/ THE PHILADELPHIA SYSTEM OF OBSTETRICS, IN TWELVE PARTS. FULLY ILLUSTRATED DESIGNED FOR A TEXT-BOOK FOR STUDENTS, AND AS REFERENCE FOR THE PRACTITIONER. By JOS. S. LONGSHORE, M. D. PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE PHILADELPHIA UNIVERSITY OF MEDICINE AND SURGERY, AND LATE PROFESSOR OF OBSTETRICS, ETC., IN THE PENN MEDICAL UNIVERSITY OF PHILADEL- PHIA, AND FEMALE MEDICAL COLLEOE OF PENNSYLVANIA, FELLOW OF THE MEDICO-CHIRUROICAL COLLEGE OF PHILADELPHIA, MEMBER OF THE NATIONAL MEDICAL ASSOCIATION OF THE UNITED STATES OF AMERICA. AUTHOR OF THE PRINCIPLES OF NURSING, ETC., ETC., ETC. r.r-V. -'CI/ ^M*a PHILADELPHIA: UNIVERSITY PUBLICATION SOCIETY. 1868. yvq L81 18 bt L8 5Jp Fu>> ->a> . totf&f 4 Lrcx* £ Entered, according to Act of Congress, in the year 1868, by W. PAINE, M. D., In the Clerk's OflSce of the District Court, for the Eastern District of Pennsylvania. JAS. B. RODGERS, ELECTROTYPES AHD PRIKTJIH, 52 ft 54 North Sixth Street, Fhilada. PEEPACE. In offering to the profession and medical students of the United States a new work on obstetrics, we are not unmindful of the number of excellent books already extant upon the subject. It is not that we are vain enough to suppose that the result of our labors will surpass these in excellence, or receive a higher apprecia- tion. Our object has not been to excel the productions of our learned predecessors and contemporaries, either in scientific merit or dejoth of research, but to present in a plain, familiar manner what we have learned from others, the result of our own experience, and what conclusions we have arrived at from long and mature reflections. What we have gathered from our researches, that appears sound in philosophy and correct in theory, we have adopted, while that which bears the impress of fallacy or error, has been discarded, without regard to the obscurity, on the one hand, or the respectability or weight of authority that may have passed under review, on the other; our sole object has been to collect the glittering gems of truth from whatever source we could make available, and arrange them in a casket that may remain imperishable through all coming times as the truth itself is imperishable. 3 4 PREFACE. When we received the degree of Doctor of Medicine and our diploma in the University of Pennsylvania, just one-third of a century ago, we had laid no plans, nor formed any purposes for the future, our highest ambition was to secure a comfortable life-sustaining practice in some pleasant country village. This was soon accomplished, and our success was equal to that of most young men fresh from the lecture rooms. We then had made choice of no particular branch of the profession, but diligently applied ourselves to the study and duties of general practice. Within the first few years of our professional career there occured two instances that inclined our mind strongly towards making the study of obstetrics and the diseases of women the special one of our life. The first was a case of most terrific puerperal convulsions, that occurred in the person of a very near and dear relative, which recovered under our charge, after being abandoned as hopeless by three of the most experienced and distin- guished physicians of the neighborhood. Encouraged by our success in this case we engaged in the study and practice of obstetrics with zeal, and a determination to further be able to surmount what other difficulties might be lying in wait for us along the pathway of professional life. A short time subsequently to this event, we were consulted by a distinguished medical friend, in an adjoin- ing district, in regard to the case of a most estimable and accomplished young lady, the only daughter of very respectable parents. The difficulty was serious menstrual derangements, with chlorosis and a hopeless deterioration of her general health, which, after a protracted and painful duration, finally terminated fatally. This sad mischief resulted from a misdirection of that innate modesty which is the PREFACE. o gem of the female character. She refrained from acquaint- ing her mother even with her condition, until the visible marks of declining health betrayed the presence of some grave internal difficulty, from a dread of making the necessary revelations to her physician; finally, when the alarmed mother summoned to her aid a medical friend it was too late, the vital springs had already been tapped, and her young life was gradually ebbing away. This case, in connection with the difficulties we had frequently encountered in our owTn experience, in gaining satisfactory information with reference to the peculiar ailments of young and timid females, led us seriously to consider the propriety of supplying, what appeared to us, a most important desideratum in the profession, by properly educating women in the art and science of medicine. . The relation between the sensitive and delicate female invalids, and these medically educated ladies, as their physicians, would be more intimate, and the difficulties, familiar to every male practitioner attending the acquisition of neces- sary information in reference to such cases, would not exist in regard to them. And it was thought that much good would result to the sex from such an arrangement. After more than ten years earnest deliberation, during which time many observations wer,e made in confirmation of the necessity of the measure, and receiving encourage- ment from a large number of liberal-minded members of the profession throughout the country, and most especially from our excellent friend, Dr. John H. Gordon, of Pa., a retired Surgeon of the U. S. Navy, who has long since departed to a brighter and better world, and from the brilliant achievements of those two French ladies, Madame La Chappell and Madame Boivin, who are renowned throughout the world, and whose works have added lustre to the scientific character of France, and to the medical 6 PREFACE. profession everywhere, we applied to the Legislature of our own State, and procured a charter for " The Female Medical College of Pennsylvania," granting it equal privi- leges and immunities with any medical institution in the commonwealth. With the co-operation of a few friends the college was organized under the charter, and on the 7th of September, 1850, with a full faculty, commenced the first course of regular medical instructions ever given to a class of women in the United States, or the world, ourself occupying the chair of obstetrics and the diseases of women and children. Thus were we the humble instrument of opening to woman a new field of enterprise, and at the same time honestly endeavoring to fill a most important blank in the profession that no man possessed the natural qualifications of doing; and we have never regretted the part taken in the transaction, further than that which arose from a failure of the organization to meet the high expectations we, and its best friends, had entertained of it. After the third course of lectures delivered in the institution, we dissolved our connection with it, with feelings of regret that the management of it was, unfortunately, committed to hands incompetent to insure it success. We should not have intruded this item of medical history upon the reader in this place, were it not that our identity with it constituted one of the events that led us to make the subject of the present work the theme of a life-long study; and had it not been for that, our interest in the subject might have waned instead of increased as time advanced. Though at present dissolved from all connection with the medical education of women, we yet regard it as one of the advanced epochs of the age, from which will date a most important improvement in medi- cine, one that will redeem the sex from much needless PREFACE. 7 suffering, and often premature death, when it comes to be appreciated in the light in which it was commenced, and conducted by competent and efficient managers. After our appointment to the professorship of obstetrics and the diseases of women and children in the Phila- delphia University of Medicine and Surgery, in 1865, we were requested to prepare a text book upon our especial branch for the school, which should embrace, as far as a work of the kind can be made to do, the broad and liberal principles upon which the teachings of the institu- tion are based. After due reflection upon the matter, and opening an extensive correspondence, and accumula- ting a large amount of material for such a work from our past experience, and that of our correspondents, and making such preparations as were necessary, so as to enable it to proceed as uninterruptedly as possible, we commenced the work on the 20th of October, 1866, since which time we have given it almost our undivided attention. Disputed points we have endeavored to discuss with candor, having no malice towards any one, nor unkind feelings to gratify, we have entered into the examination of all mooted questions, only with a desire to elicit the truth. Enter- taining no prejudices against, nor predilections for any of the dominant medical sects of the day, we have neither favored one, nor censured another; but have endeavored to deal fairly with all, and without referring to any as a particular system or ism, have drawn more or less of what we conceive to be the truth from each. In this respect the book goes into the hands of the medical student and the profession with a different character from any other med- ical text-book extant. In addition to the broad liberality of thought it inculcates, simplicity and perspicuity have been studied in its details, an excess of technicalities has been avoided. Every subject is treated upon the 8 PREFACE. presumption that the reader is only a novitiate in the science and art of obstetrics, whose sole desire is to learn, hence the subject-matter of the volume is presented in as plain and comprehensible language as is consistent with scientific accuracy. In the