon as os is dilatable,
even though size be only half a dollar.  If not, use tampon,
and watch* the patient.
   2nd.  In extreme exhaustion, do  not  turn until reaction is
effected.
   3rd.  If os is rigid, tampon.  If exhaustion threatens, detach
placenta and leave, rather than to force hand through  undilat-
able os;  bearing  in mind distinctly  the relaxing effects of
bleeding on cervix uteri.

   HEMORRHAGE AFTER BIRTH OF CHILD.—May occur
from, 1st. Want  of care on the part of  the accoucheur,  in not
following down uterus as the child is expelled.   2nd. By im-
prudence in soliciting  descent of shoulders.  3rd. By blood
collecting behind  placenta, as it clogs the cervix.  4th. From
                            14* 
170
MANUAL of  obstetrics.
inertia of uterus.  5th. Irregular contraction.   6th. Adherent
placenta.
   Circumstances leading to Hem.—First: To  ensure safe ex-
pulsion of child, to promote expulsion of secundines, and to pre-
vent hemorrhage, no adjuvant means is of more importance than
steadily to crowd down the fundus uteri as the child is passing.
   Second : Too often it happens that the wear of patience in
a tedious labor,  or the fear of asphyxia after delivery of head,
prompts the  "  hooking down of the arms,"  and permits a
vacuum to occur in the non-contracting uterus, that is 60on
filled with blood.
   Third:  If  the placenta be detached  in such wise as to be
rolled up  longitudinally, a channel is  formed  that allows the
blood to drain  off, and  no accumulation ensues; but if it is
thrust down so  that it completely closes os, blood may collect
behind it, distension and concealed hemorrhage result.

   RETAINED  PLACENTA.—Occurs  from inertia.   Hour-
glass contraction, or Adhesion.  With each there may or may
 not be flooding.
   Not every case of delayed expulsion constitutes retention  of
placenta.   Often said so by young practitioners,  and  yet find
the organ in  upper part of vagina, or partly within and partly
without os, or lying loose in uterus.   Simple expedients relieve
these delays, as coughing;  bearing down ;  grasping  uterus
firmly ; " blowing into  the hand ;" or, as I  have seen, putting
a finger down the throat  to excite retching.   Blundell says:
" In  these cases you act very unwisely in leaving a patient, in-
stead of waiting to procure further assistance, and while you are
 away, perhaps some old woman comes  into the room,  puts' a
candle in her throat, excites retching, and liberates the placenta
 at once."
   A  placenta may remain several days  in utero and produce
no bad symptoms, but the patient is never free from apprehen-
 sion  of danger, from pains, from  hemorrhage, or constitutional
irritation. 
MANUAL  OF OBSTETRICS.              l7l
  A foreign body in utero gives rise to,  1. Pains, dull and
heavy in lumbar region, such  as  are called  " after  pains ;"  to
these no objection, but the contractions of  which they are the
evidences are useful to expel.
  2. To Hemorrhage, which may be more  or less copious, and
constitute the great danger;  such may  occur even after two
weeks' interval of quiet, and for relief removal alone suffices.
  3. Discharges, often excessively fetid, though sometimes re-
tention  occurs without offensive  discharge.  Why some  are
fetid and others not so, is uncertain.
  For this, the only remedy is  delivery,  either manually  or
otherwise.
  4.  Constitutional  Irritation is  apt to  result,  marked by
purging, vomiting, and typhoid symptoms; in some autopsies,
where the placenta was not expelled, I have found pus in the
veins of broad ligaments.
  Not always so; sometimes  no  ill effect.
  Inertia.—A state of loss of contractility frequently succeeds
tedious labor.  Is equally the cause and the effect  of flooding.
After expulsion of head,  there is a cessation of effort; and  if
placenta has become detached, flooding ensues.  Excess of liq.
amnii, or plurality, by over distension, impairs contractile power,
as in paralysis vesicae.   Too ample a pelvis, allowing sudden
evacuation of uterus, takes  the organ by  surprise, and before
contraction occurs, flooding  ensues.
   Symptoms : Recognise state of uterus by finding it through
the abdominal parietes, a large flabby bag, wanting  the firm-
ness of normal contraction.
  If placenta is attached throughout, there is no flooding; but
if partially or wholly detached by uterine efforts, or by officious
meddling with cord before uterus is contracted, flooding ensues,
and may be internal or external,  i. e.  "concealed hemorrhage."
   Grasp uterus, and blood  gurgles forth.   Patient is watchful
and restless,  pulse " hemorrhagic."
   Treatment:  Friction over uterus ;  cold cloths ;  cold sprink-
ling ;  ice externally and  internally; cold  douche;  ergot; 
172               MANUAL OF OBSTETRICS.
manual delivery of placenta.   Not to wait more than an hour
and a half ordinarily; if hemorrhage demands interference, pro-
ceed sooner ; if labor  has been tedious, a longer delay is per-
missible.
   Objections to long delay.—Is*.  Patient is not  safe till pla-
centa is delivered.   2nd.  The moral influence on patient; delay
excites apprehension of inefficiency or incapacity of accoucheur;
patient is restless and anxious, and friends increase her discom-
fort by suggestions.  3rd. Soon after delivery parts- are relaxed
and manipulation  is easy ; a.few  hours' delay interferes with
introduction of hand.  Placenta never to be removed without
ensuring contraction of uterus.   As long as uterus is inert, the
placenta serves as an  irritant to  produce  contraction, and  if
withdrawn,  its  place is soon supplied with  blood.   To deliver
placenta from uter.us, press one hand on  the fundus to keep it
steady, pass the  other along  the cord,  grasp placenta, and
usually the  irritation induced will expel the whole uterine con-
tents ; if so, there  is no danger: if no expulsive efforts ensue,
the hand  must be retained in  utero, and uterine walls irritated
with tips of fingers, while cold, ergot, and external pressure, are
used.
   If  patient is in syncope, it  is better to use means to rally,
than  by interference to be  " unhappily auxiliary to her destruc-
tion."
   Some recommend compressing the  bleeding surface between
the hand  in utero and that on abdominal parietes ; questionable.

   Irregular  Contraction.—Hour-glass  contraction.  En-
cysted Placenta.
   True hour-glass  contraction, i. e. stricture of uterus in middle,
seldom exists ;  most cases of this so-called, are strictures of the
os; but irregular contraction may  affect any part.
    Causes:  Rapid  delivery ;  tedious  labor;  over-distended
uterus ; irritation  of os by interfering with cord ; ergot; fric-
tion just over pubes, not  over fundus  uteri.
   Exists  in three situations,  perhaps  in any part of uterus, 
MANUAL  OF OBSTETRICS.               173
though not always  detected.  1st.  Contraction of cervix at os
may enclose part of placenta.  2nd. Contraction above cervix,
hour-glass  form.  3rd. Cylindrically.   Sometimes  two stric-
tures ;  probably os contracted  and a stricture also  in body of
uterus.
   Symptoms:  External examination  could detect only  the
third state, and here would  find uterus rolled up and extending
to epigastrium.   Per  vaginam, may find placenta closely em-
braced by  cervix, or if not  here, hand passes into uterus, and
tracing the cord, detects an  aperture which  leads into a cham-
ber in  which is  the placenta (this  sensation may be mistaken
for ruptured uterus and escape of foetus ; but it is to be recol-
lected  that while the  child  escapes through rupture,  the  pla-
centa seldom does.)
   This aperture may be easily dilatable, or spasmodically and
firmly  contracted on being touched.
   With these states, there  may or may not be flooding;  and
on this depends necessity of interference.
   Treatment.—Indications, are to  relieve spasm, and to  pro-
duce uniform contraction.
   If no special reason for hurry, friction gently and wait, recol-
lecting likelihood of hemorrhage ; anodyne.  But if flooding
occurs, proceed  to delivery of placenta.  If strictured part is
dilatable, pass through and  remove.  If it is like an irritable
stricture, assuming a " whipcord-like feel" when touched, give
chloroform.   Former practice was to bleed §xij. to xx., to give
an efficient opiate, and then,  after half an hour's  delay, to
dilate and remove ; of  course presuming the absence of flood-
ing.   Chloroform supersedes this  practice.  Ergot has  been
suggested.   Opium in large doses is objectionable:  may  pre-
vent the subsequent contraction, which is essential to safety.

   Adherent Placenta.—Ordinarily the last contractions that
expel the child also detach  placenta;  but if morbid adhesion,
either partial or complete exists, this is prevented.  If adhesion
is  entire, there is no flooding; if partial, some of the uterine 
174
MANUAL OF OBSTETRICS.
sinuses are enclosed, and dangerous hemorrhage ensues.  Often
this  complication  co-exists with  irregular contraction;  also
with inertia, adding greatly to hazard.
  Adhesion may he partial or entire.   Burns has a case which
proved fatal, the placenta being retained four  days by an ad-
hesion not larger than a shilling.  Sometimes adheres in several
spots.  May be intimate or loose ;  sometimes so complete as  to
be inseparable after death, not even by maceration.
  This abnormity is apt to recur in same woman ; the know-
ledge of  such  a probability will ensure  a more than  ordinary
celerity  when  summoned  to  such patients;  a  few  minutes
decide the question of life or death.
   Causes : Usually said to result from  inflammation, but it is
doubtful.   This form may occur altogether independent of mis-
management.
  A peculiar and perplexing mode of adhesion is when an edge
is attached, and a portion is protruded through os ; and even,
as I have  seen, through vulva.  The situation of placenta in-
fluences this, i. e. if near os.   Danger is, that reliance on the
rule  of feeling the insertion of cord being an indication for de-
livery, misleads ; if the placenta is torn  off, secondary hemor-
rhage may occur, or possibly inversion of uterus be produced.
  Symptoms :  Cannot suspect adhesion till delivery attempted;
then traction causes descent of whole uterus, the placenta re-
ceding on relaxing the  efforts.
  Treatment:  If no hemorrhage, wait and  use frictions, grasp-
ing and kneading uterus.   Ergot.
  Flooding requires  interference.   Pass  hand  into  uterus,
insinuate  fingers between uterus  and  placenta, and move
them from  side  to  side  till  all  is  detached.    Of course
flooding  ensues.  Some advise to  pass  hand  along  cord  to
placenta, to  expand fingers over the edges, and  so squeeze  it
off.   If the cord is followed the fcetal surface is touched, and
membranes  embarrass; if so, withdraw hand  to cervix, feel
for the bare uterus, pass  fingers  along it  to placenta, detach
it, and suffer uterus to expel the mass and hand. 
MANUAL  OF OBSTETRICS.               175
  (Always examine the placenta after manual delivery.)
  (Portions of membrane are apt to remain and cause second-
ary hemorrhage.)
  If adhesion  is so strong as that no justifiable force will detach
it, possibly some parts may be removed.
  If placenta be left in utero the case may terminate in  three
ways.
  1st.  Placenta expelled in 12 to 24 hours without putrefac-
tion or having caused  irritative fever.   2nd.  Expelled putres-
cent with  injury to general health.   3rd. No placenta ever
cast off, and no evidences in lochia.
  In 1st. Putrescence probably weakens attachment, and there
is sufficient energy to expel.
  In 2nd. Putrefaction advances rapidly, favored by heat and
moisture;  absorption of putrid  matter occurs, and irritative
fever of a dangerous form ensues.
  With  this  may occur  hemorrhage, either  immediate  or
remote, as late as 38 days, and one by Ingleby fatal at  end of 5
weeks, from recurrence of bleeding.
  In 3rd.  It is supposed placenta is absorbed ;  such cases are
recorded by Naegele, Salomon, &c.
  If the disrupted portion escapes notice, suspect its existence
in utero from  pains, and from lochia at first normal, afterwards
dark and fetid ; also hemorrhage.
    Treatment.—Indications are  to  arrest  hemorrhage;  to
detach  placenta;  to correct fetor of  discharge ;  to  support
•constitutional  energy ; to check inflammation.
  To remove detached part, Burns suggests  tampon.  Ob-
jectionable.
  Cautious attempt  to separate  remnant is justifiable; but
violence is to be deprecated.
  Ergot, if no constitutional contra-indication.
  Bandage and compress over fundus.
  To correct fetor of discharge use vaginal injections;  chamo-
mile tea ; Sol. Chlorid. of Soda. 
176
MANUAL OF  OBSTETRICS.
  For local inflammation, Leeches; Poultices; Cal. et Ipecac,
or Pulv. Dover.;  Opium.
  Special  attention to ventilation and cleanliness.
  To support strength by diet and tonics.

  HEMORRHAGE AFTER DELIVERY OF PLACENTA.—
Extremely dangerous;   often  insidious;  may  occur  unex-
pectedly ;   generally within half hour.  No symptom  gives
warning, and attention less called  because danger appears over.
  May be either external or " concealed."
  Led to suspect internal form by pallor and faintness, »ausea,
vomiting,  pulse feeble  and  fluttering, restlessness, tossing;
desires fresh  air  and to  be  fanned;  respiration  quickened ;
sighing; such exclamation  as " Oh, I shall die," &c.;  and death.
  Lay the hand on abdomen, and instead of  firmly contracted
uterus, find belly nearly of the size preceding delivery, soft and
fluctuating; pressure  produces  a gurgling sound,  and  blood
gushes from vulva, either in clots or fluid.
  Examination of the napkin detects the external form.
  Causes.—Inertia, either from constitutional or local inaptitude
to contraction of muscular fibre.  Sometimes the debility after
an ergot labor; or reaction  from  use  of stimulants; painful
mental emotions; heated  atmosphere;  too much clothing;
excitement; clot plugging os.
   Treatment.1—Steadiness and energy  on  the  part  of  ac-
coucheur are the first essentials.  Press firmly  over fundus
uteri, for  hours if necessary, with your  own hand. Conjoin.
cold  douche,  from as great  a  height  as possible  on  naked
abdomen.   Ergot.  Less efficient means  are ice to hypogastrium
introduced into vagina or into uterus.   Inject cold water into
the uterus.  After the flooding  is controlled, but not till then,
use  a bandage with firm compresses;  but if it  returns, trust
only to manual pressure.
  Alum plug.  Compression of abdominal aorta.
  Sometimes coagula distend uterus, and gradually increasing,
great flooding ensues; pass in  the hand;  detach and  scoop 
MANUAL OF  OBSTETRICS.              177
out clots; conjoining cold, pressure, and  ergot.  (Authorities
differ as to inserting  hand.)
  Tampon advised by some; is bad practice.
  If patient seems just hovering between  life  and death, give
Ergot or Tine. Opii, but not introduce hand or apply cold.
  Brandy, Carb. Ammon.; Aq. Ammon.  to nostrils.
  Opium in Tine.; dose,  a teaspoonful.
  Hot bricks or bottles;  Sinapisms ; Capsicum.
  Transfusion.
  Nursing the infant.

  Hemorrhage with Firmly Contracted Uterus, is
mentioned by Gooch, and considered to be result of excessive
vascular action.   He found it accompanied  by " red face  and
throbbing pulse," and suppressed  it by introducing  the hand
and applying cold.   Subsequently he prevented it by venesec-
tion, and strict antiphlogistic regimen before labor.
  May it not arise from  attachment of placenta near the os
uteri, producing  great  vascularity,  and  possibly  imperfect
contraction ?  Has been found  where a small piece of placenta
had  been  left; also in  lacerations of os;  with intra-uterine
polypus.
  Montgomery thinks  it may arise from thrombus near os
uteri.
  Remedy.—Alum plug.
  Hemorrhage with Polypus, rarely occurs.   The fol-
lowing case will serve to elucidate  this form.   In May, 1852, I
was  called to see a primipara flooding  after delivery.   The
labor had  been normal, the placenta being expelled  spontane-
ously.  Flooding  followed, but the uterus  was small  and  firm.
On inserting the finger between the labia  a  tumor was found,
which being traced up was found to be  attached  to  the ante-
rior  lip of the uterus; hemorrhage became very considerable
(about two quarts).  The treatment pursued was, Tine. Ergot
in drachm doses, firm manual pressure over the uterus, and the
introduction of the  hand.  The hemorrhage  did  not recur.
                          15 
178
MANUAL OF OBSTETRICS.
Three weeks after, I examined the uterus and found the tumor
diminished to a mere excrescence on the uterus; the length at
the time of the hemorrhage was at least three inches, and the
tumor very much resembled a virgin uterus in size and shape.
The main point of interest is the propriety of operating.  The
hyper-nutrition of all parts connected with the  uterus in its
impregnate condition, admonishes of  the  propriety of waiting
till the organ returns to its physiological state  before attempt-
ing the removal of the abnormal growth.
   Secondary Hemorrhage, though not very frequent,
occurs more frequently than  systematic writers  lead  us to
believe.  I have  met  with several cases, some  of them of
severity.  Roberton records 14 cases.
   Occurs at any period after delivery up to  30th day.   Dr.
Putnam mentions a case at 6 weeks after delivery.
   Fatality: Not frequently fatal. Roberton relates a case fatal
at a month after delivery.  Boivin a case fatal at 30th day.
   Causes.—Relaxation of  uterus.   (Inertia  may last  for
several days.)   Retention of clot, or  membranes, or placenta.
Premature exertion in rising, walking, &c.  Polypus.  Inver-
sion.  Mental  emotion (a case by Murphy).   Excitement from
visits of friends.  Softening of uterine fibres and subsequent
sloughing, a kind of  aneurismal sac forming  in uterine walls.
Dr. Montgomery  alludes  to a form  of thrombus  situate  in
uterine walls near the os, and relates,  on  the  authority of  Dr.
Johnston, a case of hemorrhage fatal  in one and a half hours,
occurring five  days after  delivery.  A fatal  case from same
cause related in Med. Exam., Oct. 1851.  A draining  may
follow in cases of  placenta  praevia where  the hand  has been
forcibly introduced.  Inversion should be inquired after.
   Treatment.—Rest;  Ergot;  Alum  plug ; Pressure.  As  a
last resort, Tampon.  Be sure that  no portion of membranes
or placenta is retained.

   States of Uterus after Delivery.—If labor has been
well conducted, the uterus will generally be about  size of fcetal 
MANUAL OF OBSTETRICS.
179
head, firm and hard.   It is possible  for hemorrhage  to  occur
in this state.   (Gooch, Ingleby, Porter.)
  Again, uterus may be contracted, but large, as in multiparae.
Not a dangerous state.
  Another form, is large,  doughy, and indisposed  to  contract,
and even  under  friction  sluggish  in action, and not firm.
Often connected with serious flooding.
  Occurs  in  feeble constitutions;  protracted illness;  over-dis-
tension by plurality, or liq. amnii; multiparae.
  A fourth variety, alternately contracting and relaxing.   Al-
ways dangerous.

  After-Treatment of Flooding.—Insist on horizontal
posture.
  Rising up  has often proved fatal.   Maintain for 24 hours.
  Gently insinuate dry clothes under; a blanket best.
  Head to be kept low.
  Drinks and food cold, but not innutritious.
  Sleep not to be  prevented, but  nutriment to be given  fre-
quently.
  Watch pulse carefully; if quick, compressible, and jerking
(hemorrhagic) ; be on guard for recurrence of flooding. 
Before  Normal
     Labor.
During  Labor. -
After Delivery.
After-Treat-
   ment.
Menstruation during )
     Pregnancy.     J
Hem. with Abortion.
     Hydatids.

  Accidental Hem.
  Excessive Show.
Placentary Apoplexy.
  Placenta Previa.
After Birth of Child.
   After Placenta.

With firm Contraction.
    With Polypus.
Cauterized os; Gallic Acid; Tannin; Matico; Oxid. Argent.; Acet. Plumb, et Op.
Horizontal posture; SUght covering; Cold drinks; Plumb, et Opii; Antim.; Ipecac; Tannin; Gallic Acid;
     Matico.—Cold; Alum plug; Tampon; Ergot; Removal of ovum by finger or placental forceps.
Tampon ; Alum plug; Cold; Ergot; Removal by hand introduced.
Secondary     )
Hemorrhage.
TABLE OF THE  TREATMENT  OF HEMORRHAGES.
Complete rest of body and mind; Lead and Opium; Alum; Tannin; cold Enemata; Alum plug; Tampon;
     Rupture membranes; Ergot; Version; Forceps; Perforation; Bandage and compress; Transfusion.
Rest; Astringents; Cold.
Rupture membranes; Ergot; Version; not Tampon.
Rest, &c.; If partial, rupture membranes; Tampon; if Centrical, Tampon Version; detach Placenta.
From Inertia.—Friction; Cold cloths or Aspersion; Ice;  Cold dash; Ergot; Introduce hand.
With Irregvlar Contraction— Friction; Cold; Introduction of hand, preceded by Chloroform.
With Adherent Placenta.—Detach and remove; Cold; Pressure; Ergot.
Cold douche; Firm and prolonged pressure manually; Ergot; Introduction of hand; Firm bandage;
     Tampon never; Opium; Stimulants external and internal; Nursing; Transfusion.
Ice in Vagina; Alum plug; Bandage.
Ergot; Pressure; Introduction of hand; Alum plug.
Be sure that the whole of placenta and membranes are removed; Watch lest Inversion; Pressure;
     Ergot; Ice; Alum plug; Lead and Opium.
Insist on horizontal posture; Head low; Cold drinks and food; Allow sleep, but feed often. 
MANUAL OF  OBSTETRICS.
181
  Remote Effects of Loss of Blood.—In Head: Throb-
bing of temples ; pain ; sense of a band ; vertigo ; tinnitus and
other noises ; intolerance of noise, more rarely of light.
  In Circulation: Fluttering or palpitation ;  sense of faintness
and  of impending  dissolution; throbbing of carotids and of
aorta;  sense  of fainting on being raised; starting  in  sleep ;
hurry  and alarm on awaking;  demand for  air or smelling-
bottle.
  In Respiration :  Panting ; hurry ;  sighing; heaving ; moan-
ing ;  catching; gasping;  sometimes an  irritating, hacking
cough, paroxysmal.
  In Stomach : Retching ; vomiting; hiccup.
  In Bowels : Constipation ; diarrhoea ; flatulence.
  Various inflammations  are  simulated, as  of head, pleura,
peritoneum.
  Sudden death may occur from suddenly assuming' an erect
posture.
  Treatment.—Restore the functions of the alimentary canal,
enemata,  aromatic purgatives,  &c.
   Give anodynes to allay irritation.
  Nourishment in small quantities, and frequently.
   Fresh air an essential.
   Quiet of body and mind to be ensured.

        PROLAPSUS  OF  CORD,  LABOR WITH.

   Occurs: 1 in 240 or 1 in 282 ; Arneth, 1  in 200. To child
it is a serious complication ;  in  392 cases 245, or over half,
still-born; " 12 in  37 alive."   To mother,  no  influence in
labor.
   The close  embracing of child by uterus is  chief obstacle to
prolapsus ; hence, whatever prevents this, acts as a cause.
   Causes.—1st. Malposition  of  child, as belly presenting;  is
 doubtful.  2nd. Sudden rupture of membranes,  and  profuse
 gush  of  liq. amnii.  3rd.  Small child and  excess of waters.
 4th. Feet or knees presenting; which do not fill strait.  (Does
                           15* 
182               MANUAL OF  OBSTETRICS.
not occur most with footling presentations.   More cases occur
with the head, for this is  the commonest presenting part; re-
latively most with breech  or trunk.)   5th.  Excessive length of
funis, an important feature; denied by some.   6^.  Placenta
inserted  low in uterus.  1th. Large or  deformed pelvis.  8lh.
Irregular or spasmodic contraction of uterus.
  Period of Danger : Begins with pressure of head upon cord,
and, if left  to nature, case seldom terminates favorably to child.
   Causes of Death : Asphyxia.  A case recorded in which cord
burst, fatal.
  Favorable Circumstances are a large  pelvis and small child;
active and  expulsive pains ; cord situated at sacro-iliac  sym-
physis.
  Diagnosis.—By pulsation of cord, which is to he appreciated
during interval of pains.   Before rupture of membranes, it feels
like a ridge across  os.
   Treatment.—Depends on  indications from  cord.   (By no
means  is every pulseless cord connected with a dead child.)
If putrefied or pulseless, leave case to nature.  Prevent  rupture
of membranes as long as possible.
   Pushing up Cord :  Rarely succeeds.   Hooking cord around
a limb, is hazardous.  If attempted, place the patient on the
side opposite the cord ; use the-hand, the dorsum of which best
fits the sacrum;  introduce two fingers,  and, during intervals of
pains, draw the cord forward to get it to the most shallow part
of pelvis, then press up the most dependent part first.   Mechani-
cal  Expedients:  Enclosing funis  in a bag; pushing  up and
inserting a sponge ; a flat steel rod; all prove futile.  Meigs
suggests a  piece of ribbon made  into  a pocket at either end,
into the lower insert the cord, and  into the upper a thin rod,
and push up.
   Arneth  introduces the  whole hand, and  succeeded in ten of
eleven cases.
   Forceps : If os is dilated and head engaged.
   If present when membranes rupture,  Version, if  liq. amnii
 drained away, avoid'  turning.  For Version requisites  are, 1st, 
MANUAL OF  OBSTETRICS.
183
Pulsation of  cord ;  2nd, Head not entered pelvis ; 3rd, Pains
not strong;  4th, Pelvis ample;  5th, Accoucheur an  expert.
Multiparae may bear version ; but in primiparae the only resource
is placing cord near sacro-iliac symphysis.  Such is the advice
of British authors.   Of 33,435 cases, the funis prolapsed in 200,
of the children 147 were dead.  In France, 42,760 cases, 62 of
prolapsed funis,  17  born  dead ;  version employed 31  times.
Of  the risk  to  mother, no  mention is made in  the  French
table  ; in the British, no mother was lost.

              PLURALITY, LABOR  WITH.

   Occurrence: Twins in  British, 1  in  65£ (in Dublin, 1 in
64) ;  in 455,632 cases from various sources, 1  in 77f.
  Triplets, in 5,840.  Quadruplets very rare;  in Dublin, 1 in
129,172.   A quintuple premature birth is recorded in Obstet.
Review.  (A Belgian paper states, that a woman 33 years old
was confined of  triplets, being her 22nd, 23rd, and 24th chil-
dren.  In nine years she has had  24 children, all in good health,
all  girls.)
   Danger  :  Is more than in single pregnancies.  To mother, 1
in  20.   To  child,  1 in 3£; but frequently  premature births
occur.  More fatality among boys, and particularly when oppo-
site sexes.
   Signs of  Existence  are uncertain.  Two fcetal hearts, not
synchronous, and distinguished  by  two auscultators simulta-
neously, would be certain evidence.  Increased  size may proceed
from ascites; enlarged ovary ; excess  of liq.  amnii;  flatus;
 adeps ; too prominent lumbar vertebras.
   Each child possesses a separate envelope and separate pla-
 centa, though often  there is but one placental mass.   With
 such cases as Siamese twins, probably but a single set of mem-
 branes existed.  Labor is  often  premature.   Children smaller
 than in single births ;  though I knew of one case where each
 child weighed over  eight pounds.   Unequal  development not
 infrequent. 
184
MANUAL  OF OBSTETRICS.
   Opposite sexes  are most common.   Of  presentations, both
are head  most frequently.  Commonly thought that if oppo-
site  sexes, the  female is sterile; is not so.   The cow alone, as
far as known, is a " free marten."
   Symptoms :  Labor is slow notwithstanding  that  pains  are
good, because uterine force does not act directly.
   After the first birth, there  is usually an  interval, generally
less than half an hour ;  but it may be  2—10 hours, 8 days, 14
days, 6 weeks.   In one case of triplets, six days intervened be-
tween the  first and  other two births.   In two cases, I noticed
38 and 48 hours respectively between  twins.
   The second child is the more easily  delivered.  Of presenta-
tions, the breech is the-best for second child.
   After the birth of one, a second, fcetus  may be simulated by
a large  placenta, an accumulation of  blood behind a clot or
the placenta, enlarged ovary, kidney, or spleen ; flatus.
   Vaginal examination  decides such  questions.   Sometimes
the membranes of a second child can be distinguished, but pre-
sentation not manifest.
   Treatment:  Never leave one foetus  in utero (as  has been
done).
   Some advise a binder immediately after the first birth.
   Avoid  traction  on cord of  first child, lest bleeding be  pro-
duced ;  and even the second do not hasten, for the uterus re-
quires more time to contract than  in single birth.
   Authorities differ as to the propriety of informing mother of
the existence of a second child.
   The main point for decision is,  when, and how, interference
is necessary for  delivery of second child.   If delay of more than
half an hour, commence friction.   This failing, rupture mem-
branes.   No objection  to  ergot, for passages are  dilated.   If
presentation is natural, membranes may be ruptured  at once,
but  if patient  be faint, wait.   If  superior  extremity presents,
turn at once;  is  not  unfrequent.  If first  birth  is artificial,
second  will require  aid.   If head  is low, forceps.   Child  is
likely to be still-born  if left more than 3 or 4 hours.  Delay 
MANUAL OF OBSTETRICS.               185
   increases risk of hemorrhage.   Bandage is to be applied after
   birth  of first child, and  tightened after second.   Retention of
   placenta and  hemorrhage,  more  common than with  single
   births.
     Management of placenta  requires care.  Leave cord of first
   foetus entirely, for there may be but one  placental mass, and
   traction may detach it.
     Two ligatures are essential in tying funis.
     When necessary to detach placenta manually, do not with-
   draw hand till both are separated and contraction occurs.
     Plural births are more frequently followed  by danger than
   single,  from over distension,  preternatural presentations,  he-
   morrhage, hysteritis.   Convulsions also more frequently compli-
   cate.
     Occasionally the head  of one and. the feet of a second fcetus
   present; sometimes two heads ; sometimes the feet  of separate
   foetuses.

                 RUPTURE OF THE UTERUS.

     May occur during  gestation, though rarely; in  labor,  1 in
   657 cases ; in  advanced life occasionally.
     Not unfrequently in primiparae, but  comparing  first  labors
*  with subsequent in a group,  more  ruptures  occur in  multi-
   parae.   Of  155 cases,  24  were  primiparae,  131  multiparae,
   varying from 2nd to 13th pregnancy.
     More  frequent in male foetuses ; more in lower classes.
     In a large proportion labor has been of short continuance.
     Fatality.—In by far the greater number is mortal.
     Causes.—1st. During gestation, interstitial foetation ;  soften-
   ing ;  abscess ; blows; without known cause, ex.  gr.  during
   sleep.  Fatty degeneration %
     2nd.  During labor  contracted pelvis;  in 79 cases 68 were
   contracted ;  disease of uterus by inflammation, thinning,  soften-
   ing, gangrene ;  large foetal head ;  oblique position of the head
   at the brim; transverse  presentation of trunk; obliquity and
   retroversion  of  uterus ; previous Caesarian  operation ; polypus 
186
MANUAL OF OBSTETRICS.
uteri;  excessive uterine action either natural, or stimulated by
ergot or stimulants ; violence, blows, falls,, forcible attempts  at
delivery, violence in turning;  rigidity of  os (cases of os com-
pletely torn off) ; violence in removing placenta; imprudent use
of forceps ; excess of liq. amnii; plurality ; mental emotions,  as
anger.   Arneth says hypertrophy of muscular fibres of fundus,
thus overpowering the resistance of cervix.
  3rd.  In advanced  life os  may become obliterated,  mucus
accumulates,  distends uterus, and causes absorption and open-
ing.
  Seat, usually at junction of cervix uteri and vagina; cervix
alone; or through cervix and vagina.   (When cervix is torn it
is usually either opposite pubes and linea  ilio-pectinea, or pos-
teriorly opposite  sacrum.)   At  sides; through to  fundus;
direction obliquely upwards or transverse; ruptures  of vagina
alone may occur.   Of  128  cases, 15  involved  uterus from
cervix  to fundus; 14  the anterior part, 7 left side, 2 body,
7 transverse,  10 of fundus, 13 posterior part, 8 of right side,
2 of vagina, 2  involved  bladder,  47 were  at cervix either
involving vagina or a separation from it.
  Laceration may be partial or complete, i. e. involving muscle
and leaving  peritoneum  intact, or peritoneum  alone; some-
times peritoneum fissured, curved, convex towards fundus; edges  *
of laceration  ragged.
   Pathology.—States  of  uterus,  thinning;  hypertrophy;
softening,  partial or general; pulpy;  deep red; odor offen-
sive ; blood in peritoneal sac ; evidences of peritonitis;  lacera-
tions ;  fissures.
  Character  of labor.—Not confined to severe and protracted.
  Presentations.—In 303  cases, 16 were of shoulder, arm,  or
side; 2 of breech ;  the others head, or not specified.
  Symptoms.—Not uniform;  almost never  before rupture  of
membranes ;  view a fixed " crampy " local pain in uterus with
apprehension;  most  usually violent  action  of  uterus with
intense pain  gives warning.  When  rupture occurs there  is
violent intolerable pain ;  a sense of bursting or tearing; some- 
MANUAL  OF OBSTETRICS.              187
times accompanied  by noise; contractions cease ; countenance
pallid, anxious, and alarmed ; clammy sweat; lips livid ; cheeks
cold; violent  retching, and vomiting of mucus, sometimes of
coffee-ground  fluid ; surface cold;  respiration laborious ;  pulse
thready and rapid,  fluttering ; inability to lie down ; faintness;
convulsions;  hemorrhage; recession of presenting  part;  al-
tered shape of abdomen;  uterus as a round  ball in  one iliac
region and child plainly distinguishable through parietes;  if
collapse does  not prove  fatal, peritonitis ensues ; in rupture of
peritoneal  coat  only, labor may  go on; sometimes the  last
pains may both  rupture the uterus and  expel foetus.
   Diagnosis.—Two  diagnostic  symptoms.   1st. " Recession
of presenting part, which occurs almost always when rupture  is
at fundus  or  in  body; very often when at cervix, and  some-
times when confined to vagina ;" unless head is impacted.
   2nd.  Ability to feel foetus with  abnormal distinctness  unless
parietes are very thin.  Continued foetal pulsation is  an  argu-
ment against rupture, for foetus usually soon dies.  Suspension
of pains  even when  sudden does not  always betoken rupture.
Sometimes neither stomach, pulse, nor respiration is affected;
patient lies quiet, and symptoms gradually develope.   Hemor-
rhage is no proof.
   Prognosis.—" If left to nature  the chance of recovery  is
almost nothing."  Slight lacerations of os have proved fatal.
If the peritoneum is intact, the risk of peritonitis is diminished.
If the serous coat is ruptured, the extent  of rupture has  but
little influence  on mortality.   Lacerations  of muscular coat
expose to  the risks  of metritis.   Lacerations of cervix are quite
as fatal as of body  of uterus.
   In reference to child, the foetus has been found  living 15
minutes after death of mother.
   Terminations.—Fatally  by  hemorrhage  from   lacerated
walls ;  peritonitis; strangulation of intestine; psoas abscess.
Favorably, by fcetus  becoming  encysted, and remaining for
years, 20  or  even 40; (pregnancy has  occurred meanwhile;)
debris of fcetus discharged through abdomen, vagina, or  anus. 
188
MANUAL OF OBSTETRICS.
   Treatment.—If  rupture  is  apprehended  from  any  well
 founded reason, speedy delivery will be advisable; a consulta-
 tion should be called, labor pains should be moderated, chloro-
 form may be thought of; opium, venesection, and forceps; if
 the  child  be dead, perforate.  If rupture  has  occurred  and
 head is in  pelvis, deliver immediately if possible ; by forceps if
 head is sufficiently fixed to prevent recession; by perforation,
 and direct perforator from before backwards, lest the head be
 pushed up;  firm pressure by an  attendant; remove placenta,
 follow up funis, and solicit placenta by it, so as to  avoid increas-
 ing  the rent by the hand; avoid  any attempt to replace the
 intestines.
   If child  has escaped into abdomen the uterus is usually con-
 tracted, and if so,  gastrotomy is  preferable to version, or to
 absolutely  abandoning the case to  nature, especially if pelvis is
 contracted.
   Thus, of 118 cases—
     23 were delivered by gastrotomy, 16 saved,  7 lost.
     49    "      "     turning,    19   "   30   "
     46 undelivered,                  12   "   34   "
   Women delivered survive longer  than those who die unde-
 livered.  In proportion of 22 hours to 9.
   Advantages of Gastrotomy.—The original wound is undis-
 turbed ; the child is delivered more easily and quickly than by
 turning.
   Version  is the mode of practice  usually pursued.
   If there is great depression, give Opium with Ether, Am-
 monia, or Brandy, and  external stimulants before operating;
 and as soon as reaction occurs, operate.
   Treat subsequent peritonitis by heroic doses of Opium, poul-
tices, blisters, &c.

             INVERSION OF THE UTERUS.

   Def.  (A turning inside out of the whole organ, by its passing
successively through the os tincae, converting the mucous mem- 
MANUAL OF OBSTETRICS.
189
 brane into an exterior covering, and creating a new cavity lined
 with peritoneum and communicating superiorly with the cavity
 of the abdomen.)
   History :  Pare first described clearly.   Baudelocque lectured
 specially  upon  it.  Newnham in 1817, and  Crosse  in  1845,
 wrote treatises, the latter of which sums up our knowledge.
   Occurrence :  Rare.   No case in Dublin Lying-in Hospital in
 71,000 labors.
   Danger: Above  one-third prove fatal, either very soon, or
 within a month after displacement.
   Four degrees.—1st. Depressio : A portion ©f uterine wall be-
 comes  convex towards cavity of uterus; any portion may be
 affected, but fundus most.  (Even this form may prove fatal.)
   2nd. Introversio: A portion  of fundus is displaced so as to
 be grasped by an inferior part of the uterus.
   3rd. Perversio : A  more  or  less inverted  portion  projects
 through os;  in the greatest degree  the whole  body  passes
 through os, the cervix remaining in situ.
   In 4th. Total Inversion : The cervix, as well as body, is  in-
 verted, yet may be retained within the labia.  (Prolapse is not
 a necessary element  in inversion ; it aggravates danger.)
   Inversion usually  commences at fundus,  and is propagated
 downwards, rarely from cervix towards fundus.
   Occurs: 1st.  Immediately after delivery.  2nd. A  few days
 after, having probably commenced at the time of labor, and
 been completed  subsequently by uterine and abdominal nisus.
 3rd. Gradually, from presence of polypus.
   Causes.—Predisposing, are delicate and relaxed fibre, large
 pelvis, erect posture; plurality not a cause; primiparae more
 subject.  Inertia  uteri  a  decided cause; the round ligaments
 are passive.  Women not liable to  repetition.  Dilatation of
 os is essential.  Hemorrhage a cause through inertia, and again
by sudden  expulsion of coagula.  Attachment of  placenta to
fundus. Traction on funis.  Very short funis.   Rapid delivery
of foetus.  Adhesion of placenta to fundus.  Violent straining
during last pains. 
190
MANUAL OF OBSTETRICS.
  Often commences at, or  just before birth of  child, and pro-
gresses by straining.
  General Symptoms.—Sense of exhaustion ;  sinking ;  pallid
face; pulse rapid, small, fluttering; nausea; hemorrhage; ab-
sence of flooding may occur if uterus contracts strongly ; violent
bearing down and straining.
  (N.B.—Persisting hemorrhage after delivery  demands the
introduction  of the hand  to ascertain if depression is not the
cause).
  S2)ecial  Symptoms.—Of Depressio:  May be no pain ; he-
morrhage ; sinking; palpation over fundus discovers a cup-liko
depression  ; in uterus is felt a prominence.
  Of Introversio: Sudden failure of pulse; approaching syn-
cope ; distress and fulness in vagina ; pain in loins ;  flooding;
through abdomen is felt a depression ;  per vaginam  and os is
felt the fundus uteri filling the lower part of the uterus, as a
tumor, symmetrical, liable to  bleed, elastic, more or less pain-
ful ;  the  placental  site indicated  by  a  rough  surface  with
coagula upon it; per rectum  may be felt  the uninverted part
of the uterus.
  In Perversio :  The fundus  is found in vagina  as a soft con-
vex body, and the hand can be passed up to the encircling cer-
vix ;  by a  probe, the depth of the uninverted  portion mav be
traced as even in all parts; above the  pubes is a vacuity, or it
is possible for inverted uterus to rise so high as to  be  frit in
hypogastric  region.  By inspection, a  florid vascular velvety
tumor, bleeding at touch.
   In Total Inversion: A  tumour is felt in vagina, with  a cul-
de-sac around the neck ; color not purple, because no constrict-
ing cervix.   Sometimes is  incorrectly diagnosticated as in situ.
   Diagnosis.—Has been  mistaken for head of another  fcetus,
for  another placenta,  a mole, an excrescence,  a polypus, a
tumor, a clot,  aneurism of uterus, protrusion of rectum mis-
taken for inversion.
   Prognosis.—Exceedingly  dangerous.   Of 109  fatal  cases,
72  died  in a few hours, most within an hour; 8 in  from  1 to 
manual of obstetrics.
191
7 days; 6  in  from 1 to 4 weeks;  total, 86 within a  month.
Of the 23, one died  in subsequent four months.   But danger
recommences with menstruation.
  The uterus may be easily'reducible, because in articulo.  The
less the degree of inversion, and the slower  it advances,  pro-
gnosis is improved.  Rapid inversion and atonic uterus increase
danger.  Cases occurring spontaneously are more perilous than
thooe produced by traction of funis.   Hemorrhage and nervous
shock are the causes of death ; in the chronic form, hemorrhages
and hectic.  Success in reduction can be expected as a  general
rule only within a few hours.   Cases on record of success after
11 weeks'continuance;  one 16£ months.   Gangrene  of the
uterus has sometimes proved a means of safety.  Spontaneous
reduction  of depressio and  introversio may occur, but  not  of
total  inversion.  Cases recorded of chronic inversion spontane-
ously reduced.
  Sterility is a consequence of  persistent inversions ;  but preg-
nancy has followed after reduction.
  Treatment.—(" Maltreatment has often proved so injurious
that it has been asserted the patient has a better chance where
the disease is  entirely overlooked, provided the inverted organ
remain in  the vagina."—Crosse.)   Indication is immediate
reduction.   Oil both hands ; grasp the uterus; press up steadily,
and  remember the  axis  of both  straits;  press the perineum
back.
  Another mode, with the fingers in a conical form, indent the
fundus and  press upwards.
  Of detaching placenta before returning,  much diversity.
  English authors mainly object to it;  the French mainly ad-
vocate it;  will depend on  degree  of-contractibility;  if ener-
getic, probably peeling off will not increase hemorrhage, and
will  facilitate  reaction ; if loose, flooding  will  be  made more
serious.
  Dewees recommends in introversio to draw down the uterus
and  produce perversio.
  If  uterus has been long down, still attempt reduction, but 
192
manual of obstetrics.
with great care ; empty rectum and  bladder, and give chloro-
form before operating.
  If irreducible, palliatives and bandages.
  Extirpation, by knife or ligature, has been recommended.
  In  34 cases of extirpation, 19 were successfully treated  by
ligature, 5 unsuccessfully (3 died);  by excision, 1 successful, 2
unsuccessful;  by ligature and excision combined, 5 successful,
1 unsuccessful.