arrangement of the work, no plan has been studied, no author imitated, but the various subjects have been considered from the first, as they naturally grow out of each other, and as we have always considered them in our public lectures; thus the student is conducted on. step by step, from one topic to another, in the natural order of their occurrence, and, as far as possible, the connecting links between them are maintained from the first to the last. In the progress of the work it will be observed that some new ideas have been incorporated, and that some of the old ones, which have prevailed from time immemorial, have been examined and discarded. It is conceived to be a great fault with medical writers, in view of the much needed advance in medical science, to follow each other, and thus perpetuate erroneous doctrines, without tho- roughly examining their claims to the credence of tke profession. Where an author has gained great celebrity and distinction in his day, it has generally been by expo- sing and correcting the errors of his predecessors, w-hile at the same time he has transmitted to his posterity as great errors, overlooked by him, as those he has corrected. These have been unnoticed and repeated by his successors, or allowed to pass from a dread of the criticisms their exposure and correction might excite from the too confi- ding disciples of the former. Thus, either from a want of -discernment, or a dread of criticism, have gross errors and grave fallacies been perpetuated, and permitted t<> encumber our text-books, until the student, relying upon PREFACE. 9 the wisdom and judgment of his teachers, is misled into a labyrinth of difficulties, of which he is not aware, until he comes to test his acquired skill at the bed-side of the patient, when he finds, too late, that many of the so-called truths in theory and facts in practice are deceptive, and one of his first duties to insure him success is to commence unlearning much that he has learnt, and to rely upon good common sense, instead of the theories of the schools. In our efforts to purge obstetrics of what is false and erroneous, we may have failed to discern much that needs reviewing, but we disclaim that we have been influenced by the dread of criticism. We acknowledge that we have reviewed several, what appeared to us, palpable absurdi- ties, that have been sustained by the most eminent authorities, and, in doing so, we expect in return to pass under the review of the critics; but as our sole object is to disabuse science, and institute truth for error, we are willing to submit our strictures upon, what we conceive to be, unsound in philosophy and false in point of fact, to the ordeal that awaits every divergence from established theories, whether true or not, and abide by the result. If we have, in our endeavors to improve a science acknowledged to be defective, strayed so far from our intentions as to substitute new errors for old truths, or new follies for ancient wisdom, we would be under obligations to have our misdirected efforts corrected, and crave pardon for the injury we may have unwittingly com- mitted to the cause of science. And, on the contrary, if our observations be found to accord with truth and phi- losophy, we expect our reviewers will be as free to award us the credit of having done something for science, as they otherwise wrould be to condemn our efforts as chi- merical or stupid. 10 PREFACE. To those kind friends who have extended to us their generous sympathy and a helping hand in our arduous and responsible undertaking, we tender our sincere grati- tude; and to Mr. Hugo Sebald, the artist, we award our particular thanks, for the promptness and skill in the execution of the engravings with which the work is illustrated. THE AUTHOR. August 6th, 1868. INTKODUCTION. HISTORY OF OBSTETRICS. Marriage is an institution of great antiquity. Whether we take the Mosaic account of the early history of man, or refer to Mytho- logical Chronology, we find the relation of husband and wife re- cognized from the first. Adam and Eve afford an instance of the first. Saturn was one of the most ancient of the gods, called Chronos by the Greeks, and Saturnus by the Romans. He is said to have been' the son of Uranos and Titcea—the heavens and the earth, and to have possessed the government of the Uni- verse. In this instance of Heathen Mythology, we find Uranos, the heavens, the first god; and Titsea, the earth, the first goddess. Rhea, the Sister of Saturn, became his wife. Jupiter and Juno, a Son and a daughter of Saturn and Rhea, also became hus- band and wife. These two deities are of interest in connexion with our subject, since Jupiter is represented as the father of Apollo, who was regarded as the god of the sciences and the'arts, especially poetry, music and Medicine. iEsculapius, who was deified as the god of medicine, was said to be the son of Apollo, and the nymph Coronis. Two sons of iEsculapius, Machaon and Podalirius, were celebrated physicians during the age of the Trojan war. His two daughters, Panakeia and Hygeia, were no less distinguished than their renowned brothers, the latter was deified as the goddess of health. The worship of Juno, the third and most distinguished 11 12 HISTORY OF OBSTETRICS. wife of Jupiter, was far spread, and the number of her temples and festivals was very great. Both Greeks and Romans honored her as the protectress of marriage. Her daughters were Hebe, goddess of youth, and Hi thy a, who presided over births. Thus four generations anterior to the time of Hygeia, daughter of iEscula- pius, we find Ilithya, daughter of Juno, taking charge of parturient women. > The first intimation that history affords of any especial attention being given to the parturient process, or wherein the act of child- bearing was regarded as of sufficient account to render it worthy of the presence of a presiding deity, dates at an antiquity of more than three thousand years. Here we find woman the presiding deity —woman with her inherent sympathies, her quick perceptions, her patience, her natural qualifications, was most fitted for, and worthy of this peculiar province, this high station, of presiding at the birth of the gods. And as we descend from the fabulous records of these etherial or imaginary beings, and scan the earliest history ot those of sublunary origin, we find that birth-giving has, among all civil- ized nations, been attended, if not by a presiding deity, a presiding genius at least, whose presence has always been regarded necessary for the safety and well-being of both mother and child. Midwifery indicates a woman acting in the capacity of a mid- wife, an obstetrix, an accoucheuse; and we find from the earliest records, down to within a comparatively recent date, women alone practised in this department of the medical profession. Parturition being coeval with the existence of the race, all that was known of it previously to the use of letters, and much anterior to the dis- covery of the art of printing, must have been drawn from indi- vidual experience and observation, aided perhaps by tradition, a most imperfect means of transmitting knowledge from one gener- ation to another. Old Testament history informs us that women, alone, practiced this art among the Jews, and we find the same important post assigned to them by the most refined nations of antiquity. In the brightest and most palmy days of philosophic Greece, classic Rome and imperial Carthage, woman, and woman alone presided over the duties and offices of the parturient cham- ber. In some few cases of extreme severity and rare danger, the aid of the physician may have been solicited. Observe, in those HISTORY OF OBSTETRICS. 13 early periods there were female as well as male physicians; but the presence of the male physician could be of but little service in those cases of great extremity, because of the paucity of his knowledge of the subject. The practice being entirely in the hands of women, experience and observation afforded no resources for him to draw from. The practice of midwifery and medicine must, alike, have been the extremes of empiricism. Anteriorly to the time of Hippocrates, medicine was neither studied as a science, nor practiced as an independent profession. This Grecian sage lived about four hundred years before the Christian era, and to his labors in behalf of his favorite art, does the science of medicine owe its origin as such. All the accounts which have been transmitted, on the subject of medicine, from a date prior to this epoch, are either conjectural or fabulous. Pos- terity, by common consent, have awarded to this great philosopher the enviable title of the " Father of Physic." He wrote the first treatise of which we have any account, on the subject of midwifery. This work furnished the only written guide to midwives, for nearly two thousand years, and as it was in manu- script, the presumption is, that but a comparative few who prac- tised the art were in possession of it. But granting every midwife possessed a copy, it could have been but a very poor apology for a correct and reliable guide, as it was produced at a time when a knowledge of human anatomy consisted of but a few observations made on rudely dissected bodies, and before the science of Physiol- ogy had yet begun to dawn upon the human mind. Thus for nearly two thousand years, until after learning had been revived by the discovery of the art of printing, the art of midwifery made but very little, if any, advancement. For generation after generation, and century after century, it continued to be the same empirical routine of practice. In those remote ages, all the recourses to art in facilitating dif- ficult labor, were either certainl ydestructive to the child, or highly prejudicial to the safety of the mother. When it was deemed necessary to operate on the child for the relief of the mother, no other expedient was thought of but the reduction of its size by mutilation. The crochet, the knife, and other destructive instru- ments were used for this purpose. So much less an estimate was 14 niSTORY OF OBSTETRICS. placed on the life of the child, (and very properly too,) than on that of the mother, that it was usually selected as the subject of the operation; but when from extreme deformity or other adverse causes, the delivery could not be thus effected, the Ocesarian operation was resorted to as the only forlorn hope for the safety of the mother. The Ccesarian operation consists of opening the body of the woman and extracting the child therefrom, when it cannot be born through the natural passages. " Being lost, as it were, (says Vel- peau,) in the night of time, the origin of this operation has not as yet been precisely ascertained by any one." In the fabulous ages, it was said that a foetus, the son of Jupiter, was extracted from the belly of Semele by Mercury. The Romans made the same statement concerning JEsculapius, who was thus extracted from his mother by Apollo, after she had already been placed on the funeral pile destined to consume her. Virgil also says that Lycus came into the world in the same manner. These vague traditions, a passage in Pliny, and certain Roman laws, induce a belief that the Caesarian operation must have been employed in the most remote ages. There is, however, no certain proof that it was performed upon a living woman anteriorly to the year 1520, unless we admit as authentic the case of the lady at Craon, who was subjected to the section in 1424, and who, as well as her child, survived the operation. The ancient Greek and Latin phy- sicians make no mention of it whatever. Guy de Chauliac, who seems first to have described it, founding his opinion upon a pas- sage from Pliny, believes that it took its name from Julius Coesar; others, on the contrary, think that the general and his family took their name from the operation. We are, therefore, obliged to con- fess that the etymology of the Caesarian operation is as ambiguous as its origin. Rousset was the first author who dared to maintain that it may and ought to be had recourse to in the living subject. He mentions seven women who had been subjected to the operation with com- plete success. It is related that a woman named Gf-odon was oper- ated upon seven times, another three times. Dr. Gibson, of this city, operated twice on one woman with success, first a daughter, second a son. According to Boudelocque, the Oossarian operation HISTORY OF OBSTETRICS. 15 has been successfully performed twenty-four times from 1750 up to the commencement of the present century, and perhaps in quite that number of well authenticated cases since. Notwithstanding the success thus attending it, it is nevertheless a very dangerous operation, and should never be resorted to ex- cept as the last extremity. That it has often been unnecessarily employed, cannot be denied, in view of the many cases on record of women who have survived the operation, having had children subsequently in the natural way. About a hundred years after the invention of type and the printing press, viz., 1540, Dr. Raynauld, of London, published the first work on midwifery ever printed in the English language. It was entitled "The Woman's Book, or the Garden of Lying-in Women and Midwifes." It was originally published in Latin, and subsequently translated into several European languages. It is not at all surprising that his vanity should have become some- what excited, and that he should have felt himself flattered by his great achievement, for he had accomplished a great work. He had published the first book in his language on a great subject, of which he knew but little, because of it but little was known. No wonder that he thought that his extraordinary production pos- sessed magical influence, and that the mere reading of it in the parturient chamber would afford relief to the sufferer. "He en- joins that ladies and gentlemen do have this book on their hands, and that they cause such parts of it as are applicable to be read before the midwife and the rest of the women present at the labor, whereby," he says, " the laboring woman may be greatly comforted and alleviated in her travail." Twenty-five years after the publication of Dr. Raynauld's famous book, viz.: 1665, Ambrose Parre, a French surgeon of great celebrity, issued another work, in which he advocates the operation of turning the child and delivering head foremost, or by the feet in cross-presentations, hemorrhages and convulsions. Had Am- brose Parre achieved nothing else for science and humanity but the discovery of this great expedient, it should be enough to have constituted him one of the greatest benefactors of the race; but when we add to this, the discovery of the application of the ligature, in the place t)f burning pitch, to staunch the hemorrhage in am- 16 HISTORY OF OBSTETRICS. putated limbs, and the many other brilliant achievements of his highly philosophic mind, we almost feel inclined to bow in venera- tion to his god-like powers—powers that were almost infinite and omnipotent to crush the hordes of persecutors who were ever crying, "crucify him, crucify him," because of his innovations on time- honored usages, and the sublime original contributions he was continually making to the healing art. This, the operation of turning, was the first important improvement in midwifery of which we have any record since the time of Hippocrates. It was for Ambrose Parre, by the wand of his mighty genius, to break the mystic spell that held the world in darkness for two thousand years, to dispel the cloud of midnight blackness, and cause a ray of light and hope to fall upon the bed of suffering, dying woman. Honored be his name! Ambrose Parre was possessed largely of liberality of mind—that indispensable element of true greatness. He did not disdain to instruct woman in the art of healing, and about the year 1700 the world was still further illumined by a work written by Louiza Brewster, one of his highly-gifted pupils. This was the first undisputed work written on midwifery by a female. She wrote on sterility, abortions, fertility, child-birth, and diseases of women and new-born infants. The next important advanced step we find taken in the science of obstetrics was the invention of the forceps. Although allusion is made by both Hippocrates and Galen to "instruments for the purpose of facilitating difficult labor," they were of a kind designed merely to extract the child without reference to its life. Among the ancient writers on medicine and surgery, we meet with no description of any obstetrical instrument at all resembling our forceps. The first gleam of a contrivance, designed to facilitate delivery, without mutilating the foetal body, sparkles in the works of Rhazes, the Arabian, who, in the latter part of the tenth cen- tury, described a fillet, supposed to be adapted to this purpose. We find in Avicinna, whose work appeared nearly one hundred years after Rhazes wrote, the obstetric forceps mentioned by name, but what resemblance, if any, it bore to the forceps now in use, we have no information, further than that they were blades with teeth in them for extracting the foetal head. HISTORY OF OBSTETRICS. 17 The earliest trace of the modern midwifery forceps which we possess, is under the form of a secret, in the hands of an English family by the name of Chamberlain. This appears to have been a family of physicians, as we have knowledge of Dr. Chamberlain and his three sons, one of whose names was Hugh and one Peter Chamberlain, the name of the third we have been unable to learn. Dr. Hugh Chamberlain appears the most conspicuous in connection with this invention, and has been by some authors accredited with its origination, but, according to Rigby, "as to when or by whom it was first invented, this must probably remain forever unknown; at any rate there is no more reason to suppose that Dr. Hugh Chamberlain was the inventor than his father or brothers were." The honor of inventing this instrument has been attributed to several persons; but at the present day it is clearly established that the forceps was invented by a member or members of the Chamberlain family prior to the year 1650. One of the Chamberlains, with his imagination glowing with the prospect of sudden and great riches, repaired to Paris in the year 1670, with a view of selling his secret, but failing to accom- plish delivery in a case of extreme deformity of pelvis, which he conceived his instrument capable of doing, he failed in getting the ten thousand crowns for his secret, which he was to have had of the king's chief physician, had he succeeded, and returned to England covered with disappointment and mortification. Many interesting incidents connected with this family and their invention might be given. The next important step taken in the science of obstetrics, whether an advance or retrograde one, is a matter of dispute with many good people, was the introduction of the male obstetrician into its general practice. This occurred in the year 1663. Pre- viously to this period, it was exclusively in the hands of women, except where surgical operations, either on the mother or child were deemed necessary. So improper was it regarded for a man to be present at an ordinary labor, and so revolting to the preju- dices or tastes of the populace, that a Dr. Vites, of Hamburg, was publicly branded, or as another writer has it, was condemned to the flames, for being present on the occasion of a birth, disguised in female attire. 