  Syncope.—Besides from  hemorrhage, may arise with the
nervous and hysterical, or those exhausted by intemperance and
bad ventilation ; also, and more seriously, in cases of cardiac or
pulmonary  disease, or  aneurism, or  abscess; also  in  rapid
labors where pressure is suddenly removed ; in despondent.
  Treatment.—Fresh air;  stimulants ; binder.

  Sudden Death.—Sometimes occurs soon after delivery
without hemorrhage.  One  such case I attended,  where recog-
nised cardiac disease was the cause of  death.  By some it has
been thought  that air entering the uterine  sinuses, denuded of
the placenta,  has  caused the fatal issue.  Some deaths occur
immediately after  birth of  child, or soon after delivery of pla-
centa ;  more within a few days after a labor attended with he-
morrhage,  sudden  rising in bed being the  immediate causa
mortis.  Meigs thinks the last form arises from " heart clot."

        Management of the Puerperal State.

  Requires  less the interference, than the  superintendence of
the accoucheur.  A natural process has been performed, no aid
is requisite to  restore to normal health.
  The symptoms occurring  after labor may be included under
three heads.  1st.  Those immediately  succeeding parturition.
2nd. Those  having for their object the restoration  of the uterus
to  its  ante-impregnate  condition.  3rd. Those which  attend
the secretion of milk. 
MANUAL OF OBSTETRICS.
193
  Of 1st. A. Muscular  Fatigue:  Caused  by  efforts  during
labor; affects not only shoulders, but also abdominal muscles;
sometimes lasts two or three days.  Requires repose simply.
  But it is important to distinguish from peritonitis ;  by absence
of fever, pressure does not increase, pulse not accelerated.
  B. Vascular Excitement: During the second stage of labor
the pulse increases; after completion  diminishes,  to increase
again on secretion of milk.
  Avoid confounding with pulse of peritonitis.   A  pulse above
100, though not always indicative of danger, should be watched.
A quick pulse immediately after delivery often indicates hemor-
rhage.  A quick pulse often co-exists with severe after-pains;
may occur with  a large clot  in utero, with diarrhoea, gastric
disturbance.
  A quick,  weak, fluttering pulse occurs in collapse from ner-
vous shock, &c.
   C. Derangement  of Nervous  System:  Varies  from mere
restlessness  to absolute hysteria.   Usually requires  rest only.
  The  nervous  shock may be severe, marked by  exhaustion,
aberration of senses,  panting, respiration, countenance anxious,
pulse either slow and labored or rapid  and fluttering.  Avoid
mistaking this for peritonitis.  Opium 1 to 3 grains ;  Hoffman's
Anodyne;   moderate  stimulation;  nutritious   diet.  Avoid
nursing for  a few days.   Perfect quiet essential.
  2nd Class: Those tending to restore uterus.
  A. After-Pains are caused by the contractions of the uterus
in expelling coagula, and also the fibrinous clots which  plug
up the sinuses, these  also come away in the lochia ; pieces of
membranes also.
   Occur slightly in primiparae, occasionally, though sometimes
well marked.  Said  to be in dysmenorrhoeic women.  Almost
always in multiparae.
  Vary greatly in intensity and duration; often 24—48 hours.
  A tedious second stage usually has less severe after-pains.
  Aggravated by nursing, warm drinks, clots in uterus.
   Useful by expelling  clots,  and thus  preventing irritating
                             16* 
194
MANUAL OF OBSTETRICS.
fever;  by  preventing  hemorrhage.    Hence  always  to give
opiates, is injurious.
   Objectionable by constant irritation and preventing sleep.
   Point of Most Interest: Is not to confound with peritonitis.
Are paroxysmal; lochia and milk continue ; no fever ; pain on
pressure does not increase distress, except such as arises from
mere soreness of abdominal  muscles ;  pulse not excited.
   Treatment: Unless  severe, none.   Early nursing diminishes
intensity. If severe, Mist. Camph. with 20 drops of Laudanum ;
Pulv. Doveri; Op. et  Camph. gr. j. to grs. ij.; Sol.  Sulph.
Morph.  5  to  10 drops; Opiate suppository.  (Objection  to
Opium is the constipating effect.)  Ext. Hyoscy. grs.  iij., with
Camphor gr. j.;  01. Ricin. with Tine.  Opii.
   Liniment with T. Opii to abdomen ;  or, still better, to breasts.
   If peritonitis threatens, use a Turpentine stupe.
   An  early and effectual cathartic will often stop after-pains.
If clots distress, give Ergot.
   A severe  pain sometimes occurs in coccyx after delivery
very intense.   Opiate  suppository.
   Flatulence sometimes causes severe pain ;  known by disten-
sion ; relieved by turpentine or assafetida enema.
   State of Uterus.—A day or  two after delivery, it appears
internally loose,  corrugated, covered  with patches of decidua,
especially  in  relief at the  placental site;  color  pinkish  or
grumous,  red, sometimes greenish  (this  is not gangrenous);
texture loose, sinuses evident; os and  cervix bruised and ecchy-
mosed,  often greenish ;  abrasions and lacerations seen, that
often degenerate into ulcers.
   Vagina: Soon recovers its dimensions, but is more or less
 sore.
   Abdominal Integuments :  Remain long flaccid; lineze albi-
 cantes evince the abrasions produced by distension, and are in-
 delible marks of pregnancy.
   B.  Lochia.—Xo^auw, to bring forth ;  " Discharge," " Cleans-
 ings."   The  discharge succeeding parturition.   Nature:  At
 first is bloody, then sero-sanguineous; serous;  muco-purulent; 
MANUAL  OF OBSTETRICS.
195
pus.  Source:  The mouths of vessels opened by the detached
placenta.   Odor :  Peculiar ; disagreeable.   Color : Red ; yel-
lowish ;  brownish;  greenish;   "green  waters."   Duration:
Six days to three weeks, or even  more.   Useful:  To  re-
lieve  congestion and to diminish the risk of inflammation;
also as  a sign  of the non-existence  of fever, for fever checks
the flow.
   Treatment:  Cleanliness.  Wash with  cool water three times
a day.
   Alterations : Offensive  sometimes, especially in hot weather
from want of cleanliness ; .decomposition of portions of placenta
or clots.  Soap-suds,  Sol. Chlorid. Sod.  3j. to §iv.  If longer
than  ten days  profusely, it is mischievous.  Sol. Alum as in-
jection, 3ss. to Oj.; or Sol. Acet. Plumb, grs. x. to §j.   If vas-
cular excitement co-exists, use a cooling purge,  as Crem. Tart.;
cool bed ; cold drinks ; lower diet.  If suddenly profuse, may
arise  from premature sitting up or walking;  if it is bright red,
watch against secondary hemorrhage.  Ergot.
   If continued by debility, skin is moist and cool, pulse feeble;
use tonics; Infus. Calum. with Elix.Vitriol, &c. Attend to bowels.
   Occasionally the lochia continue purulent long after delivery,
accompanied by lumbar pains, sense of weight,  and  bearing
down.   Look to state of os and cervix  by speculum.   Ulcera
often found, or unhealed  abrasions of vagina.  Treatment as
for ulceration.
   Is  suppressed, usually as symptomatic of fever or inflamma-
tion,  and excites anxiety.  I have known  it checked by cold,
causing febrile  excitement, headache, and  abdominal distress ;
relieved by sinapised  pediluvia, and  a  large  poultice sprinkled
with  Pulverised Camphor applied  to vulva and abdomen.
   State of Secretions and Excretions.—Skin is moist and
perspirable, sometimes a greasy feel  and  sickly odor.
   Kidneys secrete freely, from the liquid diet used.
   Bowels sometimes unaltered, usually costive.
    C. Secretion  of Milk.—Usually  takes place  before de-
livery ; diminished, but not entirely suspended, by excitement 
196
MANUAL of obstetrics.
of labor.   Is said to " return" on the third day, but  this ia
not strictly true.
  The early secretion called colostrum is peculiar,  by micro-
scope globules  are seen  larger than of milk, is yellow,  serous,
sweetish, and laxative.
  Milk Fever.—Is usually the result of mismanagement;  too
long delayed nursing;  too much clothing;  too stimulating
diet.  To avoid it, direct the child to be nursed as soon as  the
woman  is a little rested after labor.  Give a purge early.
  When  it occurs, it may either simulate or mask puerperal
fever.   Shown  in shiverings, hot  skin, headache, quick pulse,
furred tongue,  pain,  tumefaction,  and hardness  of breasts;
usually  soon subside.  In the graver affection, the breasts  are
frequently flaccid.
  Saline  aperients, low  diet,  cool temperature,  and efficient
nursing, constitute treatment.


             Attentions before Leaving.

  Delay one or two hours, longer if flooding.   Be  sure there
is no Inversion  or Rupture of  Perineum.  See the  " napkin."
Examine the pulse, and press the uterus;  if gurgling is felt or
heard, or the napkin is saturated, there is flooding.
  Direct  the room to be  darkened.   No  company whatever.
To remain at least two hours before being " made comfortable."
Patient by no means to assist in the changes necessary.
  Diet, to be black tea and toast,  gruel of Oatmeal  or Indian,
soda biscuit, cold water.   No change in diet for three days in
ordinary circumstances.
  Sleep all important;  to be watched, however,  lest in pro-
found sleep the uterus relax, and unnoticed hemorrhage occur.
Examine child's navel lest it bleed.
  Second visit, always within  12 hours.
  Inquire  as  to sleep, urine,  after-pains,  discharge, pulse,
tongue, bandage, uterus, skin, above all the countenance. 
MANUAL  OF OBSTETRICS.
197
   Of the child, as to bowels, urine, if it has sucked ; if not put
to breast.  See it attended to.
   At next visit if no urine passed, as may be caused by tume-
faction  of meatus,  apply  a flannel  cloth  wrung out in hot
water, over abdomen and vulva; pour water  from one pitcher
to another in woman's hearing; these failing use Catheter.
Do not allow urine to distend the bladder; it causes  subse-
quent  trouble.  Inflammation  or  paralysis  may  result.   If
Catheter required once, repetition will be requisite twice a day
for some days.
   Direct a purge for the third morning.  01. Ricin., Senna in
fluid extract,  Rhubarb, Seidlitz, Ext. Coloc. Comp.  Salines if
breasts distended.   Enema, if no piles.
   Regimen.—Woman  to  be kept in bed until after 5th day;
prejudice in regard to 9th day  to be respected only as  a means
of keeping quiet.  If prolapsus has occurred previously, a pro-
longed  recumbency will contribute to  a radical cure; 8 or 9
weeks.   If lochia profuse and  red, the  patient should  not rise.
Not, however, to be confined too long.   To sit up first in bed,
for 10 minutes, then half hour, finally in chair brought to side
of bed.   Expect to  be about the house in 3d or 4th week.
   Diet, for first four days,  slops,  tea  and toast, soda biscuit,
bread, panada,  arrow-root, oatmeal  or Indian  gruel, tapioca,
sago, chicken or mutton broth.  This liquid diet is not usually
as digestible  as solid food ;  after ascertaining this, use mutton,
chicken, oysters, game, beef, eggs.   Gradually return to ordi-
nary diet, avoiding acid articles for sake of the child.
   To prevent milk, in case of  child's death, &c.   Keep shoul-
ders cool, give  salines frequently ;  diet abstemious  and not
liquid;  cool  lotions to  breasts;  breasts jto be drawn  mode-
rately three times or twice daily.
   To promote  milk, attempts are made  by using fermented
liquors  and  stimulating food, which  cause  a febrile state and
diminish milk; in such case evacuants  are desirable.
   A poultice of Castor bean leaves is said to possess galacta-
gogue properties. 
198
MANUAL  OF OBSTETRICS.
              Laceration  of Perineum.

   Extensive is not common, of posterior commissure frequent,
in fact usual in primiparae.  Said to be prevented by support.
(See  Management  of  Labor.)  If slight, is of no moment;' if
extensive, life is rendered miserable.   Mucous membrane of the
posterior vaginal wall is often  everted and torn,  while  true
perineum remains intact.
   Extent.—Appear more extensive  at first than after the dis-
tended  state  has passed.  1st.  To  an inch  from fourchette,
occasions no  serious inconvenience.   2d.  From fourchette  to
rectum but not through sphincter ani or recto-vaginal septum.
3d.  Rent  between constrictor  vaginae  and  sphincter  ani
without  lacerating  either; even permitting a small child  to
pass.   4th. Through  constrictor vaginae, through the  whole
perineum,  sphincter  ani,  and  even  through  recto-vaginal
septum.
   Direction, along  raphe, in form of Y or V.
   Causes.—1st.  Violent and sudden action of the uterus before
the os externum becomes dilated.  2d. More moderate pressure
in some cases.   3d. Instruments.   4th. Too broad perineum.
5th. Rigidity of an old cicatrix.   6th. Occlusion of vagina by
hymen.  7th.  Mal-position or mal-presentations, as face  or
breech.   8th. Excessive bearing  down efforts.
   Symptoms.—If slight, but little ill effect; if extensive, invo-
luntary discharge of faeces; sense of dragging down of pelvic
viscera;  procidentia uteri; inability to stand.
   Cicatrization is prevented by motion and lochia.
   Treatment.—Preventive, by  proper support, not retarding
advance of the  head, not  retracting  the perineum ; warm and
unctuous applications to rigidity; incising  hymen; avoiding
straining severely.  Chloroform  said to favor dilatation.
   Curative.—Perfect rest and cleanliness ;  tie knees together,
and draw urine by  catheter;  suture, quilled best;  cold water
dressing; Opium to  constipate  for 11 to  15 days; catheter 
MANUAL OF OBSTETRICS.
199
every 5 or 6  hours  for 10 days; urine to be kept carefully
from wound;  to lie  on the side; Collodion  suggested.  Diet
to be not productive of feculent evacuation, as gum, rice.

   Vesico-Vaginal and Recto-Vaginal Fistula?.

   Are not very rare.   The first more common, sometimes the
two  forms  co-exist.  Either form is  extremely  distressing;
either difficult to cure ; the vesical being more refractory.
   Causes.—Instruments;  long retained pessary ;  delay of
head and pressure ; retained urine; corroding ulcer, or cancer.
Sometimes  rupture of uterus extends to bladder, but rarely.
   Situation.—Important.   At junction of urethra and blad-
der ; in the neck  of bladder;  in some portion  of posterior
wall; in rectal form  any part may be the seat.
   Shape,  circular, longitudinal,  transverse.   Size, pea, to half
dollar.
   Symptoms.—Inability  to retain urine, or to retain faeces.
But usually not till 3d or 4th  day after delivery, when slough
separates.   If in  cervix vesicae, urine flows constantly;  if in
body,  occasionally.  Introduce catheter into urethra,  and a
finger into  either vagina or rectum, and trace along.   Specu-
lum.   Easy to ascertain if old  cicatrices do not obscure sen-
sation.
   Treatment.—Rarely succeeds  in vesico-vaginal.  A funda-
mental rule is the prone position for a long time, which allows
the urine to drain off without touching the rent.  A catheter
constantly worn.   Cauterization by Nit. Arg., Mineral acids,
Acid  Nit.  of Mercury.  Actual   cautery.   Suture.  Elythro-
plastie.  Closure of vagina.
   For incurable, a plug or  India-rubber bag.  For recto-vagi-
nal, the same methods.   Easier to cure.

              Inflammation of Vagina.

  Vaginitis.  Usually  some after  parturition, which rest and 
200
MANUAL OF  OBSTETRICS.
 quiet remove.  If severe, use saline purges, and poultices, and
 perfect cleanliness.
   If pain is persistent, and becomes throbbing, sloughing is to
 be feared, to which will  succeed contractions.
   Leeches, scarifications, poultices.
   To prevent adhesion, use a  cylindrical speculum,  rectum
 bougie, or a candle, twice a day, and persevere a long time.


             Ecchymosis or Thrombus.

   An  extravasation  of blood  in  one,  or more  rarely,  both
 labia, from a ruptured artery.  Sometimes size  of an orange.
 May also occur in substance of uterus.  (See page 178.)
   Excessively painful.
   Left unaided it will slough, and extreme fetor ensue.
   Treatment.—Early and free incision.
   For small, a cold lotion.


                  Paralysis of Legs.

   Occasionally occurs after labor;  to various extent.
   Most after tedious and painful labors ;  sometimes after rapid.
   Cause.—Not cerebral, but from pressure on nerves in pelvis.
   Characterized  by,  pain, numbness,  and  inability  to move
limb.
   Usually lasts but a few days ;  sometimes for weeks.
   Treatment.—Fomentations; stimulating liniments; douche;
tonics ;  gentle motion.
   Sometimes after a  first and  tedious labor,  pain occurs in
defecation, arising from stretching of coccygeus muscle.


               Laceration  of Vagina.

   Often  complicates  rupture of uterus;  but may occur while 
MANUAL OF OBSTETRICS.
201
uterus escapes, but child still passes partially into abdominal
cavity;  rarer than rupture of uterus.
  Such cases resemble ruptured uterus, and  require  same
treatment; are nearly as dangerous.  But sometimes rupture of
mucous and muscular coats of vagina occurs while head is in
pelvic cavity.  Most in first labors with rigid parts.
  May cause but little increase of pain.  Inflammation super-
venes, and  a cicatrix results.
  Treatment.—If  trifling,  leave  to nature;  if  threatens to
extend, use  forceps ; care  to perineum ; poultice; enemata;
opium.

                 Rupture of Bladder.

  More fatal than of uterus. Sometimes the two co-exist.  Is
very rare.  May result from inattention, or rash use of instru-
ments.
  Symptoms.—Violent and severe pain; sensation of some-
thing burst; rapid sinking; tumefaction ; tenderness ; reces-
sion of  presenting part,  but   no  preternatural  distinctness
through abdomen.
  Treatment.—Prevent by catheter (flexible).  Save child by
version or forceps;  gastrotomy.


                   Prolapsus Uteri.

  Not uncommon after labor.
  Arises, usually from rising too soon ; vomiting; sneezing;
coughing;  purging.
  Varies in degree, from depression to complete procidentia.
   Occurs from  relaxed ligaments  and vagina;  in women of
lax fibre; multiparae; tedious  or instrumental labors;  among
poor.
  Symptoms.—Sense  of weight and pressure aggravated by
                            17 
 202               MANUAL OF  OBSTETRICS.

 standing; lumbar pains;  aching in  iliac  regions ; increased
 lochia;  vesical and rectal tenesmus ;  tumor in vagina.
   Treatment.—Perfect rest.
   Bowels to be regulated; tonics internally ;  not use pessaries
 or injections.

                      Hemorrhoids.

   After labor  are frequent, and very painful.   Sometimes
 attain considerable size.
   Terminations.—May recede; may inflame ; slough.
   Symptoms.—Dullr heavy J sometimes acute^pain at anus;
 tenesmus; bloody passages;  to  the sight, bluish, livid tumors.
   Treatment.—Avoid operations, return a protrusion imme-
 diately after  labor ; Leeches ;  Poultices ;  Fomentations;  In-
 jections; Opiate ointments.


                     Sore  Nipples.

   Are exceedingly distressing, and are frequent, especially with
 primiparae.
   Beginning  as a simple crack, the excoriation  sometimes
 extends  to  destruction  of the  nipple;  sometimes involving
 simply the base, or extremity of nipple.
   Along the  lactiferous tubes inflammation may pass back-
 wards and produce mammary abscess.
   Child  swallows  blood and pus, and vomits; is injured  by
nursing.
   Treatment.—Preventive :  Frequent washing  during preg-
nancy in cold water ; in a weak solution of alum ; brandy and
water; green tea ;  exposure to cold air.
   After  occurrence: If recent, emollient oils; butters; Gly-
cerine 3j. with Aq. Rosar. §j.   Bibor. sod. in water  in slippery
elm tea  or  rose water.   Sulp. Zinc, in  Aq. Rosar. or Sulp.
Cupri.  Sol. Chlorid. Sod.  Linen cloth  constantly wet with 
MANUAL OF OBSTETRICS.
203
rum.   Kreasote in  Sol.  gtt. iij. to  vi. in water 5j.  Tine.
Catechu.   Sol.  Tannin.   Tine.  Gallar. with Friar's  balsam,
equal parts.  Nit. Argent, in fine pencil, or in solut.
   ty. Liq. Plumb. Diacet. 3ij.;  Solut. Opii 3j. ; Ung. Simp.
(fresh) I]. M.
   fy. Bibor. Sod. 3ij.;  Cret. Prsep. 3j. *, Alcohol et Aq. Rosar.
aa. 5iij- m.  Applied alternately, with the following, fy Cerae
Alb. 3ivss.; 01. Amygdal. dulc. 5j.;  Mel. Despum. £ss.; dis-
solve et adde Bals. Peruv. 3ijss. M.;  Ft. unguent.
   Collodion.
   A prepared cow's teat.   Nipple shields of sheet lead.