2 18 HISTORY OF OBSTETRICS. The distinguished individual first to make the innovation on the ancient and time-honored custom, was a no less personage than the Duchess of Villiers, a favorite mistress of Louis XIV. of France. The fortunate attendant was Julien Clement, a distin- guished professor of surgery. He was conducted, in disguise and with great secrecy, into the house where the lady was, with her head covered with a hood. She desired the matter might be kept a profound secret. The case terminated favorably; the secret soon found its way out, and Clement was translated to the novel and lucrative office of accoucheur to the Princess of France. The same surgeon was employed in subsequent labors of the same lady, and the princesses made use of other physicians on similar occasions. It soon became fashionable, and the name of accoucheur was invented to signify that class of surgeons. Foreign countries soon adopted the custom and likewise the name of accoucheur, for they had no such term in their own language. The next matter occurring in the order of time worthy of remark, was the discovery of the operation of Symphyseotomy. This con- sists in separating the pubic bones at the symphysis, and thereby giving amplitude to the diameters of the pelvis. Some modern physicians, from a remark by Galen, suppose this operation must have been conceived of in the remotest antiquity. Two cases are upon record of its having been performed immediately after death, for the purpose of facilitating the delivery of the children while yet alive. One of these occurred in 1766, but no one had thought of proposing the operation in the living subject until 1768, when Sigault, who, yet a student in medicine, made it the subject of a memoir, which he presented to the Academy of Surgery. The idea of symphyseotomy, let its value be what it may, is really due to that surgeon. The renowned Academy, as is too often the case with reference to new discoveries, in organized com- binations, was hardly willing to hear the first proposal of it and Louis, who communicated it to Camper, treated it as a ridiculous project, engendered in a young man's brain, that was as yet inca- pable of any reflection ; but not so with the celebrated Hollander who, after performing several experiments upon the dead subject, replied to the secretary of the Academy that at some future day it might be advantageously resorted to. On his part, Sigault was HISTORY OF OBSTETRICS. 19 not disconcerted, and reiterated the same idea in his thesis, at the school of Angers in 1773. Four years afterward he performed his operation in the presence of Leroy, upon a woman named Supiot, and saved both mother and child. This success gave rise to an extraordinary degree of enthusiasm ; the hundred tongues of fame, says Velpeau, seemed insufficient to celebrate the glory of the author of so brilliant a discovery. The faculty of medicine at Paris, thought that they could not reward him too highly by passing a solemn decree, and causing a medal to be struck in honor of him, so that the same Sigault, whom the Acadamy of Surgery would not deign to hear a few years before, was soon proclaimed the greatest benefactor of humanity, and almost equal \p the gods. Such exaggeration as this soon gave rise to a lively opposition among the surgeons, and was the signal of a combat in which a great number of medical men of different countries felt themselves called upon to take part. But at the present day, when all the passions awakened on the occasion of this quarrel have become extinct, it is an easy matter to estimate the operation of sym- physeotomy at its just value. It is now regarded as little other than one of the vagaries of the past, and as such, discountenanced by every intelligent obstetrician. In the year 1760 there appeared a treatise on the "Art of Mid- wifery," by a Mrs. Elizabeth Nihell, professed midwife, setting forth its various abuses, especially in the use of instruments. It was addressed to all fathers and mothers, and those likely to be either. The avowed object of the book was to inculcate a prefer- ence of women to men in the practice of obstetrics. It is said that nothing; can exceed the vehemence of her invectives against male attendants. "There is," she observes, "a curse that attends their operations, for difficult and fatal labor have never been so rife or so frequent as since their intermeddling." There can be no doubt but that her abuse was mainly directed against Smellie, Burton, Mackenzie and Hunter, as among the most extensive practitioners of midwifery in that day. The first public lecturer on midwifery in the United States was Dr. Shippen, of this city. His first course was delivered in 1762, and it was attended by only ten pupils; but he lived to lecture to a class of two hundred and fifty. 20 HISTORY OF OBSTETRICS. A Dr. Atwood was the first, in the city of New York, to adver- tise himself a man-midwife, which he did in 1762. In the latter part of the last century, Dr. Bard, born and educated in Europe, came to this country and established himself in practice at New York, and was elected the first President of the College of Physicians and Surgeons in the University of the State of New York. It is believed his treatise on Midwifery was the first work on the subject that was published in the country. It was designed for the use of midwives and students, and was a work of great practical usefulness. In this particular, its superiors have been but few since. But it has fallen into disrepute, on account—mainly of its greatest excellence—its bold and unsparing denunciations of the useless employment of instruments, and the reliance it places in the resources of nature. In the introduction to the third edition of this book, after recommending some three or four authors, he says: " It may appear singular that in this enumeration of authors I have not mentioned Smellie, whose works are in the hands of almost every practitioner in this country, and more generally read than any other. But, although one of the first and greatest improvers of the art of midwifery of the last century, Smellie certainly was not acquainted with all the resources of nature in their full extent. Having greatly improved the instruments of his day, he has pre- scribed their use with great precision, and I own I am apprehen- sive that many of his readers may thereby be induced to suppose them equally safe in their hands as they appeared to have been in his ; and hence, be led to a more frequent use of them than modern practice has found necessary or safe." "I confess, not without severe regret, that towards the end of thirty years' practice, I found much less occasion for the use of instruments than I did in the beginning, and I believe we may certainly conclude, that the person who, in proportion to the extent of his practice, meets with most frequent occasion for the use of instruments, knows least of the powers of nature, and that he who boasts of his skill and success, in their application, is a verii dangerous man." These were the expressions of a great and good man a half a century ago, and they are equally applicable, nay, more so, at the present time. HISTORY OF OBSTETRICS. 21 Parturition—the act of bringing forth young—is a natural process, and when unaccompanied with accident, or unfavorable conditions, is without danger. As a matter of science its study is exceedingly interesting, but in point of practical utility, its inves- tigation—a familiarization with its various stages and phenomena; the accidents and dangers that may accompany it; the length of time involved, and how it may be shortened ; the amount of suffer- ing, and how it may be relieved, &c, became matter of study of the highest importance to both mother and child. The science of midwifery is too little understood in relation to its physiological bearing, but is regarded by most practitioners as a mere mechanical operation, to be enhanced or facilitated by tools and mechanical appliances. Never, even in those days when primitive inventors and im- provers of obstetrical instruments ran wild with enthusiasm, did the instrumental mania rage to a greater or more ruinous extent than at present. The destroyed health, the ruined constitutions of the vast num- bers of female invalids that are now dragging out wretched lives in suffering and torment, and rendering families miserable by their unceasing complainings; and the multitudes of halt and maimed, who are pining in anguish within the retirement of the private sick room, owe their sufferings mainly to the unwarrantable oflficiousness of those in whom they confided in the hour of nature's greatest extremity. By the specious pretext of shortening their sufferings, and through an overweening anxiety for the reputation of a skill- ful operator, this confidence has been most wantonly abused, and women without number ruined for life. It has been a question with many very distinguished obstetricians, whether the invention of obstetrical instruments has been a blessing or not to the sex. While they have proven themselves omnipotent to save, in cases of extreme peril, and under circumstances when both mother and child must have been overwhelmed in certain destruction, their use has been so extensively perverted to subserve the interest and enhance the sordid motives of the many operators of the past and present time, regardless of the terrible and fatal consequences to the health and well-being of the unsuspecting and too confiding victims of their knavery or ignorance, that while they are a bless- ing to the few they are an unmitigated curse to the many. 22 HISTORY OF OBSTETRICS. " Let, therefore, the young practitioner of Midivifery study first the symptoms and progress of natural labor as they may be found in all the standard works on the subject, and above all, as they will be seen at the bedside of the patient, when left to their own uninterrupted efforts—whence may be learned the powers and resources of nature—and when these are fully understood, and not before, will the practitioner be enabled to form a just opinion when interference is necessary, and recourse to art ought to be had. And let every practitioner, when supposing it necessary to practice any remedy by which the lives or safety of the mother and child are endangered, or the life of the infant necessarily sacri- ficed, reflect that in all such cases we reason only from strong probabilities, that the resources of nature are almost infinite, and that the event frequently disappoints our expectations. No per- son, therefore, who has been fatigued by several days and nights' watchful attendance, whose sympathies for the sufferings of the patient have been greatly excited, and whose fears for her safety are augmented by the fears and distress of her friends, can be sure that that cool and dispassionate judgment is at command, which alone ought to determine so intricate a question, in which the lives of two human beings are involved. It becomes a duty, therefore, on all such occasions, to call for the aid of some other in whose experience and judgment we have confidence, and whose mind is free from the embarrassments under which our own labors, and who, at all events, will share our responsibilities and lessen our regret's."—Bard. This branch of medical science has struggled against far greater difficulties than have beset the general practice of medicine and surgery, for both ignorance and prejudice have lent their aid towards retarding its progress. The functions of the procreative organism of the human female being so essentially different in their manifestations from those of any of the lower animals, the opportunity of studying them comparatively by vivisections have been but few, and of but little value. It has been by immense labor and a long course of physiological research, coming down from generation to generation from the remotest antiquity, that we have arrived at our present knowledge of the science of woman. This reign of ignorance has been sustained and perpetuated by the HISTORY OF OBSTETRICS. 23 natural prejudices that females themselves must entertain against admitting persons of the opposite sex to undertake the duties required under the trying time of labor, and from the repugnance they have to communicate with man in relation to the pheno- mena of their peculiar functions, either in health or disease. So little was known of the science of midwifery, and so poorly was its importance appreciated, previously to the commencement of the present century, that but few, if any, of the Universities of Europe had enrolled it among their obligatory studies, and it was not until after the year 1826 that the British schools adopted the measure. An association, entitled " The Obstetric Society of London," of which Dr. Francis H. Ramsbotham acted as Honor- ary Secretary, and which had the influence of Sir Robert Peel and many other distinguished individuals, did much to elevate obstet- rics in that kingdom. They induced the Royal College of Physi- cians and the Society of Apothecaries, not only to make obstetric science the subject of examination, but to oblige all candidates who offered themselves for their diplomas, to adduce testimonials of having diligently applied themselves to its study. The Royal College of Surgeons now grants a special diploma, namely, that of Licentiate of Midwifery, to such candidates as successfully pass their examinations upon that branch. In the Medical Department of the University of Pennsylvania, which was commenced on the 3d of May, 1765, midwifery does not appear as a branch of study until 1791, during which year midwifery was united to the chair of anatomy and surgery, under the professorship of Dr. William Shippen. It remained in that connexion, as a mere subordinate branch, until the year 1810, when it was elevated to the dignity of a distinct professorship, and Dr. Thomas C. James was elected to the chair, which position he retained until 1834, when he retired on account of feeble health. For some years previously to his retirement, the active duties of the chair were performed by Dr. William P. Dewees, who was adjunct professor. I shall ever cherish the remembrance of the venerable appearance of that excellent old man as he entered the lecture room for the last time in 1832, supported by two of his colleagues, Drs. Chapman and Gibson ; his long locks were whitened 24 HISTORY OF OBSTETRICS. by the frosts of eighty winters; his nearly exhausted frame was trembling and bending under a weight of years devoted to science and humanity; he was seated in a chair, and in a low and feeble voice addressed the class on the vast importance of that branch of the profession to which his long life had been devoted; he spoke with all the tenderness of a father addressing his children for the last time, and there was not a student present but who felt that it was good for him to be there, and the emotions created upon that occasion will remain indelibly fixed upon the minds of all during life. Thus, for more than half a century, was midwifery regarded as an inferior branch in the oldest and most honorable medical school on the American continent, and during one half of that period it was not considered worthy of a place among the catalogue of studies. At the present time there is no branch connected with a sound medical education, that occupies a higher position in the catalogue of obligatory studies than obstetrics. And during the present century, there has been more attention given to, and more labor bestowed upon it, in Europe, than has been devoted to any other branch of medical science, and with the most brilliant results. Notwithstanding the great advancements that have been made, the subject demands, and there is room for, still further investiga- tion and more progress. FRONTISPIECE. WOMAN. Gynaecology, the science of woman, embraces the anatomical structures and relations of the genital system, its physiological and pathological conditions; ovology, or embryology, the function of parturition, and all the phenomena pertaining to it; and the treatment of those diseases and derangements incident to the sex. Woman is liable to most of the diseases to which man is subject, while she is also the frequent victim of a train of distressing and painful maladies, from which he must always remain exempt from the very nature of his organization. Unfortunately for suffering woman, the importance of this department of medical science is too lowly estimated, or not sufficiently regarded, by the general prac- titioner of medicine. Medical schools do not seem to have a full appreciation of the vastness of the subject, in view of its relation to the physical and mental welfare of the race, or they could not be content to pass it over with so superficial a course of instruc- tion as they generally bestow upon it. While we are fully aware of the difficulties under which medical schools labor, in being able to thoroughly elucidate all the branches they undertake to teach, in the short time they devote to instruction, we cannot hold them ex- cusable for not impressing upon their classes the great magnitude of this department, and the necessity of the close and persistent study of it after the period of their pupilage shall have expired, and they become engaged in the active duties of professional life, 25 26 WOMAN. when every day's experience will reveal to them the necessity of a more thorough accquaintance with the subject, to enable them to acquit themselves with more satisfaction and credit to themselves, and benefit to their patients. All the knowledge that can be acquired by a few months' attendance upon lectures, is but a pitiable apology for that proficiency which is indispensable to success in the treatment of invalid women. But this knowledge, though merely rudimental, is requisite for the basis of future success ; and with- out it, it is impossible to get a clear comprehension of the physio- logical relations and vast pathological sympathies existing between the reproductive organism and the general economy. In contemplating gynaecology, we find ourselves surrounded by a subject replete with the highest interest, and greatest physiolo- gical and pathological importance,—one vast in magnitude, and beautiful in its adaptations to the ends in view. Woman may be regarded, in one sense, as a twofold being, pos- sessing a compound system—the general and the genital—distinct in their characters, their purposes, and their ends; the one essen- tial to individual existence, and the other destined only for .the re- productive functions; the latter being in nowise concerned in con- tributing to the vital continuance of the individual, while the former is indispensable to the existence and development of the latter, and to the continuance of animal life. In contemplating the vast universe with which we are surrounded, and of which we form an integral part, we see much to admire and reverence; but the grand and gorgeous developments of creative power, with all their magnificence, beauty, and harmony, are not comparable, in design and fitness, with the wonderful arrangement destined for the reproduction of man, the crowning workmanship of Deity as manifested in woman. As man is superior to all the orders of nature—so, also, this organism, by means of which his existence becomes individualized, and upon which the perpetuity of his race depends, is of the highest possible consequence, evincing an indefinite degree of creative skill. The first organs in the assemblage, and those upon which the pro-creative function mainly depends, that most especially claim the attention of the student, are two in number, called the ovaries or WOMAN. 