                 Retracted  Nipples.

   Often occur from tight dressing.
   Best  treated  by  breast pump;  in  the absence of a pump,
fill a quart bottle with hot water, pour it out, and then as soon
as it is sufficiently cool apply it to nipple.


                   Puerperal  Fever.

   Child-bed fever.—Puerperal peritonitis.—Peritoneal fever.—
A severe disease, causing seven eighths of all puerperal deaths;
proving fatal in a large majority of those attacked.
   Was known by ancients; noticed by Plater, 1602, as  child-
bed fever.   In  1746 visited Hotel  Dieu, and  frequently since.
Many epidemics are now on record.  Extends over a considera-
ble country ; is epidemic; worse in hospitals ; occurs most in
lower classes.
   Divisions : Many by different authors. Inflammatory and
Typhoid.
   Causes.—Very various assigned.  Difficult labor is  not  a
cause ; but manual  operations are a frequent  source, especially
in cases of hemorrhage ;  portions of placenta retained;  mental 
204
MANUAL OF OBSTETRICS.
emotions;  most in  unmarried;  cold;  intestinal irritation ;
purulent absorption;  stimulants; is communicable.
   Most in cold months;  damp, moist weather.
   Non-pregnant females while menstruating, if in attendance
on those affected, have been attacked with a quasi fever.
   INFLAMMATORY  FORM.—Occurs mostly sporadically,
and in vigorous.  Attacks before the 4th day ;  sometimes 2nd
or 3rd (the  earlier  the worse); sometimes  as late as 10th or
12th, though  in  general if a patient escapes for 10 days she
is safe.
   First symptom usually a chill, or chilliness, partial or general,
of variable severity.   (Supposed by Denman to indicate by its
violence the subsequent severity, or lightness  of the attack, but
erroneously.)
   Next is usually pain, though this  may have  existed mode-
rately before the chill; at first localized, usually in  one  iliac
region ; sometimes  sudden ;  oftener  insidious; aggravated  by
pressure, and  by the  cough which frequently attends; at first
moderate, it increases and spreads as from a focus over abdo-
men ;  is persistent,  but subject to exacerbations, probably after-
pains.
   Fever succeeds the chill;  skin hot and dry; pulse quick,
rarely as  low as 115 (always watch a puerperal  pulse  over
100) ;  thirst distressing ; nausea and vomiting ; pain in head,
sometimes delirium; more usually  mind is  clear and appre-
hensive ; respiration rapid and thoracic ; cough common.
   Countenance peculiar, anxious, distressed, pallid, and ghastly;
eyes  livid beneath; defined crimson  patch on one  or both
cheeks.
   Decubitus  dorsal;  knees  drawn  up;  meteorismus, great
tenderness.
   Tongue  no  uniform  appearance;  moist,  white,  creamy;
deep brown or red centre, with yellow or brown edges.
   Urine,  scanty and high  colored.  Lochia  suppressed, di-
minished, offensive, or unaltered.  Milk sometimes secreted ;
suppressed, and breasts flaccid. 
MANUAL  OF OBSTETRICS.               205
  Hiccup sometimes, denoting extension of disease to diaphrag-
matic peritoneum.
  As disease progresses (and  24 hours  may finish it), pulse
increases in rapidity,  140—160, or more; weak  and thready;
vomiting  at first  bilious, then  green,  brown  or blackish ;
diarrhoea thin, watery, dark ;  respiration hurried, and thoracic;
delirium; tongue  dry  brown;  flush  circumscribed  on  one
cheek;  decubitus dorsal; finally collapse, with cold extremi-
ties, partial and offensive sweats ;  subsultus tendinum ;  carpho-
logia;  sliding down in bed ; death.
  Between  the stage of inflammation and  of collapse there
often occurs a delusive  calm, which Ferguson supposes  to
indicate the stage of  effusion ; the pain abates ;  mind is tran-
quil; respiration  less  rapid, but the pulse retains its frequency;
the abdomen  its  distension.   The  change is too sudden, the
case will be fatal, often within 24 hours.
  All the above  phenomena  do not  occur in one case ;  the
frequent pulse is perhaps the most uniform.   Apathy  towards
child is common.   Rigors, pain, vomiting, peculiar  aspect,  are
generally noticed.
  Diagnosis important but not easy.
  From After-pains,  by tenderness localized.  Pulse rapid in
one, unaltered in  other; lochia and milk; chill.
  From Hysteralgia  and  Hysteric tenderness.—In these, the
attack is very sudden, very severe,  rapidly reaching its acme ;
but there is no chill, no hot skin,  no rapid pulse;  the patient
tosses about, which does not occur  in inflammation; again the
tenderness is exaggerated, and by withdrawing the  attention is
found to be imaginary.
  In a case of doubt,  a full opiate with a poultice  and  a visit
in three or four hours, will often assist the decision.
  From Depraved Secretions and Intestinal Accumulation,
most difficulty is  experienced.  These are the " violent cases of
peritonitis in  which  the  patient  dies  between  the stage of
excitement and of effusion, and no effusion or signs of inflam-
mation  are found;" they are mistaken in diagnosis.
                            17* 
206
MANUAL  OF OBSTETRICS.
  The puerperal state is one of great susceptibility to morbid
impressions, and irritating causes produce exaggerated effects;
hence sources of irritation (of which fecal accumulation  is one
of the most common),  occurring  during  gestation, produce
severe effects after  parturition.  When  to  this is  added the
exhaustion of labor, and still more especially that arising from
considerable losses of blood, symptoms arise which make the
discrimination between irritation and inflammation a matter of
much doubt.  In both there is chill, heat of skin, abdominal
pain with tenderness, furred tongue, headache, and rapid pulse.
Still farther is the diagnosis  obscured by the  effect of  loss  of
blood, for venesection temporarily relieves, but the symptoms
soon recur, and with renewed force.
   In the enteric lesion the attack is more sudden, and  sooner
reaches its  height;  the cephalalgia  sooner  occurs,  and the
abdominal  pain, instead  of creeping over, involves the whole
abdomen, and is  at once equally diffused; the pulse  does not
creep up, but rapidly increases, and is variable  in frequency;
though distended, the abdomen is not tympanitic, but soft and
puffy.
   If the headache arises from loss of blood,  it is increased by
raising the head.
   The  position also assists, for the patient  is not supine and
motionless, but tosses about the bed.
   The effect of medicine will  assist; a large enema Oj.—Oiij.
of simple water will frequently bring away black and fetid and
enormous discharges, and decide the question.
   Do not allow previous supposed evacuations to  deceive; a
dose of Calomel, grs.  xv.  to  3j,  followed  by 01. Ricin., will
often clear up the case.
   Treatment.—Two plans, Antiphlogistic and Narcotic.
   Blundell says, " In less vehement attacks  if you bleed within
six hours after the chill you will save the patient often, if within
 12 not unfrequently, if not till 24 hours epidemic cases usually
die.  Sporadic cases are frequently, perhaps usually curable."
   At the first visit bleed  5 xx. or  more, until an effect is pro- 
MANUAL  OF OBSTETRICS.
207
duced, give Calomel 3j, and combine with it, if the visit is late
at night, Pulv. Dover., grs. v. to x.   Bran poultice over abdo-
men.  If the skin is hot and dry, and mouth unpleasant, order
effervescing draughts with excess of Soda; if they make the
mouth more clammy, and cause abdomen  " to bloat," substi-
tute warm tea or small bits of ice.
   Visit again in three or four hours.  Indications are to extin-
guish abdominal pain, and to  open bowels.  If pulse is firm, skin
hot  and dry, and pain has  returned, bleed again.   If VS. is
doubtful use leeches, 15  to  20, insinuate under lifted edge of
poultice.  Give  01. Ricin. if stomach  will tolerate it, if not,
repeated Enemata; if Enemata produce but little fecal dis-
charge do not repeat.   After free evacuation avoid purging.
   For tympanites, 01. Ricin.  or 01. Tereb., Enema of 01. Tereb.
or Assafet.; a long tube passed up anus.
   After opening bowels give Calomel with Pulv. Dover, or Opi-
um, and push to salivation, assisting by Ung. Hydrarg.   Watch
abdominal tenderness, and use relays of leeches.  Use poultices
of bran, linseed wet with 01. Tereb., Hops, &c.
   Blisters not  to  be used till an impression is made; objec-
tionable, 1st, as masking progress of disease;  2d, as preventing
examinations ; dress with Ung. Hydrarg.
   Vaginal injections essential, uterine injections objectionable.
Various other remedies  proposed;  Ipecac  by Doulcet.   Tur-
pentine by Brennan.   Stevens1 Saline mixture.  Ice internally
and externally.   Digitalis.
   Second method.— Opium  to full  narcotism, by Sol. Sulph.
Morph., Opium,  Tine.  Opii,  &c.   Begin as  soon  as  pulse
begins to rise, or immediately after  chill; give Sol. Morph. 20
drops, repeat it every hour,  varying the dose and interval till
full  narcotism is produced, the  evidences of which shall be a
semi-stupid state, contracted pupil,  moist  skin, and above all
slow respiration.  I have seen respiration reduced to 7 in the
minute, in one case to 9 in two minutes, and this state maintained
for one or two days.  The pulse does not diminish with respi-
ration,  but when  it begins to  decrease in frequency, gradually 
208
MANUAL OF  OBSTETRICS.
diminish Opium.   Do not give evacuants, allow the  Opium to
regulate the  bowels,  unless diarrhoea  comes on.  Such treat-
ment may be continued  for days, with ice or iced-water as only
nutriment.  As disease  declines,  improved diet succeeded by
tonics.  The  Opium  treatment requires assiduous and intelli-
gent watching, and in fact throughout a case of Puerperal Fever
the practitioner must almost be the nurse also.
  TYPHOID FORM OF  PUERPERAL  FEVER  is  by far
the  most  fatal.   Prevails especially  in  hospitals;  is  usu-
ally endemic, sometimes epidemic, and very extensive ;  during
its  prevalence not only  puerperal, but  even  pregnant wo-
men are in danger.  This is the most markedly contagious
form, and  in some occult  way is connected with Erysipelas,
especially of phlegmonous  form;  other diseases, as Scarlatina
Maligna, Typhus, &c, give rise to it;  also it is communicated
after  making autopsies even of  those  not  dying  of the
disease.  Strongly marked  evidences of this have been elicited
in the Vienna Lying-in Hospital.
  1. The hospital at Mayence possesses  no clinique  for stu-
dents, and no epidemic has ever been noticed.
  2. Routh says, that in one of the Paris hospitals, which is
situated  near an  abattoir,  P. fever prevails  while  the wind
blows from the  abattoir, but is not noticed while it is in the
contrary direction.
  Inference from  such  facts  is clearly that the practitioner
attending Puerperal  Fever should  suspend obstetric practice,
that nurses should be interdicted from their occupation, that
friends  should  avoid visits, that students and  others should
abstain  from  attending  women soon after  making  autopsies.
Immediate washing after an autopsy with Sol. Chloride of Soda,
carefully cleansing the nails (which should be kept short), and
changing the dress, are  indispensable after autopsies or dissec-
tions.
  Approaches insidiously ;  pain not marked and severe (I have
seen it without any) ; skin moist, not flushed ;  chill usually but
not always, sometimes not severe;  pulse soon rises and becomes 
MANUAL OF OBSTETRICS.
209
very rapid, 140 to 160 or more, soft, compressible,, sometimes
variable (a bad sign) ; skin dirty, sallow, brown, leaden ; coun-
tenance not that of pain, but anxious, imploring; sometimes, if
nervous centres are attacked, stupid ;  debility great; sometimes
restless, sometimes calm;  stomach  easily affected,  vomiting,
green or  brown, diarrhoea; lochia  and milk, unchanged or
suppressed, former fetid ; tympanitis.
  As disease  progresses, respiration anxious and rapid;  eyes
livid beneath, leaden hue extending over face; circumscribed
flush on  one  cheek; delirium; tongue dark sometimes and
dry;  head rolling from side to side, gulping up, not vomiting,
a greenish  or coffee fluid; extremities and surface cold and
clammy, pulse thready; coma sometimes precedes death, more
frequently dies by exhaustion.
  Runs its course in 24  hours.  In one casej I saw  only 15
hours elapse between chill and death.   Sometimes occurs during
labor.   I  have seen the peculiar vomiting and countenance of
well-marked fever, while woman was actually in labor.
  Usually makes attack within  three days;  in one case I saw
12 days elapse between labor and the attack.
  There are many varieties, and each epidemic has its peculiar
features.  When the digestive apparatus  is specially disor-
dered, vomiting, diarrhoea,  and tympanites are most marked.
In nervous apparatus are noticed starting, tremors, insomnia;
delirium,  and  coma  precede  death.  In respiratory  system,
cough,  pain in side, bronchial affection, and serous  effusion.
Phlebitis,  whether as the  origin of  the disease, or as a subse-
quent affection, is one of the worst forms; metastatic abscesses
occur.  The secondary affections are arthritis, abscesses in the
muscular  and cellular tissues, and in parotid; pleuritis, inflam-
mation  of the eye, with purulent deposits; ulceration of the
intestines; eruptions of large  bullae  or miliary vesicles; ulcer-
ation of cartilages, of hip, knee, and shoulder; deposits, in lungs,
liver, spleen, sub-peritoneal  tissue.
  Erysipelas frequently prevails simultaneously, and  the two
diseases will reciprocally communicate each other. 
210               MANUAL  OF OBSTETRICS.
  Prognosis, very  bad,  and friends  should be so informed,
both because patients usually die, and  because delusive calms
occur and treacherous changes.
  More fatal in  epidemic; in typhoid, to  earliest attacked.
Endemic worse than epidemic, epidemic than sporadic.
  Prognosis from Special Symptoms : Lochia not always sup-
pressed, sometimes recur,  and yet die.
  Pulse over 160 frequently.  I have seen  one fatal case in
which the pulse was barely 100.
  Tympanites is unfavorable, and intestinal disorder also.
  Delirium is very bad ;  mental  depression, as  in illegitimate
births, is very unfavorable; so also the alarm that occurs  in a
hospital on the appearance of P. fever.
  Respiration, if over 50,  is grave.
  Vomiting  green is  significant, but not so  bad as coffee
ground.
  Tongue dry and rough, with cerebral symptoms, bad.
  Immediately preceding death, are cold, clammy skin; thready,
fluttering pulse ; involuntary stools ; and dilated pupil.
  Most fatal periods are beginning of third  and end of fourth
day.
  Favorable symptoms are pulse gradually less  and gaining in
volume; ability to turn  in bed, lie on side, and  take a full
breath; stomach  ceasing its irritability; bowels free, but not
watery; skin warm;  perspiration not  profuse, not  partial;
clearness of skin returning.
  Treatment.—Usually in vain.  Venesection not tolerated ;
leeches sometimes useful.   Always evacuate  bowels.   Calomel
followed by Ol. Ricin.; avoid salivation ; bran  poultices ;  tur-
pentine  stupes;   vaginal injections ;   relieve tympanites  by
enema of turpentine, or assafetida, or by tube.
   Copland, in the malignant form, gave immediately a bolus
of  Camphor, grs. viij.—xvj., with Calomel, grs. x.—3j., and
Opium, grs. j.—iij., repeated every four,  five,  and six hours.
After the  second dose, Ol. Tereb. and Ol. Ricini aa. gss., and 
                 MANUAL OF OBSTETRICS.               211

repeated to purging.  Hot turpentine epithems constantly to
abdomen.  He lost two of thirty cases.
  Study the  special organ affected.  If  from gastro-intestinal
irritation, Ipecac, followed by 01. Ricin., may do good;  ice;
morphine.  For diarrhoea, Pulv. Dover with Hyd. cum Cret.
  When purulent  deposits form, usually fatal; fomentations ;
open abscesses early.
  Post-Mortem Appearances.—Abdomen : Usually  swollen
and tense; gas escaping on incising.
  Peritoneum:  Both parietal and visceral most affected, espe-
cially over uterus and broad ligaments; simple redness; opacity.
Effusions, serum; sero-purulent  pus ; lymph, from consistence
of curd to firm membrane ; pus in sub-peritoneal areolar tissue.
Adhesions, from slight to complete agglutination.   (In those
who escape death, these  adhesions may cause strangulation,
and  usually  do cause sterility.)  Gangrene said to occur, but
erroneously.
  Intestinal  Canal: Inflammation  in patches ; softening; per-
foration ; usually distended with gas.
  Stomach :  Contains brownish or green fluid ; altered blood;
ulcers.
  Liver : Most affected of parenchymatous organs ; inflamma-
tion of its serous  coat; congestion ; softened; metastatic ab-
scesses.
  Spleen: Increased vascularity.
  Kidneys :  Not often affected ; purulent deposits are found in
vicinity on psoas;  subsequently abscess may point in groin.
   Uterus: Volume increased;  sub-peritoneal  deposits;  sub-
stance gorged, flabby,  markedly softened.
  On inner surface, a  thick layer of reddish brown, brown  or
dark green, shreddy material; most marked at placental site.
  Cervix ecchymosed, and even  greenish; is  not gangrenous,
but merely a result of labor.
   Ovaries: Enlarged; softened; inflamed; pus  on surface or
in substance. 
212
MANUAL OF OBSTETRICS.
  Fallopian Tubes: Injected; pus;  sero-pus.
  Pleura :  Effusions;  sero-purulent
  Pericardium:  Effusions sometimes.
  Heart: Softened;  abscess has been found.
   Veins: Usually  affected; pus  usually found in veins of
broad ligament, especially just at the junction with uterus, and
if no pus, vascularity exists ; coats thickened; cavity obstructed
by coagula or lymph.
  Lymphatics: Sometimes contain pus;  at intervals like beads.
  Pathology.—The post-mortem appearances do not give the
pathology.  Behind  these lesions there is a malignant form of
fever, which has some consanguinity to erysipelas.   Is it, as
has been said, a malignant erysipelas, having its origin in  the
placental site, where the veins of the uterus are  bathed in pus,
purulent absorption being  thus  facilitated, and pyaemia re-
sulting !
  Puerperal fever and puerperal peritonitis are distinct diseases.
  So frequent are cases of puerperal fever in lying-in hospitals,
so fatal  are they when they occur, that it has been doubted
whether the advantages derived by the  parturient woman are
compensated by the increased risk of confinement in such insti-
tutions.  Constant vigilance is requisite to discover the threat-
enings of an  outbreak, and most  energetic measures  are  de-
manded  to prevent extension on its first manifestation.   As far
as possible  to avoid its occurrence, but  few recently confined
inmates should be allowed in a ward, and wards should be used
in rotation.   The medical attendant should not make autopsies,
and should not attend severe cases of erysipelas. When  the
disease has appeared, the ward should be immediately vacated,
and  both medical attendant and nurse changed.  The ward
Bhould be thoroughly  cleansed, ventilated,  and  whitewashed,
and chlorine be freely used; after this, it should  remain vacant
for a considerable space of time, at least a month. Recently it
has been proposed to keep up a sustained heat of at least 150°
by means of stoves, for at least two days, as a means of purify-
ing the ward. 
MANUAL OF OBSTETRICS.
213
     Pelvic Cellulitis, Inflammation of the Sub-
                   Peritoneal Tissue.

   Occurs usually later than  peritonitis, about twelfth or four-
teenth day, even as late as third week ;  being often a mere ex-
tension of disease from uterus.
   May be a sequel of metritis, oftener extending from uterine
appendages.  Either after abortion, or full term of labor.
   Is frequently overlooked or mistaken.   Apt to come on while
puerperal fever prevails.
   Symptoms.—Often distinguished by precedent inflammation.
Thus an attack of metritis seems to yield, uterus may be free
from pain on pressure, abdomen soft, patient unable to move,
pulse frequent, and slight rigor occurs.   Rigors recur with ir-
regular perspirations ;  sleeps badly;  pain in defecation ; some-
times  diarrhoea  carries patient off.   Lever says decubitus is
peculiar; lies on back  or  on sound side, thighs flexed, limbs
of affected  side resting on limb of sound side, and  rotated
inwards as  in morbus  coxarius.  If pus finds its way  to  sur-
face, either  in groin, hip, or rectum, case  becomes clear; if it
pass along  iliac vessels into abdomen, the case will terminate
fatally.
   Per vaginam the uterus will be found displaced, less movable
than it ought to be.  Swelling found in posterior part of cul
de sac like a retro verted uterus, or the  anterior wall depressed
into  vagina; pain on pressure, and  doughy cedematous feel;
fluctuation.
  Terminations.—Resolution; suppuration; absorption of in-
flammatory deposit; abscess may burst externally or internally,
into vagina  and  surrounding viscera, sometimes  burrows deep
into pelvis and bone becomes diseased.
  Treatment.—Two  Indications:  1st.  To prevent formation
of pus.   2nd. To evacuate it early.
  For 1st, Apply leeches through a speculum to swollen part,
fomentations, and warm vaginal  injections.   Hyd.  cum Cret.
with Pulv. Doveri given moderately.
                            18 
214
MANUAL of obstetrics.
  As soon as pus is evident, support strength with diet  and
tonics,  and evacuate speedily.
  Blisters  are useful  for  subsequent induration,  also  Iodid.
Potass.

                    Pelvic Abscess.

  Attention drawn to it only recently.
   Occurs : Not only unconnected with parturition, but even in
unmarried; in some  cases from  local  irritations,  as  uterine
sound, pessaries, &c.;  as complicating or terminating an attack
of hysteritis ; in  certain epidemics of puerperal fever; may fol-
low labor or abortion; with either  small or large child; not
necessarily from mismanagement;  most on left side.
   Causes.—Mechanical  injuries;  metastasis of inflammation
from uterus;  cold; extension of diseased action in puerperal
fevers.
   Pathology.—A phlegmonoid inflammation.
   Seat of Abscess.—1st. A tumor just above brim of pelvis,
connected with it, immovable, extending downwards internally,
outside  the  vagina,  and felt through vagina,  involving the
lining of pelvis.
   2nd. Distinct  from pelvis, ronnded,  movable;  limited to
ovary, broad ligament, and tubes.
   Symptoms.—Usually commences with fever ;  rigor and  heat
following; pain or uneasiness in lower part of abdomen.   By
careful examination, a tumor either  just above Poupart's  liga-
ment, of varying size, and firmly fixed;  or else a movable tumor,
ronnded, firm, and elastic, lying in abdomen.  In this latter
variety, an examination per vaginam traces a swelling in pelvis,
very tender; nterus pilshed to one side, not tender, but pained
by moving.   In  the  former class, there are pain, tenderness,
 and inability to  stretch limb out  straight; and  patient,  in
 standing or walking, bends forward.
   Tumor varies  in size;  is sensitive;  may irritate bladder or
 rectum. 
MANUAL OF  OBSTETRICS.              215
  Constitutional  Symptoms : Sometimes slight;  sometimes
pulse rapid, night sweats, anorexia, irregular bowels, no sleep,
emaciation ; in puerperal epidemics, the disease partakes of the
general affection.
  Duration: From one to three or four months.
  Terminations : By resolution or suppuration.
  1st.  By  Resolution,  after more or less duration; liable to
exacerbations.
  2nd. And usually by Suppuration, attended by rigors, &c
  Situations of Openings.—1st. Into peritoneum; is rare ; peri-
tonitis.
  2nd. Into bladder.
  3rd. Through vaginal parietes.
  4 th. Into rectum; most common in spontaneous opening.
  5th. Through abdominal parietes.
  Diagnosis.—By tumefaction; pain  down  the  limbs, and
difficulty of extending  limb.
  Prognosis.—Not usually fatal.    Is  tedious, and reduces
strength ; may excite other disease.
  Treatment.—Leeches to  tumor ;  bowels kept  free;  diet
low ; confine to bed; poultices.
  Open  by exploring  needle and bistoury,  in  vagina; above
Pou part's ligament.
   Improved diet; blisters;  Tine. Iodine; hip baths.

                  Phlegmasia Dolens.

   "Milk  Leg;"  "CEdema Dolens;"  "CEdema  lacteum;"
" Depot du lait ;" " Metastasis lactis ;"  " Crural Phlebitis."
   Was early known, but not well understood.
   Def. A swelling of  one or both legs, occurring shortly after
delivery, with pain and tenderness.
   May occur with primiparae, but most in multiparae.
   A similar swelling  noticed  in non-puerperal, in connexion
 with menstrual disorder or  malignant uterine disease, or after
 injury, or as a sequel  of typhus. 
216
MANUAL OF OBSTETRICS.
  Also is noticed in  arm unconnected with pregnancy.   A
unique case of occurrence in  arm after delivery, in London
Lancet,  Oct. 1852.   Is seen  in  men.   But  though  analo-
gous, the  lesions  of these affections  are not identical, and as
phlegmasia  dolens is usually,  if not  always,  connected with
puerperal metritis, a palpable distinction exists.
   Occurs, most in delicate  constitutions ;  after lingering la-
bors ; hemorrhagic  labors;  those whose  limbs have been
anasarcous and painful during pregnancy; non-nursing.
   Commences,  usually  from  10th to 16th day;  variations,
4th—20th.
  Pathology.—Mauriceau  thought  it arose  from reflux of
matter that ought to have passed in lochia ;  Puzos and Levret,
that depots  du lait existed.  In 1784, White considered  that
obstructed lymphatics caused it.  In 1792, Trye, that lympha-
tics were ruptured at the brim of pelvis.   Ferrier, inflam. of
absorbents.   In  1800,  Hull  thought  it inflammatory,  pro-
ducing serum and lymph.  In 1817, Davis  made an autopsy,
and found inflammation of veins, and published in 1823.  In
1823, Bouilland found crural veins  obliterated.  In 1829, Lee
traced inflamed veins to uterus, and  called it crural phlebitis.
Crural phlebitis usually is found, not invariably, nor is  it  the
totality of the disease.  Objection to the doctrine of Phlebitis
has been  urged that this disease is rarely fatal, while venous
inflammation usually is so; but there is   marked  difference
between  adhesive  and suppurative phlebitis;  often coincides
with puerperal fever, especially if it appears  early.
  Causes.—Exciting, usually cold ; disease  of uterus; injury;
absorption of putrid matters ; a sequel of fever.
  Symptoms.—Premonitory pains or uneasiness in  lower  part
of abdomen ; patient irritable, depressed, and feeble.
  Appears  about 15th day;  12th  to 20th  usually; with
rigors; heat;  headache ; tenderness in the  limb ;  disorder of
digestive organs; faeces pale and clayey.
  Pain sometimes sudden in calf of leg;  back; hip; when
commencing in the  pelvis it soon descends; pain is constant, 
MANUAL OF OBSTETRICS.
217
not relieved  by change of posture;  is increased by dependent
position;  is  all over  the  limb, but chiefly  along  the large
vessels.
   Swelling may begin at groin and extend down; in calf, and
extend up ; in popliteal space.
   Temperature is usually increased.
   At the commencement, and towards close, pressure produces
pitting ; but  at  height it does not pit; is tense, white (excep-
tional  cases  red),  shining,  and elastic.   Puncture will not
discharge more than a few drops of fluid.
   The femoral vein can usually be felt, hard, rolling  under the
finger, and painful.
   The glands are swollen, hard, and painful;  rarely suppurate.
   Leg attacked, mostly  the left;  sometimes both;  usually
when both  are affected it is not simultaneously, but the disease
subsides in the first attacked ; this is not the result of metasta-
sis ; patients  are more  apt to succumb under second attack.
   Mobility is lost, not  simply from pain, but want of power.
   Constitutional symptoms:  Pulse  quick, often 140,  weak;
tongue coated  white; *thirst;  headache ;  anorexia; derange-
ment of bowels ; urine turbid; restlessness; sleeplessness, with
morning sweats profuse.
   Lochia offensive, or  unaltered.
   Continuance  of acute stage, 10 to  14 days;  may become
chronic; swelling  and  lameness remaining for months or
years.
   Terminations. 1st. In resolution.  2nd. Gradual subsidence
with thickening, varicose veins and lameness for months.  3rd.
Suppuration  in  patches, rare,  dangerous.  4th. Death, some-
times suddenly.   5th.  Toxemic phlebitis.  6th. Gangrene.
   Post Mortem Appearances.—Limb distended with serum.
   Veins:  Inner coat deep red, clots of blood  adhering; fibrin,
pus;  veins attacked  are,  femoral,  iliac, epigastric, uterine,
6aphena, cava.   Absorbents, pus, like a  string of  beads;
abscesses in limbs, or joints.
   Prognosis.—Not usually fatal. Commencing in the calf it
                             18* 
218
MANUAL OF OBSTETRICS.
is  usually light; coming on  early, say fifth  day,  it ia  more
likely to be connected with metritis.
   Treatment.—Venesection  not  usually required;  leeches
along the course of veins, in relays, and followed by poultices;
(care is requisite lest leech-bites bleed too much.)
   Bowels to be opened, but active catharsis not advisable.
   After bleeding,  blisters along  veins ; turpentine fomenta-
tions sometimes useful;  also bran fomentations or Goulard's
extract and laudanum ; a flannel roller covered with oiled silk.
   Opiates for pain; Pulv. Dover, with Calomel; Antimonials
with Diuretics ; Mercury pushed to gentle constitutional effect
recommended by some.  Horizontal position to be observed
with limb elevated.
   Diet antiphlogistic.
    Chronic stage: Flannel roller; frictions ; Camphorated oil;
 Ung.  Hydrarg.; Iodine;  Blisters.   Tonics;  Bark; Quinine
 with Acid. Sulph.  Dil.; conjoin diuretics.
    For lochia, vaginal injections.
    Improved diet, very gradually ; exercise;  sea-bathing.

          Puerperal Mania,  rather Insanity.

    A serious  and alarming affection.   By no means rare.
    Not confined to puerperal state, but occurs  before delivery,
  and subsequently during lactation.  Occurs most in nervous
  and irritable, those with acute  feelings  and  excitable tempera-
  ment ; more in unmarried.
    Duration may be  for a  few days, or many months, rarely
  permanent.   Two forms, Mania and Melancholia.
    MANIA.—Causes.—Predisposing.—During gestation the
  mind is in a state of great susceptibility, and impressions more
  easily become  morbid;  anxiety;  fright  during gestation;
  mental emotions ; depression ; disorder of digestive functions a
  very common cause; hereditary predisposition commonest of all.
     Exciting: Uterine  irritation ;  suppression of lochia;  com-
   pany. 
manual of  obstetrics.
219
  Mode of Attack.—Sudden, as in a single night, or gradual.
  Symptoms.—Usually  there are  precedent  symptoms, as
alteration of manner, odd, unnatural, sharpness of tone of voice;
headache;  sleeplessness ;  incessant  talking ;  incoherency ;
vacillation ; sullenness ; listlessness ; jealousy ;  suspicion, espe-
cially of those most loved previously ; obscene language singu-
larly common; apt to assume suicidal form, or to kill child;
lochia may be suppressed; milk usually deficient; voids urine
and faeces in bed.
   Two opposite states of  sanguiferous system.  In  one, pulse
runs 120 to 140 with headache, throbbing of  carotids, flushed
face,  intolerance  of light, great  mental excitement, incessant
raving, difficult  to restrain, thoughts on genital  function; is
frequently fatal.
   In the other, pulse but  little quicker than natural, and weak ;
 surface  natural;  very little  headache;  tongue white  and
 loaded ; stomach  disordered ; bowels confined.
    MELANCHOLIA.—Rarely sudden, premonitory symptoms
 for some days.  Sits quiet, moves mechanically, nights sleep-
 less, pale  sunken  or placid  aspect, pulse not  accelerated, skin
 natural, tongue unhealthy, bowels costive, loses  flesh.  Loses
 interest in all things.  Is aware, of insanity ; mental apprehen-
 sion ; religious mania; tendency to suicide marked ; irresistibly
 driven to  commit.
    Diagnosis.—Most apt to be confounded with, 1st, Phrenitis;
 2d, Congestive Headache; 3d, Delirium Tremens.
    From Phrenitis.—By pulse not so sharp and  hard, skin not
 hot, pain not marked.  Phrenitis  presents fever, pain in head,
 vertigo, tinnitus,  congestion of adnata, intolerance of light and
 sound, is  rarer even than mania, appears sooner, occurs in full
 habits, plethoric  or imprudent.
    The 2d, does not commence with delirium.
    From  3d.—Delirium  tremens after labor  usually occurs
 within three days, sometimes  24 hours.   Mania rarely before
 three days to three weeks.   Del.  Trem. not sudden;  has pro-
 fuse sweats, cold  clammy skin, tremulous tongue.   History and 
220
MANUAL OF OBSTETRICS.
habits good guides.  Are similar in character of delirium, rest-
less, impatient of restraint, incessant talking, same capacity to
return a correct  answer when roused,  same recurrence to one
subject.
  Prognosis.—One of the  most curable forms  of  insanity,
except in that variety  where pulse ranges 120 or more, with
constant undeviating rapidity, and great restlessness, insomnia,
warm profuse sweats and prostration occur; these usually die.
Mania is more dangerous to life, melancholy to reason.   If the
pulse  is regular,  patient sleeps, and not much  exhausted, usu-
ally recover.  A frequent and increasing pulse is probably con-
nected with Puerperal  fever, and indicates fatal result.  Free
discharge of fetid fecal evacuations indicates favorably.
   Terminates in death, recovery, permanent madness.
  Is it liable to  return in a  subsequent delivery ? Not except
hereditary or injudiciously managed.
  Treatment.—Preventive, Medical, and  Regimenal.  Indica-
tions  are to  combat morbid symptoms as they arise, to allay
excitement, and to husband strength.
  Preventive.—If reason to anticipate it, as in hereditary,
attend specially to state of alimentary canal, and early remove
all  sources  of irritation; keep from mental excitement; relieve
insomnia by anodynes; do not allow the  system to run down
in any way ; be cautious as to company, yet do not allow soli-
tude.   Occupy,  without  exciting,  the mind,  by exercise, and
moderate occupation in household  duties.
  Medical.—VS. less required  in  this  than in  any other form
of mental derangement.  As a  general rule do  not draw  blood
in insane, when you would not if sane.  Even if pulse is rapid,
and somewhat firm, local bleeding by cups or leeches is pre-
ferable.
  Antim. Tart, is useful when pulse is  quick, but not if skin is
cool,  &c.
  Purgatives are very useful to remove intestinal irritation, but
not violent remedies.  01. Ricini, Rhubarb, Senna, Aloes, Calo-
mel, Mass. Hyd., combination of Mass. Hyd., Ext. Coloc, Comp.,
and Ext. Hyoscy. 
MANUAL OF OBSTETRICS.
221
   First clear the bowels, then keep in a soluble state.  If medi-
 cines by mouth are refused,  give  enemata of Turpentine or
 Assafetida.
   Counter-irritants are  of great value.   Begin with  warm
 bath and soap, Ung. Antim. Tart., Blisters, and Ung. Sabinae.
   Narcotics are  the  sheet anchor.  Not  before bowels tho-
 roughly cleared out; not while cheeks are hot and flushed, and
 thirst. Best form is Hyoscy. and Camphor, Opium, Pulv. Doveri
 at night with  an  alterative;  doses  must be full, ex. gr. Mor-
 phine gr. i. to grs. iss.
   If sleep ensues patient will  do  well.   Keep up the influence
 by smaller doses.  If excited  on  waking, wait till  night, and
 then give a warm bath and Pulv. Doveri.
   Regimenal.—Remove from home and place  in an asylum.
 Requires constant care to prevent  suicide; never to be left
 alone; windows to be  secured;  knives, &c, to be removed.
 Experienced nurse requisite.
   In regard to seeing  husband  and friends, in early  stages
 forbid it strictly, much more injurious than useful.  In chronic
 and  passive stage sometimes interviews  are advantageous, but
 should be short and distant.   Child is to be removed.
   Diet, at first, is to be unstimulating.   Get digestive organs
 into  good condition.  But  it is very important to keep up the
 strength, hence diet is soon to be  improved.


                 Mammary Abscess,

   Is liable to occur late  during gestation, though very rarely;
 or during lactation, not unfrequently.  Most in primiparae, and
 during first three months.
   Causes.—The congestion that normally attends the secretion
of milk  may  run  on  to  inflammation  and  abscess.  Some
women  are more  disposed, as those with sore nipples,  the
breasts not being fully drawn; in those  in whom some of the
lactiferous tubes have  been obliterated by sore nipples, &c, in 
222
MANUAL OF OBSTETRICS.
former confinements, it is apt to recur.   Tight lacing; not nurs-
ing either because of sore nipples, or its interference with visit-
ing, &c.
  Exciting  causes.—Cold, wet, mental  emotion,  blows, com-
pression, cold applied to drive away milk.
  Symptoms vary with extent involved.  When skin and areo-
lar  tissue only involved, there are localized pain and soreness,
circumscribed hardness and tension, and  flush of inflammation
on the skin.  If the gland is interested pain is severe.   Swell-
ing, tension, constitutional symptoms, pulse quick and full, skin
hot, headache, thirst, sleeplessness, uniform dusky red  appear-
ance, nodulated feel, hot and shining.
  When both  structures involved, some  parts harder, some
softer.
  Progress  to  suppuration is rapid, even  on third day, when
in areolar tissue.   Is marked by shivering, heat, perspirations,
oedema, fluctuation, and enlargement.
  In simple  and superficial variety, pus  is laudable;  in more
extended, sloughs present.
  • In scrofulous the disease is protracted  and even fatal.  Gra-
dual loss of strength, appetite, and flesh; daily rigors, unre-
freshing sleep, profuse night sweats, and  diarrhoea.
  Prognosis.—Not often fatal, but  tedious and difficult to
cure, and very  distressing.  May excite  lurking predisposition
to disease.
  Treatment.—Indications, 1st, To promote  resolution;  2nd,
Promote suppuration.
  In mere congestion, simple and continued frictions with  the
hand,  and Camphorated Oil or Soap  Liniment; free purge
with salines; cover with oil-skin ; support  with bandage.
  If much heat and pain and some duration, resolution is rare;
use Linseed poultice sprinkled with Goulard's Extract; tobacco
poultice requires care for child ;  Collodion painted thoroughly
has been advised; Leeches, six  to  ten,  not more.  (Leeching
the inflamed mammae requires  caution,  lest bleed too much.)
Continually wet with warm vinegar and  water,  and  covered 
MANUAL OF OBSTETRICS.
223
with  oil-silk.   Internally, Salines with  Antim. Tart.;  Vin.
Antim. et Spts. Nit. Dulc.  If tongue is foul, Calomel followed
by 01. Ricin.   If  early seen,  an emetic of Ipecac, and Ant.
Tart.   Diet to  be  bland.  Breasts  to be drawn thoroughly.
Support by long adhesive strap.
   If  not  seen for two  or three days, fulfil second indication.
Emollient poultices;  bran ; hops ; poppy; linseed.  Poultices
long  continued produce eruptions.   Modify this, 1st, By oil-
silk covered with hot salt; 2nd, Oil-silk and poultice alternately;
3rd, Lint wetted, and oil-skin over ;  4th, Spongio-piline.  Ex-
posure to cold while nursing is hazardous.
   Keep in bed.   Keep  bowels free.
   Of Opening:  Variety of opinion.   Some  say early; others
not till skin is thinned.  Abscess near  the nipple not to be
opened so early.   Compress breasts by straps.   Sometimes
sloughs stop the exit  of the pus.
   Sinuses result from too early opening, and  leaving unsup-
ported.  Keep orifices  open and use compress.  This failing,
put in seton, and keep in until some time after laudable pus is
formed ;  use well graduated  pressure by straps.
   With  suppuration, the diet must be improved  and tonics
soon given ; tonics  and anodynes.
   A breast once the seat of mammary abscess,  requires careful
watching  to prevent re-accumulation of milk.
   Though long  unhealthy, cancerous degeneration is not apt
to follow.
   Of Nursing  the  Child:  Before  suppuration, keep breast
empty by nursing ;  if child is ineffective, get  an older child, or
a puppy, or breast-pipe.  If  actual  suppression has occurred,
weaning will become necessary, and  is better for both ;  it re-
lieves mother of a double drain, the child of taking insufficient
nutriment, and perhaps pus into stomach. There is no use in
attempting to continue  nursing with one breast and at the
same  time to cure a diseased one. 
224
MANUAL OF  OBSTETRICS.
               OPERATIVE MIDWIFERY.

  Operations for Premature  Labor.—This proceeding
was suggested by cases  occurring in which a viable foetus was
prematurely expelled  through a deformed pelvis.  In 1756 a
consultation was held in London to decide upon the morality
of the operation.  By the  English it has  been  advocated ; by
the French,  until recently,  condemned,  owing  to  religious
motives.
  Is now admitted.
  Danger:  Females undergo no special  immediate danger.
To child, less than half  fatal.  Danger  arises from, 1st, Com-
pression of cord ; 2nd, Irregular presentation.
  Objections: 1st. Difficulty of appreciating  size  of pelvis.
2nd. Difficult to ascertain precise period of gestation.  3rd.
Abnormal presentations  are more frequent in premature labors.
4th.  Cervix uteri not being unfolded,  child dies from  long
labor.
  Utility :  Saves more  than half of children, 1 in 16 mothers
only dies ; while by Craniotomy, infants are of course all dead,
and 1 in 5  mothers are  lost; by Caesarian, 1 child in 3£ dies,
1 mother in 2 J.
  Available:  1st. Where the pelvis is too much deformed to
allow a full grown, but yet will permit a viable  fcetus to pass.
  Two and a half inches in antero-posterior  diameter will per-
mit a viable foetus; through three and a half a living child can
pass.
  Bi-parietal diameter from 32nd to  33rd week, measures 2f
inches; from 34th to 35th, is 3£ inches; from 36th to 37th,
is 3 J inches.
  If antero-posterior  diameter is 3 inches, wait till 38th week
or 8th month ; if 2J inches,  wait till 1\ months; if 2\, wait
only till 7th month.   If less than two inches, the decision lies
between abortion and the Caesarian  section.
  Is not to be  used  in  primiparae ; nor if twin pregnancy be
clearly ascertained, relying on the small size. 
MANUAL OF OBSTETRICS.
225
  2nd.  In certain cases, death of the foetus occurs at a time
when extra-uterine life is practicable ;  in a succession of such
cases, the operation is admissible.
  3rd.  Where mother's life is endangered  by excessive vomit-
ing, effusion  into serous cavities, strangulated hernia, convul-
sions, cardiac disease, aneurism, uterine hemorrhage
  Other reasons  are, narrowing of bis-ischiatic diameter; ex-
ostosis in pelvis ;  fibrous tumors of uterus, which during preg-
nancy sometimes  suppurate ;  cancer;  rupture of uterus in pre-
vious labor, occurring from some mechanical obstacle.
  Modes  of  Operating: 1st. Separating  membranes  in the
vicinity of os; frequently fails.
  2nd.  Rupture  of  membranes  by  catheter  or  trocar.   Is
effectual but hazardous.
  3rd.  Sponge tent of compressed sponge inserted into cervix,
and then plug the vagina.  (To make a sponge tent.—Soak a
piece of fine sponge in Mist. Acaciae, wrap it round an awl, and
then  around  it a string, very tight;  when dry, cut into any
desired  shape.)
  4th.  Use ergot for  a day or two,  and then rupture mem-
branes.
  5th. Injection of cold or warm water ;  sometimes succeeds.
  6th.  Galvanism.
  Labor usually  comes  on in from  24 to 96 hours,  and  is
ushered in by nervous symptoms.
  A wet-nurse should be provided for the infant.