27 ovaria, situated about two inches from the uterus, on each side, and entirely disconnected from the cavity thereof. These little bodies, in shape not unlike a flattened almond, are for thirty years of woman's life, constantly generating, maturing, and every twenty- eight days, casting off ova, or eggs, not larger than those of the butterfly, containing all the essential elements of the eggs of ovipa- rous animals. The maturation and escape of the ovum constitutes the menstrual function—a function that perplexed philosophers to comprehend until a very recent date. Though modern science has thrown much light upon this wonderful provision, yet there re- mains much for farther study. The tubes of Fallopius, next in importance in the reproductive process, stand like sentinels, guarding the functions of the ovaria, and with their fimbriae, that float loosely in the abdominal cavity, seize the ova as they escape, and transfer them to the cavity of the uterus, whence they are carried off, unperceived. But the ovum, impregnated, does not thus escape; it passes into its receptacle, and by another wonderful provision is there retained until expelled by the powerfully expulsive contractions, at the full period of utero-gestation. The uterus, matrix, or womb, the next organ in importance, is a hollow muscle, about two and a half inches in length, one and a quarter in width, and three-fourths of an inch in thickness, in shape resembling a flattened pear, situated in the cavity of the pelvis, is destined to receive the fecundated ovum, to nourish, and finally expel the foetus ; its walls are of a firm, thick, and dense structure, susceptible of a vast degree of expansion, and possessing immense strength. This property is almost self-existent, and incredible in degree, capable of overcoming almost any amount of resistance afforded by a disproportion and deformity of the maternal bony structures. This wonderful organ, its anatomical position, structure, and relations; its physiological functions, both in quiescence and activity; its pathological conditions, both functional and organic, is of the utmost importance to study and thoroughly comprehend. This, together with the first two organs named, will be found to exert a greater control over the female system than any other apparatus belonging to the economy. The ten thousand aches and 28 WOMAN. pains, whether constitutional or local, that harass the lives of very many women, are traceable, either immediately or remotely, by the intelligent and observing physician, to ovarian or uterine distur- bances. The physiological influence exerted over the economy by the de- velopment of the genitalia, at puberty, is truly interesting and won- derful, affording a theme for deep study and reflection. If we go back, in our observations, to the first periods of gestation, we will find great difficulty in ascertaining to which sex the embryo belongs, the male or the female, presenting as it does no external marks of distinction, the external organs bearing so strong a resemblance to each other, that the difficulty of distinguishing the sex becomes insurmountable. As the development progresses. early in foetal life, this difficulty subsides, and the distinguishing marks become more and more apparent, until we arrive at a full knowledge of the fact. But, during foetal life, no appreciable physiological difference exists between the male and female ; and, during the periods of infancy and childhood, this sameness con- tinues; their physical growth and mental develop nent are the same ; their natural habits, sports, and attainments, uninfluenced by educational training are the same ; the diseases to which they are liable are the same, and the remedial treatment and required hygienic care are identical. This physiological oneness continues, with but very little deviation, until the period of puberty arrives, when the female commences a wide separation from her pristine physiological condition. This period, which, in this latitude, occurs about the fourteenth year, is marked by great and almost incredible changes, in every particular. Now commences the regular monthly, or catamenial flow ;—at first, when perfectly natural, small in quantity, and faint in color,—but after two or three apparently abortive periods, the function becomes fully established, which continues, when uninterrupted by pregnancy, lactation, or other influences, in the aggregate, for thirty years of woman's life. With this function commences a complete metamorphosis of the whole being. The sharpness, angularity, and awkwardness that characterize the period of childhood, are changed into rotundity, symmetry, and grace. Every portion of the body undergoes a marked and decided WOMAN. 29 change. The limbs become developed, round, and symmetrical; the neck and shoulders assume a form of gracefulness and beauty ; the swelling bosom, gracefully ascending and descending with every breath, gives additional physical interest and attractions to the object of our admiration and study. The whole trunk sym- pathizes in the universal change, and takes on a fuller development, with exact proportions, and perfect adaptations. The vagina, also, becomes enlarged in its caliber; and by the enlargement of its numerous muciferous glands, is freely lubricated, and prepared for its legitimate use. The other internal genital organs also freely participate in the general transformation, and become enlarged, and aroused from their primitive quiescence, to perpetual activity, and the performance of the various functions for which they were designed. The physical changes that take place in the face, are equally distinct with those of the other parts of the body. A roundness and fulness are given to all the features, which impart proportion and beauty not possessed before ; the lips become more prominent, and more deeply tinged with red; the cheeks become round and full, and by the rising blush, easily betray the emotions within ; and the eye, the unmistakable index of the soul, possesses a softness, lustre, and expression, before unknown to it. The interior being is no less affected by the changes peculiar to this interesting period of life, than is the external organization. The habits, disposition, and condition of mind all undergo cor- responding changes. The trivial and senseless diversions of the child, give way to more rational and substantial amusements. Companionship with children ceases, and associations are formed with those of maturer age. That child-like confidence, that allowed a free, innocent, and unrestrained commingling of the sexes in their joyous pastimes, gives way to a shyness and modesty that were before unknown; associations with the opposite sex are now only maintained in accordance with the set rules and fixed laws of society. Sensations, feelings, and thoughts, are now en- tertained by her in regard to the man, that were never experienced in reference to the boy. The mind now develops much more rapidly; the individual becomes more pensive, more staid; a higher order of enjoyments is craved. Her reading becomes of a 30 WOMAN. different order; the toy-book gives way to works of science, history, or the delineations of character. Real friendships and attachments are formed, the affections become developed; and, in a word, the child is transformed into the woman. And the time required to complete the transformation is incredibly short. A person leaving a neighborhood, village, or circle of acquaint- ances for a season, and returning after a lapse of a few months only, will be astonished to find her, whom he left, the laughing romping, confiding child, transformed into the thoughtful, modest retiring young lady. But such is the rapid and thorough change that is effected through the whole economy, simultaneously with the normal development of the genital system. From what has been said, it will be perceived that there exists between the genital and general systems the most extensive sympathies, the source and centre of which are the ovaries. These sympathies exist no less in a state of disease, than in health; and any lesion of the latter pervades the whole economy, as exemplified in the constitutional disturbances arising from menstrual irregula- rities, &c. The uterus may be extensively involved in disease, or inhabited by morbid growths, without producing a corresponding amount of constitutional symptoms, save where debilitating discharges are present. In view, then, of the extensive sympathetic relations existing between the ovaries and every part of the animal organism, too much study cannot be bestowed upon this system, in order to arrive at a correct diagnosis, and the application of proper and efficient curative agencies. Ovology, or embryology, that science which treats of the development of foetal life, and the growth of the embryotic being, is full of interest to the naturalist, presenting, as it does, an ex- tensive field for observation and inquiry. Commencing our researches low down in the vegetable kingdom, we readily discover the law that governs the reproductive functions there; and as we proceed along the scale of development, ascending step by step, through the floral, and from thence through the various families of the animal kingdom, to the genus homo, we will perceive the ' same great law pervading the whole, but manifesting itself in various ways, according to the different habits and requirements of the subjects of its operations. WOMAN. 31 The study of gestation, and its effects upon the future of the embryotic being, in regard both to its physical and mental welfare, has been too shamefully neglected by the profession, and left to be pursued by philanthropists, outside its pale, who, for want of correct rudimental knowledge, and a strictly scientific basis for their inquiries and researches, have been led into many errors, and vague hypothetical speculations, which tend to mislead, rather than instruct the mind. This subject invites and requires a more thorough investigation than has yet been bestowed upon it, which it is desirable, for the benefit of the race, will not be much longer delayed. From the few hints that have been here thrown out, it will be perceived that the study of woman is not merely the work of a few weeks or months, but one in which a lifetime may be profitably employed. \ CONTENTS. PREFACE, 3. INTRODUCTION, 11. Frontispiece, 25. Sbctiox I. Section II. Suction III. Suction IV. Section V. Section VI. Section VII. Section VIII S BCTION IX. Suction X. PART FIRST. CHAPTER I. the pelvis. Of the Bones of the Pelvis. 1. The Os Innominatum. 2. The ilinc por- tion or Os Ileum. 3. The Ischiatic portion or Os Ischium. 4. The Pubis. 5. The Innominatum entire. 6. The Os Sacrum or Os Basilare 7. The Os Coccygis or Os Coccyx. The Articulated Pelvis. 1. The Ligaments of the Pelvis. 2. Of the Sacro-Iliac articulations. 1. The Ligamentum Sacro-Spinosum. 2. The Sacro-Iliac Ligament. 3. The Pubic Articulation. 4. The Sacro-Coccygeal Articulation*. 1. The Anterior Coccygeal Ligament. 2. The Posterior Coccygeal Ligament. 3. Poupart's and Gimbernat's Ligament. Of the mobility of the bones of the Pelvis. Of the divisions of the Pelvis. 1. Diameters of the Superior Strait. 2 Diameters of the Inferior Strait. The position of the Pelvis and its Axes. 1. The axes of the trunk and. Superior Strait. 2. The axis of the Inferior Strait. 3. The inclined plane of the Pelvis. The difference between the male and female P<1vi*. The deformid and distorted Pelvis. 1. Distortion from disease. 2. The elliptical deformity. The angular deformity. Of pelvimetry and j" h-imetcrs. 1. Baudelocque's calipers. 2. Cautouley's pelvimeter. 3. -Manual measurements. Of the fetal head at term. 1. The Os Frontis, or Frontal Bone. 2. The Ossa Parietalia. 3. The Os Oocipitis. 4. The Ossa Tempora. The Sutures and Fontanels. 1. The anterior Fontanel. 2. The posterior Fontanel. 3. The dimensions of the feral head. Of the descent of the head through the Pelvis, and its mechanism. 41-83 PART SECOND. CHAPTER I. ORGANS OP GENERATION. Section I. External Organs. 1. The Mons Veneris. 2. The Labia Majora. 3. The Labia Minora, or Labia Interna, or Nympha. 4. The Clitoris. 5. 3 33 P>4 CONTENTS. Section I. Section II. TheVestibulum. 6. The Meatus Urinarius and Urethra. T. The Hymen. 8. The Carunculse Myrtiformes. 9. The Fossa Naviculare. l». me Forchette and Posterior Commissure. 11. The Perineum. 84-Vo. CHAPTER II. INTERNAL ORGANS OP GENERATION. The Particular Organs. 1. Vagina. 2. The Uterus. The Cavity. The Os Uteri. The structure of the Uterus. The Blood-vessels supply ng the Uterus. The Nerves of the Uterus. The Absorbents The weight of the Uterus. The Uterine supports. 3. The Ovaries. The Graffian Vesicle. Recapitulation. The Ovum. The Vitellus or Yolk. 2. The Germinal Vesicle. 3. The Germinal Spot. The Corpus Luteum. 4. The Fallopian Tubes. 5. Of the Broad Ligaments. 6. .Of the Round Ligaments. Of the Nerves of the Genital System. 1. The Cutaneus Externus. 2. The Crural is Anterior. 3. The Nervus Obturatorius. 4. The Nervus Ischiadicus. 96-125. CHAPTER III. THE MAMMjE 127-133. PART THIRD. CHAPTER I. THE SYMPATHETIC ACTIONS AND REACTIONS BETWEEN THE THREE GREAT REPRODUCTIVB ORGANS, NAMELY, THE OVARIES, UTERUS, AND MAMMJS. Section I. Ovarian Actions. Actions of the Ovaries upon the Mammae. Action of the Ovaries upon the Uterus. Section II. Uterine Actions. 1. Action of the Uterus upon the Ovaries. 2. Action of the Uterus upon the Mammas. Section III. Mammary Actions. 1. Action of the Mammae upon the Uterus. 2. Action of the Mammae upon the Ovaries. 134-140. CHAPTER II. menstruation. 140-157. CHAPTER III. OF HUMAN CONCEPTION, 157-176. CHAPTER IV. GESTATION. Section I. Embryography. The first changes effected in the Ovum by fecundation. Division of the Vitellus. Mulberry Mass. Blastodermic Membrane. Embryonic Spot. Development of the Umbilical Vesicle. Membranes. Allantois. Umbilical vessels. Placenta. Rudiments of the various organs. Corpora Wolffiana. The Cloaca. The degree of develop- ment at three months of gestation. At four months. At five months At six months. At seven moaths. At eight months. At nine months' The average size and weight at term. Extremes in excess and diminu- tion, 177-203. CONTENTS. PART FOURTH. CHAPTER I. OP PREGNANCT, 204-205. CHAPTER II. Section I. Natural or uterine pregnancy, and its duration. Section II. Section III. Section IV. Section V. Simple Pregnancy. 1. Of the Membrane Dicidua; of its formation. Of the Chorion. Of the Amnion. Of the Liquor Aranii. The properties of the Liquor Amnii. Its chemical properties. Whence is it derived ? Its use. Of the Placenta. Of its development. Its attachment. Of the Funiculus Umbilicalis. Its length. The thickness of the Cord. The nodocities of the Cord. Spinal arrangements of the vessels of the Cord. Valves of the vein. The point of attachment of the foetal end of the Cord. The divisions of the Cord. Of the Umbilical Vesicle. Of the Allantois. Of the modification of the Uterus. Size. Shape. Position. Of the shape of the Cervix Uteri. The ramollescence of Cervix Uteri. Of the mo- dification of the Structure of the Uterine body. Of the Serous Cover- ing of the Uterus. Of the muscular Structure. Of the mucous lining of the Uterus. The Arteries. Veins, Lymphatics and Nerves of the Uterus. Changes effected in the Uterine appendages by Pregnancy. Changes effected in the parts circumjacent to the Uterus by pregnancy, 205-268. PART FIFTH. COMPOUND, COMPLICATED AND EXTRA UTERINE PREGNANCY. CHAPTER I. COMPOUND PREGNANCIES. Section I. Of Twins. The shape of the Uterus, and position of the foetuses in twin Pregnancies. 2. The membranes and placentae in twin Pregnancies. 3. Monstrosities. Section II. Triplet Pregnancies. Case I. Case II. Case III. Case IV. Case V. Case VI. Case VII. Section III. Quadrigemini, or Quadruplet Pregnancies. Case I. Case II. Case III. Case IV. Case V. Section IV. Quintriplet Pregnancies. 369-2.95. CHAPTER II. complicated pregnancies. Section I. Fibrous and other tumors coexisting with the foetus in utero. 2. Polypi. 3. Molea and Hydatids, 295-298. CHAPTER III. SPURIOUS OR FALSE PREGNANCIES. DIAGNOSIS, 298-300. CHAPTER IV. PRETERNATURAL OR EXTRA UTERINE PREGNANCIES. Section I. Ovarian Pregnancies. Section. II. Tubal or Tubarian Pregnancies. Symptoms. 36 CONTENTS. Section III. Abdominal Pregnancies. Section IV. Interstitial Uterine Pregnancies. 301-315. Diagnosis. Prognosis. Treatment. Section I. PART SIXTH. CHAPTER I. DIAGNOSTIC SIGNS OF PREGNANCY The Physiological Signs. 1. Suppression of the Menses. 2. Morning sickness and capricious appetites. 3. Flatness of the lower abdomen, and depression of the Umbilicus. 4. Modification of the Mammae and nipples. 5. Modification of urine. Kyestein. 6. The features and countenance. 7. Abdominal enlargement. 8. The Umbilical changes. 316-356. PART SEVENTH. CHAPTER I. POSITION OF THE FG3TUS IN UTERO. 357-360. CHAPTER II. OF THE NUTRITION OF THE EMBRYO AND FC3TUS. 360-362. CHAPTER III. OF THE POSTAL CIRCULATION. 1. The Heart. 2. The Internal Iliac Arteries. 3. The Liver. 4. The Umbilical Vein. 363-370. PART EIGHTH. CHAPTER I. abortion. causes of abortion. Section I. Reflex Nervous Action. Explanation of the Caust of Abortion. 1. Irri- tation of the Ovarian Nerves. 2. Irritation of the Rectal Nerves. 3. Irritation of the Uterine Nerves. Section II. Symptoms of Abortion. 1. Of Ovular Abortion. 2. Of Embryonic Abor- tion 3. Of Foetal Abortion. 4. Of Premature Delivery. 5. Of Pro- voked or Induced Abortion. 6. Diagnosis!. 7. Prognosis. 8. Treat- ment of Abortion. First, Prevention of Abortion. Second, the Man- agement of Abortion. Delivery of the Placenta and Controlling Hemorrhage, 371-411. PART NINTH CHAPTER I. LABOR. DELAYED OR DEFERRED LABOR. 412-417. CONTENTS. 37 Section I. CHAPTER II. NATURAL OR UNASSISTED LABOR AT TERM. Cause of Labor. Determining Cause. 417-426. CHAPTER III. THE DIFFERENT STAGES OF LABOR, AND THEIR PHYSIOLOGY AND MECHANISM. Section I. Section II. Section III Section IV. Section V. The Preliminary Stage. The Stage of Dilatation. The Stage of Propulsion. The Stage of Expulsion. The Supplemental Stage. 426-418. CHAPTER IV. THE DURATION OF LABOR. 418-451 CHAPTER V. PUERPERAL PAINS. Section I. True Labor Paint. Section II. After Pains. 451-457. PART TENTH. CHAPTER I. classification op labor. 458-462. CHAPTER II. Section Section Section Section Section Section Section Section Section I. II. Ill IV. Cephalic Eutocia. Cephalic Presentations. Cranial Presentations. The First Presentation and its Mechanism tion. Extension. The Second Presentation and its Mechanism. Third Presentation and its Mechanism. Fourth Presentation and its Mechanism. VIII. Fifth Presentation and itn Mechanism. IX. Sixth Presentation and its Mechanism. V. VI VII. Flexion. Restitution. Rota- 463-486 CHAPTER III. IRREGULAR OR ANOMALOUS VERTEX PRESENTATIONS. 486-488. CHAPTER IV. FACIAL PRESENTATION. CAUSE. DIAGNOSIS. Section I. The Different Presentations of the Feice. Table of Face Presentations. SECTION II. 1. The Left Fronto-Acetabular Presentation and its Mechanism. Section III. 2. Right Fronto-Acetabular Presentation and its Mechanism. Remarks. 489-498. 38 CONTENTS. CHAPTER V. PELVIC EUTOCIA. Section I. Cause of Peloic Presentations. Diagnosis. Section II. The Different Pelvic Presentations. Table of Peloic Presentations. Section III. First Pelvic Presentation and its Mechanism. Section IV. Second Pelvic Presentation and its Mechanism. Section V. Third Pelvic Presentation and its Mechanism. Section VI. Fourth Pelvic Presentation and its Mechanism. 499-510. Section I. Section II. Section III. Section IV. Section V. CHAPTER VI. PRESENTATIONS OF THE FEET. The Different Feet Presentations. Table of feet presentation. The First Feet Presentation. The Second Feet Presentation. The Third Feet Presentation. The Fourth Feet Presentation. 510-516. CHAPTER VII. PRESENTATION OP THE KNKES. 516-518. CHAPTER VIII. MANAGEMENT OF AND CONDUCT DURING LABOR. THE PREPARATION OF THE WOMAN. PREPARATION OF THE BED. Section I. Section II. Section III. Section IV. Section V. Section VI. Section VII. Duties towards the Woman Supporting the Perineum. Removing the Placenta. The Bandage. Duties towards the Child. Washing and Dressing the Child. Feeding the Child. Section VIII. Putting the Woman to Bed. Section IX. After Pains. 518-557. CHAPTER IX. Rupturing the Membranes, etc. MANAGEMENT OF THE LYING-IN WOMAN AND HER CHILD. Section I. Excessive Lochia. Section II. The Green Waters. Section III. Retained Urine. Section IV. Secretion of Milk. Section V. The Colostrum. Section VI. The Milk, or Ephemeral Fever. Treatment. Section VII. Regimen. » Section VIII. The Thrush, or Child's Sore Mouth. Treatment. Section IX. Strophulus Licheniasis, or Red Gum, Treatment. 