                        Version.

  Turning:  (See also  under Shoulder Presentation.)   First
applied  to living child by Pare.
  Advantages: 1st. Enables the operator to control the whole
labor.   2nd.  Though inferior in safety to head presentations,
the breech is superior to others.  3rd. Is sometimes the only
alternative of evisceration.  4th.  In some cases affords a pro-
bability of saving mother.
                            19 
226               MANUAL OF OBSTETRICS.
  Disadvantages : 1st. All introductions of the hand into the
uterus enhance the danger of mother's life.  2nd. Mortality to
child, one in three.   3rd. The difficulty of effecting it in certain
circumstances.
  Applicable:  1st. In  irregular presentations.   2nd. In  all
cases of placenta praevia ; in many of ruptured uterus ; convul-
sions ; prolapsed funis ; hemorrhages ; great debility ; syncope ;
danger of suffocation.
 ■ Simpson proposes it in cases of slightly deformed pelvis, but
it  would  be objectionable in primiparae ; again, in ordinary
version, one-third of children are lost; if the size of the pelvis
be over-rated, the difficulty and danger would be increased, for
embryotomy must then be  performed under unfavorable cir-
cumstances, danger  of contusing the maternal  soft parts  by
dragging through a narrow pelvis.
  Mode of Operating.  (See page 145.)


              Obstetrical Instruments.

  Are, 1st, those intended to benefit both mother  and  child,
i. e. Vectis and Forceps ;  also Tractors ;  Blunt hook.
  2nd. Those to benefit mother  at  expense of child, i. e. Per-
forator ;  Crotchet;  Craniotomy forceps ; Cephalotribe.
   Operations in Paris, 1 in 78 cases; in Vienna, 1 in 50; in
Dublin, 1 in 72£.

  Vectis or Lever.—Inveuted by Roonhuysen in  17th
century.   Kept secret till 1753,  when de Vischer and Vander
Poll bought and disclosed the invention.
   Value:  Is unsettled.
  Recommended to  rectify malpositions, and as  a tractor in
face or breech cases.
  The facility of application constitutes an objection, from the
temptation to concealment.

  Forceps.—Were invented  prior to 1647, by Dr. Paul 
MANUAL OF OBSTETRICS.
227
Chamberlen.  The original instruments were obtained vby Mr.
Cansardine, in 1818,  and described.  Chapman, in 1733, first
published a description of the instrument.
  The value of the invention may be  appreciated, by consider-
ing that before their use, craniotomy with all its horrors on the
child's account, and all the dangers from delay to the  mother,
was  the only resort in  difficult labors; yet Blundell says the
total evil has considerably exceeded the advantages of forceps.
   Varieties are  principally Long and Short.  Long are 16  to
18 inches; short 10 to 12.  The long are applicable at either
superior or inferior strait; the short only at the inferior.
  The distance between the blades, or clams, is liable to varia-
tion ; about 3 inches  is advisable.
  The blades have a  "first" curve  to apply to the head, and
in long forceps a " second " curve to  accommodate  to axis  of
pelvis.
  Some forceps have solid blades; others  a fenestra to admit
the parietal bosses.
  Formerly leather coverings were  used, but are objectionable,
from  difficulty of introduction, and possibility of conveying
contagion. ,
  Varieties of lock are, the French with a screw pivot on the
male blade, fitting into  a mortise' on  the  female blade ;• the
English has a notch with  a  shoulder  fitting a corresponding
and similar notch.
  Use of Forceps.—1st. To  deliver in cases of inert uterine
action.
  2nd. To save  mother from  consequences of too prolonged
labor.
  3rd. To  deliver in emergencies, as  convulsions, hemorrha-
ges,  &c.
  4th. To deliver head left in utero, ex. gr.  in breech cases.
  The power of  the instrument is,  1st.  To grasp and compress
the head (though some deny the propriety of compressing).
  2nd. To act as a lever of the first kind, and as an extractor.
Baudelocque's experiments reduced  the bi-parietal diameter not
more than four lines. 
228
MANUAL OF OBSTETRICS.
  Frequency of use: In British practice 1 in 362f ;  French, 1
in 162 ; German, 1  in 153£ ; In whole, 1 in 168^ ; Voightel, 1
in 8 ; Siebold, 1 in 9.
  Arneth says, in Paris, 1 in 257 ; in Vienna, 1 in 80 ; in Dub-
lin, 1 in 343|.
  Results: In British there were lost of  mothers,  1 in 20<|;
of children, 1 in 4j; in French and German, 1 mother inl3^ ;
of children, 1 in 5.  Total: loss of mothers, 1 in 15 ; of children,
1 in 5.
  The frequency of craniotomy in British practice makes more
favorable results to  mothers.
   Applicable.—1st. To the  head only.   2nd. Never to save
ourselves trouble.  3rd. Not unless there  is  a certainty that
natural efforts will not  effect delivery safely to mother and
child.  4th. Os must be dilated and membranes  ruptured.  If
the whole circumference of the  os  can be felt, forceps are not
advisable, and  even if the posterior lip cannot be  felt, if the
anterior is distinguishable, great care is requisite.   5th.  Not to
be  used  in " impacted," or " locked head."  If the head fits
closely, but is not locked, they may be used.  6th.  Sometimes
in  face  presentations.  1th. And most  favorably,  if labor is-
delayed, simply from want of uterine  contraction, while there
is  sufficient space, and  the  parts are dilatable.  8th.  Hand
with the  head occasionally; also Prolapsed Funis.  9th. In
Convulsions, Hemorrhage, Ruptured Uterus, Syncope,  Great
Debility,  Diseases of the Respiratory Organs, Impending Suffo-
cation, Obstinate Vomiting.
   10th.  In breech  cases where there  is delay of head.  11th.
To head retained in utero after avulsion of foetus.
   Not  Applicable.—1st.  To breech.    2nd.  In deformed
pelvis ; tumors.  3rd. Rigid and undilatable os ; or swelled and
inflamed  soft  parts.  4th.  If child is  certainly dead.   5th.
Hydrocephalic or firmly ossified head.
   Period for Operating.—Before rupture of the membranes
it  is  unnecessary.  When  constitutional  symptoms  appear,
 interference is  requisite.   Symptoms are a better guide than 
MANUAL OF OBSTETRICS.
229
mere  lapse of time.  Do not, however, wait too long, till the
passages are dry and inflamed, and the perineum and labia are
infiltrated with serum and "will tear like wet paper," for lacera-
tion is inevitable.
  Consider, Is*. The previous state  of health  of the woman,
if she has been confined by long illness, and also if it is a first
labor.   2nd. The duration of labor ; if 24 hours elapse after the
rupture of the membranes without  advance for 4 hours, the soft
parts will be endangered.   3rd. The progress of the head ; if it
advances at all, and the strength and spirits remain good, and
the pulse does not rise, temporize: (the caput succedaneum
sometimes misleads as to apparent advance).
  4th. The strength and capacity of endurance.  Exhaustion
will be known by quick pulse (under 100 usually no danger) ;
by cessation  of  pains;  by olive  colored discharge,  faint, un-
pleasant, but not putrid ; anxious countenance ; hurried breath-
ing ; eyes sunken ;  tongue loaded  and dry ; vomiting ; shiver-
ing ; cold extremities ; muttering delirium.
  5th. The state  of passages ; if dry, hot, swollen, and painful,
labor must be terminated.
  6th. State of abdomen ;  if pressure gives great pain, deliver.
  Summary.—If pains have  subsided;  strength  is  failing;
spirits sinking; countenance anxious;  pulse over 100 ; tongue
slimy, dry, brown ;  rigors; pain on pressure; green discharge ;
soreness,  heat, and  tumefaction  of vulva  and vagina; no
progress of head  for 4 to 6  hours;  vomiting of dark fluid ;
hurried  breathing; delirium;  cold extremities;  instruments
should be used ; but it would be injudicious to wait  for dark
vomiting, dyspnoea, delirium, and coldness.
  But if the uterus  is  acting with energy, the strength and
spirits good, the countenance natural and cheerful, pulse under
100, tongue  moist  and  clean, no vomiting or  rigor, no  heat,
swelling, or tenderness  of parts, the head  advancing  and re-
treating, assistance  may be delayed."
  " No woman should be left in strong labor for more than 24
hours  after  the  discharge of  the waters.   1st. Because  it is
                           19* 
230
MANUAL OF OBSTETRICS.
unreasonable to expect that the natural efforts will expel the
child.  2nd. Dangerous symptoms may suddenly appear."
   Preliminary Preparations.—Evacuate bladder by the cathe-
ter ;  the  rectum by an  enema; have a consultant if there is
time, and inform the patient of the necessity and nature of the
operation ; warm  the forceps by warm  water,  not by  fire  ;
arrange  your own  dress and protect  the bed, furniture, <fec.;
chloroform.  Know certainly the position of.the head.
   Position.—English on left side; French on back.  Must be
quite at  the edge of the bed.
   Introduction.—Pass in three fingers,  to guard the blade  from
inclosing the os;  (at the  superior strait the whole  hand is
requisite.)  Introduce the male  blade first, and  along the left
side of the pelvis.
   Keep  the blade  constantly in  contact with  the head, and
 guide it forward by an insinuating, wriggling motion, without
force. Use the left hand  and  female  blade correspondingly.
If properly, applied, they will lock without force; if not, with-
draw the second blade, which is the one usually at fault.
   Clear  the hairs and soft  parts  from  the lock; screw down
 the  pivot; grasp the handles firmly together, to  be sure no-
 thing extraneous  is included before moving.  Motions  to be
 from handle  to handle; two-thirds  lateral and one-third ex-
 tractive  force.   Do not tie the handles, but relax  at intervals.
 Do  not  draw continuously,  but  imitate the uterine efforts.
Keep the forefinger of the left hand against the head, to know
 if the forceps are slipping.   Observe very carefully the axis of
 the pelvis, and vary the motion  so as to correspond with the
 part of  pelvis  over which  the  head is passing.  As extension
 begins,  carry the  handles  up towards the abdomen with the
 right hand and stop pulling; with  the left protect the  peri-
 neum.   Do not remove the blades till the head is delivered.
   Special  Rules.—In  Occipito-Posterior  Positions.—The
 blades are applied and locked as before; but traction is not to
 be made  towards the perineum ; on  the contrary, increased
 flexion  is produced by raising the  handles  carefully, and as 
MANUAL OF  OBSTETRICS.
231
soon as the occiput passes the perineal commissure traction is
to cease, or the handles to be moderately depressed.
   At the Superior  Strait.—The whole hand must  be intro-
duced  to  guide, so  as  to  introduce the  blades within the os.
The first tractions are to be downwards and backwards.  Much
care is requisite, for  it is both difficult  and dangerous.
   In Face Presentations.—Apply the blades so that the  con-
cave  edge looks towards the chin in the mento-anterior  posi-
tion.   In the mento-posterior, Dubois suggests that a straight
forceps might be used to bring the chin in front.
    Where the head remains after the body is expelled.  Raise
the -child well upwards, and apply upon the  sides of the  head
 as in ordinary cases, sliding the blades beneath the body.
    After  Separation of the Head, the forceps, may be used to
 restrain the head while using the perforator.   The hand intro-
 duced, brings the occipital foramen within the grasp of either
 the forceps or the craniotomy forceps, first, and while the  head
 is secured by the latter, the former instruments may be applied
 as preliminary to the scissors.
    Dangers.—To  the Mother : Laceration of vagina, including
 cervix uteri; bruising soft parts ; laceration of perineum.
    To the Child:  Ear or scalp bruised  or cut off;  head may
 be too much  compressed; paralysis of facial nerve of child
  from pressure.—(Cazeaux.)
    Cautions.—Avoid force ;  do not apply while the parts are
  rigid or the os undilated ; know certainly the position of the
  head ; do not oscillate too extensively;  observe intermissions;
  avoid severe and  continuous  pressure on the handles; avoid
  hurrying the head through the outlet; remember the peri-
  neum ; bear in mind the axis of the  pelvis.

    Embryotomy.— Varieties :  Embryulcia;  evisceration;
   craniotomy ;  cephalotomy.                            _
    Def.  The reduction of the size of the child, whether living or
   dead.                                  .          v     . ,
     Necessary  Instruments:   Smellie's  scissors,  or  JNaegeles;
   crotchet; bone forceps; craniotomy forceps ; cephalotribe. 
232
MANUAL  OF OBSTETRICS.
   Object:  To save mother when the  pelvis is too small to
transmit a  living child.
   Conditions necessary: 1st. That a head,  even when com-
pressed, will not pass.  2nd. Distortion not too great to pre-
vent a mutilated child  passing.  3rd.  Delivery  impracticable
to forceps.   4th. Hydrocephalus.
   Dimensions requiring it: Osborn  says, antero-posterior dia-
meter of 2f inches ;  Clarke, 3£;  Burns, 3£.
   Admitting:  Baudelocque, If ; Dewees, 2 ; Davis, 1.
   Statistics of Mortality : All the  children of  course  dead;
mothers, 1 in 5.   Allowance must be made in estimating the
severity  of the opera'tion, for  the feelings of humanity that
defer it as long as possible.
   Frequency:  In British  practice,  1  in 201f;  French, 1 in
1205|;  German,  1 in 1944& ;  total, 1 in 803f.
   (Arneth says, in Paris, 1 in  1628 ; in Vienna, 1 in 688 ; in
Dublin, 1 in  127*.)
   As compared with forceps operations, it is less favorable; but
the alternative  operation is the Caesarian section, which is fatal
to mother 1 in  3- ; or premature labor.
   May be  used: 1st. When strong labor has existed and  no
advance.   2nd. After failure of forceps.   3rd. Exhaustion, the
child's life being doubtful, and also  use of forceps.
   Must be used:  1st. For dead child.   (Signs of death.—1st,
Loss  of fcetal  motion; 2nd, Sense  of weight in uterus; 3rd,
Sense of coldness ; 4th, Meconium in head presentations ; 5th>
Putrescent discharge; 6th, Flatus from  uterus ;  7th, Want of
cerebral pulsation ; 8th, Loss of funic pulsation ; 9tb, Desqua-
mation of cuticle;  10th, Looseness of bones; 11th, Emphysema;
12th, Loss of stethoscopic signs.)   (If you anticipate that perfo-
ration will become necessary, watch the fcetal  heart closely.)
2nd. Antero-posterior diameter less than three  inches.  3rd.
Bis-ischiatic less than  three inches.  4th. Fibrous  and other
tumors.  5th. Hydrocephalus.   6th. Convulsions, rupture, and
hemorrhages.  1th.  Hand with head  in too narrow a pelvis.
8th. In breech cases.  9th. Head left in utero. 
MANUAL  OF OBSTETRICS.
233
  Period: 1st. If pelvis is very much distorted, operate as soon
as os is dilatable.  2nd.  If there is doubt of capacity, wait
awhile;  also in tumors,  &c, wait.  3rd. In  convulsions  and
such like emergencies, circumstances must regulate.
  Every  one  who employs the perforator, should  remember
that he  designs to kill a human  being ; whether that murder
be justifiable or otherwise, must  be answered by each  one's own
conscience.
  Mode of Operating.—Preliminaries: Os to be  dilatable ;
bladder  and rectum to be emptied.  Position as for forceps.
Dress to be arranged;  also cloths, &c, to receive brain.   In-
struments to be warmed.   Consultation.   Chloroform.  Intro-
duce two fingers,  and upon them the scissors ;  avoid a suture
or fontanelle ; rotate steadily, but with moderate pressure, until
the bone is perforated ; be sure  you are through the  caput suc-
cedaneum;  push  scissors up  the shoulder; make an assistant
separate them ; make another opening at right angles, and then
twist the scissors around so as to make a large hole ; push the
instrument  thoroughly through all the brain;  withdraw,  and
with the finger make sure of  the medulla oblongata;  wait ten
minutes for the brain to exude; pass in  the crotchet, and fix it
to  either the base or facial  bones; fold  the scalp over to  pro-
 tect ; guard the point of  the crotchet with the other hand, and
 pull 'with both, so that if a slip occurs both hands slip together;
 pull during a pain ; "remember the axis of the pelvis  ; take care
 of spicule.   Some prefer craniotomy forceps, which should be
 introduced one mandible into the skull, the other outside, and
 fully up to  the face.
   If great difficulty is  experienced, a delay of some hours will
 weaken the structures, allow  of moulding, and facilitate extrac-

    Dangers : The perforator may merely penetrate the infiltrated
 scalp, and slip on the skull.  The crotchet may slip,  and wound
 vagina.  The shock is great  from the condition of the patient;
 is diminished by chloroform.  Inflammation not  unfrequent
  subsequently.  The child has been born living. 
234
MANUAL  OF OBSTETRICS.
  After Treatment: A full dose of morphine; and, if threat-
ening symptoms arise, Narcotism.

  The Cephalotribe is a pair of long and very strong forceps,
which close much more  than the ordinary instrument.   The
blades, which are very  thick and  strong, are introduced  sepa-
rately, and then approximated by a screw, thus crushing the
head.

  Symphyseotomy, the Sigaultean  Operation.—Devised
by Sigault,in 1768 ; was highly lauded, but is now abandoned.
  Statistics :  49 cases, 16 mothers died.  An analysis of the
cases shows that 16 mothers were sacrificed to save 5 children.

  Cesarean Section, Gastro-hysterotomy.—An operation
to extract the fcetus from the uterus of the mother through the
abdominal parietes.
  Was known to the ancients as a means of saving the  child
after the death of the  mother.  Scipio Africanus,  Claudius
Caesar, Julius Caesar, are said to have been so born.
  First performed successfully on a living woman about 1500,
by a cattle-gelder on  his own wife.   In several cases it has
been repeated on the same patient.  Rousset mentions a  case
operated oh 6 times.
  Objects.—1st. To afford to mother a relief from destruction,
to the child a chance for life, when even the dead foetus cannot
pass per vias naturales ;  antero-post. diameter under 1^ inches
by 3 in transverse.
   2nd. To extract a child after sudden death of the mother;
eyen as late as an hour after death.
   3rd. To  extract foetus after  extra-uterine  pregnancy, or
ruptured uterus.  Is rather gastrotomy.
   Statistics.—Are not  reliable  from the suppression of un-
favorable cases, while successful are probably all reported.
   British and American practice  52 cases, 14 mothers saved,
4 lost.   In 49 cases, 28 children  saved—1 in 2£. 
MANUAL OF OBSTETRICS.
235
  Foreign:  382 cases, 223 mothers  saved—1 in 2£.  In 200
cases, 147 children saved—57 lost.
  Total  results:  434 cases,  237 mothers saved—197 lost.
249 cases, 175 children saved—74 lost.
  Period.—Early, if there be no doubt of- necessity.   The
duration of  labor over 72 hours is unfavorable to both mother
and child.   The greater the time after rupture of membranes,
the more hazard.
  Mode  of Operating.—Preliminaries.—Evacuate bowels
and   bladder;   ascertain  position   of  placenta;   apartment
heated  to 80°.   Chloroform.   Incision  from  6  to 10 inches
along linea  alba or by the side of rectus, or horizontal.above
pubes;  through integument and peritoneum; not so long in
the uterus; draw out liq. amnii  by syringe or sponge, then
enlarge the  incision;  remove child quickly, and membranes by
twisting, especially from near os, and  be sure that os is pervious
for the  lochia;  (uterine  contraction detaches the placenta);
uterine wound of 5 or 6  inches will  contract to 2 and requires
no suture ;  the abdominal parietes are to  be kept  close  to  the
intestines.
   Dressing  by twisted, or by quilled suture, and long  straps ;
water dressings; lower angle to be free.
   After Treatment.—Opium.
   Dangers.—Shock; hemorrhage;  strangulation of intestines;
 metritis and especially peritonitis.

   Vaginal Hysterotomy.—Incisions into the uterus  per
 vaginam.   Has been practised in cases where closure of the os
 has occurred after impregnation,  as the result of inflammation,
 either from disease, or as a sequel of attempts** abortion
   Incisions to  be made, so as to  avoid bladder  in front, and
 rectum posteriorly.

                        Chloroform.
Has been  objected  to as "immoral," as "indecent," 
236
MANUAL  OF OBSTETRICS.
" annulling only a physiological phenomenon," but more  espe-
cially as  being hazardous to life.   Of  these, the  last only
deserves consideration.   Its hazard in careless hands is freely
admitted; fatal results have followed, and doubtless will follow,
the use  of chloroform, even in midwifery, though  as yet  no
such event has occurred in its obstetrical  employment.   But
are there not concomitants and consequences of labor, as peri-
lous to life immediately, as  deleterious  to enjoyment of  life
subsequently,  often  seen in  labors distressing by severity  at
the time,  and  entailing sufferings, which  a lifetime does not
suffice  to  remove ?   The  nervous shock  attending  labor  is
frequently of  great  severity, its  effects  often very  persistent;
and from  this shock what  agent  yet discovered   offers  the
immunity  given  by anaesthetics?  In  all  cases  demanding
operations, the use  of chloroform  is  the  obstetrician's  most
valuable adjuvant, and  especially does  it disarm  version  in
severe  cases of its  terrors ; and to nothing does  irregular or
hour-glass contraction yield so ready an entrance.  Forceps and
embryotomy operations  are equally  facilitated.  The employ-
ment of anaesthetics in operative midwifery  meets with but
limited  opposition, but more objections are  urged  against their
use in  regular labor;  even  here, however, there  are many
cases where relief can be given, and should not be withheld.
   1st. Severely felt  but short  and ineffectual pains  which
restrain voluntary and bearing down efforts—here chloroform
acts as a* co-ordinator of forces, blunts  abnormal  sensibility,
renders contractions longer, steadier, and  more  efficacious, and
sometimes remarkably accelerates labor.
   2nd.  In muscular women of rigid fibre the dilating of  the
soft parts is often extremely painful.
   3rd.  Delicate and nervous women, worn out by not exces-
sively long labor, are relieved by the rest  obtained by chloro-
form.
   4th.  Of its  use in convulsions  (see  page 172).
   Not,  however, in all cases, ex. gr.:
   If  strong objections are offered, anaesthetics should not  be 
MANUAL OF OBSTETRICS.
231
forced, and even  if moderate aversion, exists it  should be
respected.
  Time of Giving.—Ordinarily not till 2nd stage; if pains are
very severe, this may be anticipated.
  Mode  of Giving.—A handkerchief or towel, sprinkled with
about half a drachm of chloroform, is to be held near, but not
upon the mouth, and the patient encouraged to take long and
deep inspirations; atmospheric air  is to  be admitted;  deep
snoring anaesthesia must not be reached, but a bare sufficiency
to mitigate suffering.   While  this is in progress the patient
may be quite sensible.   In the intermission of pains the  towel
is removed, and reapplied as the pain approaches.
   Cautions.—One hand is to watch the pulse constantly. ^
   Allow plenty of atmospheric air.  Temperature not to be high.
 At no time overwhelm the patient; do not commence with a
 full dose.
   Keep  inside of anaesthesia.
   Administration soon after a meal is  objectionable, or after
 a long fast.

         ORDINARY MANAGEMENT  OF CHILD.

   As soon as cord is divided (for time of which see Manage-
 ment  of third stage of labor, page 128), place one hand under
 head, and grasp the shoulder with the thumb; with  the other
 hand grasp the thigh furthest from the  operator, so as com-
 pletely and securely to hold the infant, and then  place  it ma
 blanket, or some flannel provided for the  purpose, and confide
 to the nurse.                                   .      , _ .
    Washing the CniLD.-Should be  in  warm water, and not
 in the lying-in chamber.   If much vernix caseosa is upon it,
 lard or sweet oil is to be freely smeared  over it and then with
 a flannel cloth and soap the child is cleansed thoroughly; the
 eyes  are to be washed with warm water without soap;  cleanli-
 ness  Tnot  so essential as to  risk the integrity of  the skin-
  nimia diligmtia nutricis. 
238
MANUAL OF OBSTETRICS.
  Dressing the Cord.—When  the child is fully dried, take
a piece of old linen about seven inches square, cut a hole in the
middle, through which pass  the  cord, and  envelope with  th^
linen;  then place upwards  along  the abdomen  and have  a
flannel roller applied loosely around to secure the cord.   Avoid
the filthy burnt rag usually suggested by the attendants.
  The cord usually falls  off  by the fifth day.   To facilitate its
removal apply a bread and water poultice over night.
  I have seen the cord still  attached on the fifteenth day.
  Child's Dress.—Essentials are, warmth, looseness, and with-
out  pins;  tapes  being  preferable.   Caps are  to  be avoided.
Long sleeves  ought to be  worn, but fashion is omnipotent
against health.  Dress should cover chest, and  be high on  the
neck.   The diapers or " squares " should be soft, and  of  old
preferable  to  new stuff;  excoriation sometimes ensues from
stiffness.
  Medicine.—A teaspoonful  of cold water :  the colostrum.
The practitioner's voice should always be  raised against  the
various compounds of butter and sugar, molasses, &c, that are
usually given.   If the bowels are not freely  opened by  the
second  day (provided  imperforate  anus is  not the cause),  a
small teaspoonful of castor oil is sufficient.
  Food.—None equal  to the. natural supply.  Always have
child nursed  within  two hours  after birth,  provided  great
exhaustion, as by hemorrhage, &c, has not occurred.   Assur-
ances of " no milk in the breasts," are frequently falsified by
the  child's swallowing immediately.   The best  substitute  is
one third of cow's milk and two thirds of water sweetened with
loaf sugar.
  Until teeth appear, milk should constitute the infant's  food.
   Child should  be taught early not to nurse at night.   Inter-
vals of two or three hours, according to the nutritive properties
of the milk, will suffice during the day.
   Experience soon teaches the injuriousness of " night-nursing."
   Sleep.—Not in a cradle.  Not  by mother if practicable.
But children of feeble  vitality require the heat .of mother's 
MANUAL OF  OBSTETRICS.              239
body.  It should always be borne in mind that the new-born
child has much less capacity to resist the influence of cold than
the adult.  An apartment comfortable to an adult is often far
too cool for child's comfort and well being.

   MORBID  STATES  OF  THE CHILD AFTER BIRTH.

   1st. In a state of ANEMIA, SYNCOPE, or ASPHYXIA.
  . Caused  by, too  early  detachment of placenta;  uterine
 hemorrhage;  defective nutrition.
   Symptoms.—Very feeble  if any respiratory efforts ; no pulsa-
 tion of cord ;  fcetal heart weak.
   Treatment.—Tie  and   divide cord;   warm   bath;  cold
 affusion; friction  with brandy and flannel; titillating nose and
 fauces with feather;  electricity ;  artificial  respiration.
   2nd. ASPHYXIA.—Caused by prolonged labor; abnormal
 presentation ; &c.
   Symptoms.—Weak pulsations of funis; color natural.
   Treatment.—Wait  before dividing cord;  frictions;  cold
 dash ; alternate warm and cold bath ;  inflation ; these failing,
 divide cord and bleed Jss.
    3rd.  APOPLEXY.—Caused by  prolonged labor; narrow
 pelvis ;  delay to  passage of shoulders.
    Symptoms.—Pulsation of cord feeble and oppressed; surface
 and face livid.
    Treatment.—Divide cord;  bleed  Sss.;  baths;  friction;
 inflation. 
 
INDEX.
	Page		Paoi
Abdomen, Enlarged,	10	Application of Binder,	129, 160
" Pendulous,	. 86, 133	Arbor Vitse,	28
" Subsidence of,	118	Arch of Pubes, .	16
Abortion,.	104	Areola, . . ,	69
" Hemorrhage with, 161		Argenti Nitras,	. 51, 58
Abscess Mammary, .	221	" Oxidum,	49
" Pelvic, .	214	Arm and Hand Presentation, 147	
Accidental Hemorrhage,	163	Arm Presentation, .	143
Accoucheur, Duties of,	124	Articulations of Pelvis,	14
Accumulation Fecal,	137, 205	Ascites,	71
Acephalocysts,	162	" of Child,	138
Acetate of Lead,	49	Asphyxia of Child,. .	239
Adherent Placenta, .	11B	Attentions before leaving, 196	
After-birth,	90	Auscultation, .	141
" Delivery of,	128	Auscultatory Signs, .	72
After-pains,	193, 205	Axis of Pelvis, .	17
After-treatment of Hem.,	179		
Agrypnia,	84	Bag of Waters,	121
Albuminuria, . .	. 82, 152	Ballotement,	74
Allantois, .	89	Bandage, .	129, 160
Aloes,	. 44, 45	Bands in Vagina,	135
Alum Injections,	. 49, 56	Barrows, Dr.,	105
" Plug, . . 60,	159, 167	Basin (see Pelvis), .	9
Amenorrhea, .	35	Baudelocque, .	227
" Varieties,	36	Belly Pendulous,	86
Ammonia, Carbonate of,	50	Binder, application of,	129, 160
Ammoniated Tine, of Guaiac.,41,45		Bladder, .	66
Amnii Liquor, .	89	" Distended, .	133
Amnion, .	89	" Irritability of,	68
Anatomy, Obstetrical,	9	" Protrusion of,	136
" of Uterus,	27	" Rupture of, .	201
Anemia, .	40	Blisters, .	. 50, 56
Anhistous Membrane,	. 60, 64	Blunt Hook,	232
Anteflexion, .	86	Boivin,	119
Anteversion,	86	Botal, Foramen of, .	100
Aorta, Compression of,	160	Breasts, Changes in,	69
Apoplectic Convulsions, Apoplexy of Child, . Apoplexy Placentary,	154	Bregma, .	99
	239	Brightii Morbus,	151
	164	Broad Ligaments,	29
 
242
INDEX.
Burns,
Page
 174
Caduca,  .    .     .    .  60, 64
Caesarian Operation,.     .     234
Calculus in Labor,  .     .     136
Camphor Mixture,  .     .      50
Cannabis Indica,    .     .      49
Cantharides,  .     .    45, 50, 56
Caput Succedaneum,     .     122
Cardialgia,    .         .      17
Carunculse Myrtiformes,  .      26
Cams, Curve of,    .    .      17
Catamenia,    .    .     .      31
Catheter, .    .    j  25, 86, 126
Cellulitis, Pelvic,   .    .     213
Cephalalgia,   ...      80
Cephalotomy, .    .     .     231
Cephalotribe, ...     284
Cervix Uteri, ...      27
Cessation of Menses,     .      68
Changes by Impregnation,      62
    "    in Bladder,     .      66
    "    Ligaments,     .      66
    '*    Mammae,   .    .      69
    "    Ovum,    .    .      87
    "    Tubes,    .    .      66
    ••    Umbilicus,     .   66, 71
    "    Urethra,   .    .      66
    "    Uterus,    .    .     64
    "    Vagina,   .    .     66
 Change of Life,     .    .     34
 Characteristics of Full Develop-
     ment,     .    .    .     97
 Characteristics of Immaturity, 97
 Child, Apoplexy oTJ     ;     239
   "   Ascites of,       .     138
   "   Asphyxia,    .   .     239
   "   Attentions to,     .     237
   "   Circulation,  .   .     100
 {  "   Dress,  ...     238
   *«   Food,    .•   .    .     238
   "   Medicine for, .    .     238
   "   Position of,  .    .     113
   ««   "Washing of,  .    .     237
 Child-bed Fever,   .    .     203
 Chill,    .    .    .    123, 204
 Chin,    .  '  .    .    .     138
 Chloroform,  41, 63, 83,  86,
    131, 132,134, 146, 154,  173, 235
 Chloroform,  Use qf,      .     235
 Chlorosis,      ...      38
Chorion,  .
Circulation of Fcetus,
Classification of Labors,
Cleansings,
Cleavage of Yelk,
Clitoris,  .
Coccyx,  .
Cold,
  "  Feet,
Colostrum,
Concealed Hemorrhage,
Conception,
Congestion of Os Uteri,
Constipation,  .
Contraction, Hour-glass,
     "       Irregular,
Convulsions, Apoplectic,
            Epileptiform,
   Page
     88
    100
    116
    194
     61
     25
     11
 49, 115
     41
196, 288
    176
     58
     66
     79
    172
132, 172
    154
    149
    "      Hysterica],   151, 154
    "      Puerperal,   .    147
    "      Pathology of,    152
    "      Treatment,  .    153
Copland, Treatment of Puerpe
    ral Fever, .
Cord,
  "  Dressing of,
  "  Prolapsus of,
  "  Short,   .
  "  Tying of,
Corpus Luteum,
Corpus Menstruale,
Cough,
Courses,  .
Cramps,  .
Cream of Tartar,
Critical Age,
Cross-birth,
Crosse,
Crotchet, .
Crural Phlebitis,
Curve of Carus,
Cystocele,
      210
       91
  129, 238
      181
      138
      128
       62
       62
       83
       31
23, 85, 122
       48
       34
  141, 144
      191
      231
      215
       17
      136
Death of Fcetus,     .    .    101
Death, Sudden,     .    .    192
Decidua,      .     .    .  60,64
Deficient Contraction,   .    130
Deformity of Pelvis,    .     20
              "   with Labor, 135
Delayed Labor,     .    .    130
Delirium Tremens,  .    .    219 
INDEX.
243
Denman,
Delivery of Placenta,
Depaul,  .
Desormfeaux,  .
Detaching Placenta,.
Detachment of Placenta,
Dewees,  .     45, 46, 76, 84,  168
Diameters of Fcetal Head,      98
  Page
52, 146
   128
    72
    76
   168
   123
         of Pelvis,
Diaphragm,
Diarrhoea,
Diet in Labor, .
     after Labor,
15, 16, 98
       66
  80, 118
      126
      197
Differences of Male and Female
    Pelvis,
Difficult Menstruation,
    "   Labor,
Dimensions of  Embryo,
      "       Fcetus,
Discharge,
Diseases of Pregnancy,
Disorders of Menstruation,
Distended Bladder,
Douglas, .
Dressing of Child,
           Cord,
Dress in Labor,
  "  of Child, .
Dropsy of Amnion,
Dubois,
Ductus Arteriosus,
Duration of Pregnancy,
     "     Labor,  .
Duties of Accoucheur,
Dysmenorrhea,
Dyspnoea,
Dystocia, .
Dysuria,  .
Eclampsia,
Ecchymosis,
Effects of Loss of Blood,
Electricity,
Emansio Mensium,  .
Embryo, .
   " "  Dimensions of,
Embryotomy,  .
Embryulcia,   .  .   •
            18
            51
           130
            95
            98
           194
            76
            35
           133
           146
           238
       129, 238
           238
           238
        133, 90
            78
           100
            76
           124
           124
in 1st stage, 124
  2nd stage, 127
  3rd stage, 128
  35, 51, 69, 109
            83
           130
            84

           147
           200
           181
            44
            36
            92
            95
           231
           231
                           Page
Emerson,      ...     99
Emmenagogues,    .    .     43
      "       Constitutional,  44
      "       Local,     .     44
Enemata, Cold,    .     .     60
     "■   Stimulating,    . •  131
Enlargement of Abdomen,     70
       "      Mammae,  .     69
Enuresis, ....     84
Epilepsy, ....    148
Ergot,    .    .   45, 56, 131, 157
  "  Pains,   .    .     .132
Evisceration,  .    .     .    231
Evolution, Spontaneous,  .    146
Examination, Vaginal,    .    125
Excessive Show,    .     .    164
Exostosis, .'   .     .     .    136
Expulsion of Placenta,    .    123
     "      Spontaneous,    146
External Organs,   .     .     24
Extension,     .    .     .    114
Extra-uterine Pregnancy,.    103

Face Presentations,  .     .    138
Facial Paralysis,    .     .    230
Fainting, .    .     .     155, 192
Falling of "Womb,   .     . 57, 201
Fallopian Tubes,    .    30, 58, 66
False Pains,   .     .     .    120
False Waters,  ...     88
Fat,  .    .    . ;   .     .     71
Fecal Accumulation,      .    137
Fecundation,  ...     58
Feet, Presentation of,     .    140
Ferrum,  .     .    .     .  40, 45
Fever, Milk,   .     .     .    196
  "   Puerperal,    .     .    203
Fibrous Tumors,    .     .     71
First Stage of Labor,     .    120
                  Duties of, 124
Fistulas,  .    .     .     .    199
Flatus,   .    .     . 71, 138, 194
Fleshy Mole,  .    .     .    163
Flexion in Labor,   .     .    114
Flooding (see Hemorrhage),   154
Fcetal Circulation,  .     .    100
   "  Dimensions,  .     .     98
   "   Head,  .    .     .     98
   "  Heart,  ...     ,     72
   "  Lungs,  .    .     .    101
   "  Motion, ,    .     .     72 
244
INDEX.
	Page
Fcetal Nutrition,	99
" Pathology,	101
Fcetus,	92
" Death of,	101, 232
Fontanelles,	99
Footling Presentation,	140
Foramen of Botal, .	100
" Ovale,	13, 100
" Obturator, .	13
" Thyroid eum,	13
Forceps, .	226
" Craniotomy,	231
" Necessity of,	228
" Special Rules for	230
" Use of,	230
Fossa Navicularis, .	26
Fourchette,	26
Funic Souffle, .	73
Funis,	91
" Ligature of,	128
" Short,	138
Galvanism,    .     .     160, 225
Gastrotomy,   .     .    .     86
Gastro-hysterotomy,    .    234
Gelatine of Warthon,      128, 91
General Health,  Influence of
    Pregnancy,     .    .     67
Generation,    ...     58
     "    Organs of,     .     23
Germinal  Vesicle,   .    .     69
Gestation, Duration of,   .     76
     "    on Disease,    .     86
Gird wood,    .     .     .     76
Gonorrhoea,   .     .    .     55
Gooch.....177
Graafian Vesicle,    .    .  59, 61
Green Sickness,     .     .     38
Griping,   .    .     .    .    118
Guaiac, Tine, of,    .    .  41, 45

Habit of Aborting,  .     .    107
Hand Presentation, .     .    147
  "   and Foot Presentation,  147
Haunch Bone, .     .     .     11
Head, Fcetal Dimensions of,    98
Head Presentations, .     .    113
  "   and  Hand Presentations, 147
Headache,    ...     80
Heartburn,    .     .     .     78
Heart, Fcetal,  ...     72
                           Page
Heart, Clot,   .    .    .    192
Hemicrania,   .    .    .     81
Hemorrhage in General, .    154
    "   Accidental,     .    163
    "   After Birth of Child, 169
    "      "   Delivery of Pla-
                centa,  .    176
    "   After-Treatment of,  179
    "   As Excessive Show,  164
    "   Concealed,     .    176
    "   Forms of, .    .    160
    "   From Cord,     .    128
    "  x Means of Suppressing, 155
    "   Remote Effects of,    181
    "   Secondary,     .    178
    "   Symptoms of,   .    163
    "   Table of Treatment,  180
    "   Unavoidable,   .     165
    "   with Abortion,
                   108, 111, 161
    "    "  Adherent Placen-
              ta, .    .    173
    "    " Encysted Placen-
              ta, .    .    172
    "    "  Firmly Contracted
              Uterus,  .    177
    "    "  Hour-glass   Con-
              traction, .    172
    "    «  Irregular Contrac-
              tion,     .    172
    "    "  Hydatids,  .    161
    "    "  Placeutary Apo-
              plexy,   .    164
    "    "  Placenta Praevia, 165
    "    "  Polypus,   .    177
    "    "  Retained Placen-
              ta, .    .    170
Hemorrhoids,  .    .    .81, 202
Hernia.....137
Hip Bone,     .     .    .     11
Hour-glass  Contraction,  .    172
Hydatids, .    .     .    . 71, 161
Hydrorrhea,   ...     88
Hydrocephalus,    .    .     137
Hydrothorax of Child,   .    138
Hymen.....25, 135
Hysterical Convulsions,  .    151
Hysterotomy,  .    .    .    234
            Vaginal,   .    235
Icterus,
84 
INDEX.
245
                          Page
Ilium,    ....      11
Impregnation, .         .       3
Incontinence of Urine,   . 84,  126
Indian Hemp,  .    .    .     132
Induction of Premature Labor,  224
Inertia of Uterus,  .     130,171
Inflammatory Form of Puerpe-
    ral Fever, .    .    .     204
Inflammation of Sub-peritoneal
    Tissue,    .    .    .     213
Inflammation of Vagina,	199
Influence of Gestation 01	1 Dis-
ease, .	86
Influence of Gestation on	Gene-
ral Health,	67
Injections.	. 44, 49
Innominatum, .	11
Introducing Hand, .	60
Insanity, Puerperal, .	218
Insomnia,	84
Instruments, Obstetrical,	226
Internal Organs,	26
Introducing Catheter,	25
Inversion of Uterus,	188
Irregular Contractions,	132, 172
" Labor,	140
Iron, Preparations of,	. 40, 45
Ischia, Planes of,	13
Ischium, .	12
Jacquemin,	70
Jaundice, .	84
Kiestine, .	. 68, 70
Kluge's Mode of Dilating	Os, 134
Knee Presentation, .	140
Labia Majora, .	24
" Minora, .	24
Labor,	112
" Causes of,	112
" Classification of,	116
" Complex,	118, 147
" Difficult,	118, 130
" " from Disproportion, 135	
" Duration of, .	124
" Easy,	11«
" Irregular,	118, 140
" Management of,	124
" Mechanism of,	113
•« Natural,	118
	Page
Labor Pains, . . . 119	
it	Premature Operations
	for, . . . 224
(<	Regular, . . 118
d	Stages of, . . 117
<i	Symptoms of, . 118
(i	with Arm Presentation, 143
"	" Ascites, . . 138
"	" Calculus, . 136
11	" Cicatrices, . 135
11	" Convulsions, . 147
11	" Deficient Contrac-
	tion, . . 130
11	" Diseased Ovary, 136
"	I1 Excess of Liq. Am-
	nii, . . 133
11	" Fecal Accumula-
	tion, . . 137
11	" Hydrocephalus, " 137
"	" Inertia, . . 130
11	" Inversion of Uterus,188
11	" Irregular Contrac-
	tion, . . 132
11	" Pelvic Extremity, 140
11	" Premature Rupture
	of Membranes, 132
11	" Presentation of Cen-
	tres, . . 147
11	" Prolapsus of Cord, 181
11	" Rupture of Uterus, 185
11	" Rigidity of Perine-
	um, . . 135
11	" Rigidity of Os, 133
11	" Short Cord, . 138
"	" Shoulder Presenta-
	tion, . . 143
"	" Thick Hymen, 135
11	" Tough Membranes, 133
11	" Tumors, . 136
"	" Two or more parts, 147
"	" Twins, . .183
"	" Tympanites, . 138
11	" Vaginal Hernia, 137
Laceration of Vagina, . 200	
	" Perineum, . 198
Lachapelle, ... . 106	
Lead	, Acetate of, . . 49
11	and Opium, . . 49
Lee,	.....76,106
Leg, Paralysis of, . . 200	
Leucorrhoea, . . .54, 56	
 
246                      INDEX.
	Page		Page
Lever,	106, 148	Menstruation, Duration ol	83
Lever, or Vectis,	226	" Excessive,	46
Levret,	165	" Its Influence on Dis-	
Ligaments, Broad, .	29	ease, .	34
" of Ovary,	31	" Nature of,	33
" Round, .	. 30, 66	" Obstructed,	35
" Sacro-Sciatic,	14	" Painful,	35, 51
Linea Alba,	66	" Return of,	33
Linese Albicantes,	66	" Retained,	36,71
Liquor Amnii, . 89,	159, 133	" Suppressed, .	"35, 41
Lochia,	194	" Symptoms of,	32
" Suppressed, .	195	" Synonyms of,	31
Locked Head, .	228	" Vicarious,	35, 46
Longings, .	67	Mental Excitement, .	133
Lugol's Solution,	56	Merriman,	76, 152
		Metrorrhagia, .	46
Mackintosh,	. 51, 54	Milk, . . .69,	195, 197
Madder, .	45	" Fever,	196
Making the bed,	125	" Leg, . .	215
Malacosteon,	21	Miscarriage,	77, 105
Malformation, .	. 20, 36	Micturition,	C8, 118
Male and Female Births,	99	Mist. Camph., .	50
" " Pelvis,	18	Moles, Fleshy, .	163
Mammary Abscess, .	221	Mole, Vesicular,	161
" Changes,	69	Mollities Ossium,	21
Management of Child,	237	Mons Veneris, .	24
" Puerperal State, 194		Monthlies,	31
Mania Puerperal,	218	Monthly Discharge, .	31
Manual Dilatation, .	134	Montgomery, .	76, 177
Matico,	49	Morbid States of Child,	239
Mauriceau,	106, 165	Morbus Brightii,	151
Meatus Urinarius, . .	25	Morgagni,	62
Mechanism of Labor,	113	Motion, Fcetal, .	72
" - Breech Presentation, 140		Murmur Placental, .	72
" Face "	138	Murphy, .	76
Shoulder "	143	Muscles, .	23
Meconium,	. 97, 141	Myrtiformes Carunculse,	26
Megrim, .	81		
Meigs, . . .76,	106, 142	Nabothi Ovula,	28
Melancholia,	219	Naegele, .	73
Membranes, Rupture of,	132, 159	Napkin, .	129
Menopause,	34	Nauche, .	70
Menorrhagia, .	46	Nausea, .	68, 77
Menses',	31	Navel, Changes in, .	71
" Suppression of,	41	" String, .	91
Menstruation, .	31	Nervous Shudder,	123
" and Acute Disease, 34		Nipple,	69
" Cause of,	33	" Sore,	202
" Cessation of,	. 34, 68	" Retracted,	203
" Difficult,	51	Nitras Argenti,	68, 51
" Disorders of,	36	Nitre,	. 45, 49
 
INDEX.
247
Nutrition, Foetal,
Nymphse, .
Obliquities of Uterus,
Obstetrics,
Obstetrical Anatomy,
     "     Auscultation,
     "     Operations,
     "     Instruments,
Obstructed Menstruation,
Obturator Foramen,
Occlusion of Os,
     "     Vaginae,
Odontalgia,
CEdema,  .     .
Operative Midwifery,
Operation for Premature
     bor,  .
Opium,
Organs of Generation
Osiander, .
Os Contracted,
 "  Occluded,   .
 "  States of,    .
 "  Coccygis,
 "  Ilium, .
 "  Innominatum,
 "  Ischium,
 "  Pubis, .
 "  Rigidity of, .
 "  Tineas, .
Osteo-malacia, .
Ovaries,  .
Ovarian Disease,
Ovaritis, .
Ovary, Enlarged,
Ovi-ponte,
Ovi-position,
Ovisac,
Ovula Nabothi,
Ovule,
Ovum,
Oxytoccic,

Pains of Labor,
    "   Double,
    "   False,   .
    •i   Irregular,
    "   in Coccyx,
Painless Contraction,
Palpitation,
Paralysis of Legs,
Page
  99
  24
 133
      72
     226
     226
      35
      13
      36
      36
      82
      82
     224
  La-
     224
 131, 154
      23
      70
      54
      36
     126
      11
      11
      11
      12
      13
     133
      27
      21
      30
      71
      51
     136
      31
      31
      59
      28
      59
61, 87, 92
     132

      119
     123
     120
     132
      194
      119
      83
     200
Paralysis, Facial,
Parturition,
Pathology of Fcetus, .
       "    Convulsions
Pelvic Abscess,.
   "  ■ Cellulitis,
Pelvis,
   "   Axes of,   .
   "   Articulations of,
   "   Brim of, .
   "   Cavity,  .
   "   Cordiform,
   "   Deformity of, .
   "   Direction of,  .
   "   Difference  of  Male
        Female,
   "   Diameters of,  .
   "   Dimensions of, .    15
   "   Divisions of,
   "   Greater or False,
   "   Less or True,  .
   "   Muscles of,
   "   Nerves of,
   "   Outlet,   .
   "   Recent,   .
   "   Straits of,
   '   Uses of,  .
   "   Vessels of,
 Pelvimetry,
 Pendulous Belly,
 Perineum,
     "    Laceration of,
     "    Rigidity of,
 Periods,  .
 Pervigilium,
 Peritoneum,
 Peritoneal Fever,
 Peritonitis, Puerperal,
 Phlebitis Crural,
 Phlegmasia Dolens,
 Phthisis, .
 Pickled Towels,
 Piles,
 Placenta, .
     "  Adherent,
     "   Delivery of,
     "   Detachment of,
     "   Expulsion of,
     "   Prsevia,
     "   Retained,  .
     "   Structure of, 
248
INDEX.
                           Page
                             72
                             72
                            165
                            164
                             81
                     50, 159, 167
     Alum,    .    .    .  59, 159
Plurality, Labor with,   .    183
Polypus, .    .     .  #  .    136
   "   Hemorrhage with,    177
Positions,     .    .     113, 117
                             97
                            125
                             73
                             76
                             76
                            103
                             67
Placental Bruit,
    "    Murmur,
    "    Presentation,
Placentary Apoplexy,
Plethora,
Plug,
Position of Child in Utero,
          Obstetric,
    "     Os and Cervix,.
Pregnancy, Diseases of,
    "     Duration of,
    "     Extra Uterine,
    "     Effects  of,
    "     Menstruation during,l 60
    "     Regimen of,  .     87
          Signs of,  .    .     67
    "        «    Table,      75
Premature Delivery,     .     105
    "      Labor,   .    .     224
Premonitory Signs of Labor,   118
Presentations,  .    .    .     116
Presentation of Arm,    .     143
       "        Breech,  .     140
       "        Centres,   .     147
       "        Diagnosis,      117
Presentations of Face,    .     138
       "        Feet,    .     140
               Hand,    .     142
               Hand and Foot, 147
                             113
                             140
                             147
                             165
              Head,
      "       Knees,
      "       Two Parts,
      "       Placenta, .
Pressure on Aorta,  .    .    176
Prolapsus Uteri,     .    .    201
         of Cord,  .    .    181
Ptyalism,      .     .    •     85
Pruritus, ....     84
Pubes, Arch of,     .          16
Pubis, Os,     ...     13
  "   Symphysis,   .     .     14
Puerperal Convulsions,   .    147
     «     "    Pathology of, 152
     "     Fever,        .    203
     "     Peritonitis,    .    204
     "     Insanity,      .    218
                           Paok
Puerperal Mania,    .    .    218
    "     State Management
             of,    .    .    194
Pulsation of Vaginal Arteries,  70
     "     Fcetal Heart,.    100
Pulse, Influence of Labor on,  122
Quevenne's Iron,
Quickening,
40,46
   71
Rachitis, ....     21
Radford, .     .     160, 165, 168
Ramsbotham,  .     .    .    160
Recto-Vaginal Fistula?,   .    199
Rectum,  .     .     .   '.     66
Regimen of Pregnancy,  .     87
Regular, .     .     .    .     31
Reid.....76
Relaxation of Symphysis,.    119
Remote Effects of Flooding,   181
Reproduction, ...     58
Restitution,    .     .    .    115
Retained Placenta,  .    .    170
Retention of Urine, .    .  25, 85
Retroversion  of Uterus,  .     85
Rheumatism of Uterus,   .    120
Rickets,  ....     21
Rigby,   .     .    .76, 165, 166
Rigidity of Soft Parts,    .    135
          Os,      .     .    133
     "    Vagina, .     .    135
Roberton,     ...    121
Rotation, .     .     .     .    114
Round Ligaments,  .     .     30
Rules for Ergot,     .     .    131
Rupture of Bladder,     .    201
      "    Uterus,      .    185
           Vagina, .     .    200
Rupturing Membrane    133, 159

Sabatier,      ...    100
Sacro-Sciatic Ligaments, .      14
Sacrum, ....       9
Salivation,     ...      67
Savine,  .    .      45, 49, 50,  56
Secale Cornutum (see Ergot).
Secondary Hemorrhage,  .    178
Second Stage of Labor,   .    122
     «        "    Duties of, 127
Secretions and Excretions,    195
Secretion of Milk,   .    .    195 
INDEX.                          249
                           Page
Semen,   ....     58
Sharebone     .     .     .     13
Short Cord,    .     .     .     138
Shoulder Presentation,   .     143
Show.....31
   "  Excessive,     .     .     164
Shudder, Nervous,  .     .     123
Sickness, Morning,  .     .     68
Signs by Touch,    .     .     73
   "  of Fcetal Death,     102,132
Sigaultean Operation,    .     234
Signs of Pregnancy,      .     67
         "    by Auscultation, 72
Silver, Nitrate of,   .     .  51, 58
   "   Oxide of,    .   .  .     49
Skin.....66, 68
Simpson, .     .     160, 168, 226
Sitting Up,    .    .     •     197
Skin of Abdomen,
Sleep of Child,
   "   after Hemorrhage,
Sleeplessness,  .
Small Intestines,
Smegma, .
Smell ie's Scissors,
Smith, Tyler, 107,122
Sore Nipples,
Souffle, Funic,
Speculum,
Spermatozoa,
Spanemia,
Spine of Ischium,
Sponge Tent,  .
Spontaneous Evolution,
       "     Expulsion,
Stages of Labor,
States of Uterus after Delivery, 178
     "   Secretions and  Excre-
             tions,
 Straits of Pelvis,
 Stomach,
 Stroma,  .
 Strychnine,
 Subsidence of Abdomen, .
 Sudden Death,
 Supporting Perineum,
 Suppression of Menses,
 Sutures,  .
 Symphysis Pubis,
      "   Relaxation of, .
      "    Sacro-coccygeal,
          66
         238
         179
          84
          66
          97
         231
l,123,>124, 149
         202
          73
          57
          58
      40, 148
       12, 21
         225
         146
         146
         117
  195
15, 19
66, 67
   31
   45
  118
  194
  127
   41
   99
   14
  119
   14
                           Page
Symphysis, Sacro-iliac,     14, 10
Symptoms of Labor,     .     118
Syncope,      .     .    155, 194
Syncope of Child,   .    .     239

Table of Signs of Pregnancy,   75
    "   Treatment of Hem.,  180
Tampon,      .     .  50, 159, 167
Tannin,  ....      49
Tansy,    ....      45
Tenesmus,     .     .    .     118
Things for Child,    .    .     125
Third Stage of Labor,   .     123
   "       "   Duties of, .     128
Thrombus,    .    .    178, 200
Toothache,    ...     82
Touch, Signs by,    .    '.      73
Toxemia,      ...     148
Transfusion,   .     .     160, 164
Trunk, Presentation of,  .    147
Tubes, Fallopian,   .    .*    30
Tumors,  .    .     .    .    13G
Tunica Media, ...      88
Turn of Life,  ...      34
Turning,      .     . 145, 225, 167
Twin Pregnancy,   .   .     74
Twins, Labor with, .    .    183
Tying Cord,   ...    128
Tympanites,  .    .    .    138
Typhoid form of Puer. Fever, 208

Ulceration of Os Uteri,  .     56
Umbilical Cord,    .   .     91
           "  Falling off of,  238
              Tying, 127,  128,129
Umbilical Vesicle,  .   .     88
          Vessels,  .   .    100
Umbilicus,    .    .    .   66, 71
Unavoidable Hemorrhage,     165
 Urachus, ....      95
 Urethra,  .    .    .   .   25, 62
 Urine,    ....      97
   "  in Pregnancy,     .      70
   "  Incontinence of,   .     84
   "  Retention of, .   25, 71, 85
 Uses of Pelvis, .     .    .     19
 Uterine Contraction,     .    119
     "       "       Painless,  119*
     "  Hemorrhage (see Hem.)
     "  Hydatids,   .    .    161
 Uterus, Anatomy of,    .     27 
250                          INDEX.
		Page			Page
Uterus, Anteflexion,		86	Vectis, . . .		226
"	Anterior Obliquity, Qc		Veneris Mons, .		24
. 11	Anteversion, .	.	Vernix Caseosa,		97
11	After Delivery,	178, 194	Vesico-Vaginal Fistula?,		199
"	Congestion of,	56	Version, . 145,		225, 167
"	Changes in, .	64	Vertigo, .		83
"	Hour-glass Contraction, 132		Vesicula Alba,		88
"	Inertia of,	130, 171	Vesicular Mole,		161
"	Inversion of,	188	Vesicle Graafian,		59
"	Ligaments of,	29, 30	Vessels,		22
11	Mouth of,	27	Vestibulum,		25
"	Neck of,	27	Vicarious Menstruation,		46
u	Obliquity,	133	Vitelline Membrane,		69
"	Prolapsus of,	201	Vomiting in Labor, .		122
11	Retroflexion,	85	" of Pregnancy,		. 68, 77
"	Retroversion,	85	Von Baer,		60
11	Rheumatism,	120			
"	Rupture of,	185	Wagner, . . (		61
u	Structure,	28	Warthon,	,	. 128, 91
11	■Ulceration of,	56	Waters, . " Bag of,	•	89 121
Vagina, ....		26	" False,	.	. ' 88
ii	Bands in,	135	Water-brash,	, ,	78
u	Changes in, .	66, 70	Whitehead,	.	106, 160
u	Inflammation of,	199	Whites, .	.	64
"	Laceration of,	200	Winslow,		101
Vaginal Cystocele, .		136	Woman in Labor, Attentions		
ii	Examination,	125	to, .		124
u	Hernia,	137	Womb (see Uterus",		27
u	Hysterotomy,	235	Falling of, .		57
Vallet's Mass, .		40	" Ulcerat	ion of,	56
 
8. S. $  W.  Wood's Medical Catalogue            6
   THE   YOUNG   STETHOSCOPIST,
     OR, THE STUDENT'S AID  TO  AUSCULTATION.
                BY  HENRY I. BOWDITCH, M.D.
                          1 Vol.  12mo.
  M This is an exceedingly clever little work—clear, concise, and to the  ft
purpose.  We know of no work on the subject better adapted to the wants
of the student who is just beginning the study of Auscultation."—Medical
Examiner.
  " We are fully convinced that this work is well adapted to the wants of
students, and that it supplies an obvious deficiency in  the medical literature
of our country.  Plain and simple in its arrangement, accurate in detailp,
and sufficiently extensive for elementary purposes, it should become the
companion of every student of auseultation."—Western  Lancet.
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may, as such, be strongly recommended to the student."—Amer. Jour, of
Medical Sciences.
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Biimrnary of the  essentials of Auscultation, by an accomplished Stethosco-
pist."—-Annalist.
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Missouri Med. and Surg. Jour.
  " We are glad to see a second edition of this little  work, and we trust
that every  young student of Auscultation will furnish himself with a copy."
— Western Jour, of Med. and Surg.


THE   OBSTETRICAL REMEMBRANCER;
                               OR,

         DENMAN'S   APHORISMS
ON  NATURAL  AND  DIFFICULT PARTURITION;  THE APPLI-
           CATION  AND USE OF INSTRUMENTS, &c.
                          AUGMENTED BY
             MICHAEL  RYAN,   M.D.
                        WITH ADDITIONS  BY
             THOMAS  F.   COCK,  M.D.,
       VISITIKO PHYSICIAN OF THE NEW YORK LYDSG-IN ASYLUM.
                    24 Engravings. 1 Vol.  32mo.

   " A concise collection of the most important facts in relation to obstetrics,
and rules for the direction of the practitioner, is here  presented to the pro-
fession."—Northwestern Med. and Surg. Jour.
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ful to the student."—Charleston Medical Journal.
   " If  every young practitioner were to carry this little volume about him aa
a pocktt-book, for which its size so well adapts it, and read it during his houra
of attendance on tedious cases of labor, we should 3ee and hear less of mal-
practice than some of us, alas ! are compelled to witness."—Med. Examiner. 
6            S. S. b W.  Wood's Medkal Catalogue.


       OPHTHALMIC   MEMORANDA
                       RESPECTING  THOSE

       DISEASES  OF   THE   EYE,
   WHICH ARE MOKE FREQUENTLY MET WITH IN PRACTICE.
                   BY  JOHN  F O O T E,
   FELLOW OF THE ROYAL COLLEGE  OF  SURGEONS IN LONDON, AC. AC.
                         1 Vol.  32mo.

  "' A delectable,  pithie. and righte  profitable worke'—a genuine rnultum
in parvo—containing a brief account of nearly every ophthalmic disease, and
the most approved  treatment, without theory, or speculation, or doubtful
practice."—Buffalo Medical Jour.
  "A  very useful little manual on Ophthalmic Diseases, drawn from the
highest sources and the best authorities, in the personal experience  of the
author, altogether forming a very convenient book of reference to the student
and practitioner of medicine."—New  York Jour, of Med.

                 MEMORANDA

 ON  ANATOMY,  SURGERY,  AND  PHYSIOLOGY;
FORMING  A  POCKET COMPANION  FOR THE  YOUNG SURGEON,
      OR FOR STUDENTS PREPARING FOR EXAMINATIONS.
             BY MARK NOBLE  BOWER, Surgeon.
                    CORRECTED AND ENLARGED
           BY  WILLIAM DARLING,  M.D.,
     Demonstrator of Anatomy in the University of New Nork, dfC
                         1 Vol.   12mo.
  l; This is a concise summary of the subjects indicated in the  title-page,
and, as far as we have looked into it, a very correct one.  From  its brevity
it is well adapted to refresh the memory."—Medical Examiner.
  " It  may be relied upon for its accuracy and adaptation  to the  real want?
of a medical student.' —Boston Med. and Surg. Jour.

               TRACTS  ON  GENERATION.
                     PROOFS
                           THAT THE

  PERIODIC MATURATION AND  DISCHARGE OF OVA,

    ARE, IN THE  MAMMALIA AND THE HUMAN FEMALE, INDEPENDENT
       OF  COITION AS A FIRST CONDITION  OF THEIR PROPAGATION.
                  BY T. L G. BISCHOFF, DM.,
              PROFESSOR OF PHYSIOLOGY, ETC., GIICSSEN.

       Translated  from  the  German   by
                     G. R. GILMAN,  M.D..
MlOFK3SOa OF OBSTETRICS, ETC., COLLEGE OF PHYSICIANS AND SURGEONS, NEW YOftK.
             AND THEODORE TELLKAMPF, M.D.,
               OEBHARD PROFESSOR, COLUMBIA COLLEGE.

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