558-570. PART ELEVENTH. DYSTOCIA, OR LABOR REQUIRING ASSISTANCE. CHAPTER I. FIRST VARIETY OF THE FIRST SPECIES OF DYSTOCIA. CONTENTS. 39 INSTANCES DEPENDING UPON ACCIDENTAL CAUSES OCCURRING AT THE TIME OF LABOR, PERTAINING TO THE WOMAN. Section I. Hemorrhage. 1. Placenta Praevia. 2. Exciting or proximate cause. 3. Hemorrhage for a rupturing of the vessels of the Umbilical Cord. 4. Too short a Cord. The condition of the Os Uteri, in connection with flooding. 1. Symptoms of Uterine Hemorrhage. External and in- ternal Uterine Hemorrhage. Internal Hemorrhage. 2. The prognosis of Uterine Hemorrhage. 3. Treatment. Section II. Convulsions. Cause. 1. The symptoms preceding an attack. 2. The Prognosis. The effects of Convulsions. 4. Post-mortem appearances. Treatment where the Os Uteri is dilated or dilatable. Treatment when the Os Uteri is undilated and rigid. Section III. Hernia, with or without Procedentia. Section IV. Sudden attack of Acute Disease. Asthma. Syncope. The cause of Syncope-Prognosis. Treatment. Exhaustion. Inertia of the Uterus. Symptoms. Treatment. Section V. Rupture of the Uterus. 1. Causes producing rupture of the Uterus. 2. Symptoms. 3. Diagnosis. 4. Prognosis. 5. Treatment. Gastro- tomy. A Vagino-Vesical Fistula, and its Treatment. Section VI. Inversion of the Uterus. Causes. Symptoms. Diagnosis. Treatment. 572-626. CHAPTER II. INSTANCES OF DYSTOCIA DEPENDING UPON ACCIDENTAL CAUSES OCCURRING AT THE TIME OP LABOR, PERTAINING TO THE FC3TUS. Section I. Prolapsus or Premature Descent of the Cord. Causes. 1. The indica- tions. The Prognosis. 2. Treatment. SECTION II. Of the Malpe>sitions that are not present until after the commencement of Labor. Spontaneous Evolution, or Spontaneous Version. Shoulder Presentation. Diagnosis Treatment. 636-651. CHAPTER III. FIRST VARIETY OF THE FIRST SPECIES OF DYSTOCIA. INSTANCES DEPENDING UPON PRE-EXISTING CAUSES, PERTAINING TO THE WOMAN. S ECTION I. Deformities of the Pelvis. Sectiun II. Of the Locked-Head. Paragromphosis Capitis Diagnosis. Effects of Locked-Head on the female organism. Case. Management of Locked- Head. Management of cases of deformed pelvis, in absence of Locked- Head. Section III. Malformation, or Diseases of the Generative Organs. Simple contractions t>f the Os Uteri. Spasmodic contraction of the Os and Cervix Uteri. Obliquity of the Os Uteri. Tumefaction of the anterior lip of the Os Uteri. Fibrous and Scirrhous tumors of the Cervix and Os Uteri. Mor- bid growths implicating the body and fundus of the Os Uteri. Ag- glutination and obliteration of the Os Uteri. Section IV. Obliquity of the Uterus. Section V. Stone in the Bladder. Section VI. Chronic diseases as Asthma, Phthisis, Dropsy, etc. (Edema of the Labia. Section VII. Aneurism. Section VIII. Bony, Fibrous or other Tumors in the Pelvic Cavity external to the Genital Ceinal. Exostosis, Fibrous and other Tumors in the Pelvis involving the soft structures, exterior to the Genital Canal. Section IX. Deformities, in respect to Height, etc. Case. 652-683. CHAPTER IV. SECOND VARIETY OF SECOND SPECIES OF DYSTOCIA. INSTANCES DEPENDING UPON PRE-EXISTING CAUSES PERTAINING TO THE FOJTUS. Section 1. Transverse Position. 40 CONTENTS. Section II. Section III. Monstrosities and Plural Births. Monstrosities from excess of parts or organs. When the parts are neither deficient nor redundant but de formed. When the parts are neither deficient, redundant nor de formed, but misplaced. Causes. Management. fPluralJ*1™"- halus Diseases as Hydrocephalus Hydrothorax, etc. Hydrocephalus. Hydrocephalus Hydrothorax. 684-795. Internus. Treatment. Diagnosis. Ascites. CHAPTER V. Hydrocephalus Externus. Treatment. Emphysema. Section I. Section II. RETAINED PLACENTA. Hour-Glass Contraction. Cause. Symptoms. Treatment. Abnormal Adhesions of the Placenta. Symptoms. Treatment. 705-718. PART TWELF TH EMBRYULCIA. CHAPTER I. MEANS EMPLOYED TO AVOID THE MAJOR OPERATIONS IN ORSTETRICS. Section I. Regimen, as a means of controlling the growth of the foetus. Section II. Premature Delivery and Abortion. 719-735 CHAPTER II. MANUAL EMBRYULCIA. Section I. Description of turning or version. Necessary preparations. The position of the accoucheur. The choice of hands to be employed. The time for operating. 735-740. CHAPTER III. Section I. Section I. Section II. ■iliCTICN III. INSTRUMENTAL EMBRYULCIA. Pacific Instrumental Embryulcia. Forceps. The Chamberlain Forceps Pean's or Bandelocque's Forceps. Short Forceps. Hodge's Philadel- phia Forceps. Actions of the Forceps. Application of the Forceps. Position of the woman and the mode of introducing the Forceps. Delivery from the superior Strait. Use of the Forceps in delivering the head after the expulsion of the body. Placental Forceps. The Vectis. The Blunt Hook. The Fillet. 740-761. CHAPTER IV. PERNICIOUS INSTRUMENTAL EMBRYULCIA. Cephalotomy or Craniotomy. Denman's Perforator. Smellie's Scissors The Cephalotome. The Crotchett guarded and unguarded. The Craniotomy Forceps. The Cephalotribe or Embryotomy Forceps The Osteotomist Mode of Operating. The Stage of Perforation. The Stage of Extraction. Symphyotomj'. Hysterotomy or the Cesarean Operation. History. The results of the operation. When and under what circumstances should Hysterotomy be employed to insure the greatest amount of safety to both woman and foetus ? V anous modes of performing the operation. The ordi- nary method of performing Hysterotomy. 761-786. PART FIRST. CHAPTER I. THE PELVIS. The Pelvis (from the Greek Moc; pelvis a basin; because its shape resembles a basin used by the ancients). It is that bony structure or frame-work at the inferior portion of the trunk, a part of which it forms. It articulates with the last lumbar vertebra, at its upper and posterior border—and with the heads of the ossa femora, in the acetabula. In the adult it is composed of four bones, but in the foetus, and in early life, of many more. All four of the pelvic bones of the adult, were composed, originally of several parts each, which primi- tively were separated by cartilaginous septa; but as life advances, the parts belonging to each, gradually become consolidated, by the ossification of the cartilaginous matter, into the following indivi- dual bones, viz.: Two ossa innominata, os sacrum and os coccy- gis, each of which presents points of study important and interest- ing to the student of obstetrics. Section I.—Of the Bones of the Pelvis. We shall first describe the 1, os innominatum, one of the two bones that form the sides of the pelvis, and which articulate with the os sacrum, posteriorly, and with each other anteriorly. It is also called os coxalium (from coxa, the hip). It is called innomi- natum because the three bones, of which it was originally formed, grew together and formed one bone, which was then left nameless. 4 41 42 THE PELVIS. {Hooper). It is a large irregular bone, divided into three portions viz.: the Iliac, Ischiatic and Pubic, which are usually described as three distinct bones. It is usual with writers on Obstetrical Anatomy, in describing the bones of the pelvis, to commence with the sacrum and coccyx, and conclude with the innominatum. This order is here reversed, because the latter bone is the largest one in the assemblage, con- stituting, with its fellow, fully four-fifths of the organ, and present- ing many other interesting points for study. It is deemed proper, therefore, to assign it the position to which its importance entitles it. 2. The Iliac portion, or os Ileum (from ilia the small intes- tines : so named because it supports the ilia). It is also called the haunch-bone. It is the superior portion of the os innominatum, and much the largest of the three composing it. The Ileum, Fig. 1, is divided into body, neck, ala or wing* and crest or spine. The body, 1, is the thickest part of the bone and forms its base; it contributes rather more than one- third to the formation of the aceta- bulum, 2 from acetum, vinegar; so called because it resembles the aceta- bulum, or old saucer in which vinegar was held for the use of the table, a name given, by the Latin writers, to the cup-like cavity of the os innominatum, which receives the head of the thigh bone. Immediately above the body there is a depression, formed main- ly by the iliac portion of the great sciatic notch, 3, which is termed the neck of the bone. Rising up from the neck, and spreading out anteriorly and pos- teriorly, there is a broad sheet of bone called the ala or wing, 4, 4, 4, the superior border of which is known as the crest or spine of the ileum, which in the recent state is tipped with cartilage, 5, 5, 5. The crest terminates in four processes called spinous pro- cesses. They are the anterior superior spinous processes, 6. Im- mediately inferior to which there is a depression, 7, which helps to THE PELVIS. 43 form the neck; below this again, we have another process known as the anterior inferior spinous process, 8. Posteriorly we have a similar termination, the posterior superior spinous process, 9, then depression, 10, and finally the posterior inferior spinous process, 11. The superior border or crest of the ileum is thicker than the other portions of the ala, it is concave on its internal surface and inclines outwardly, except the posterior third, which looks rather inwardly, giving it a twisted appearance, which has been compared to the letter S, in shape. The bone presents two surfaces, the internal and the external; the internal surface is concave and smooth, the concavity is called the fossa of the ileum and affords a bed for the iliacus internus muscle ; the posterior surface which is presented in the annexed cut, is called the dorsum of the ileum, and is rough and uneven. Anatomists have described three curved lines, the spaces above and between these are slightly concave and give attachment to the gluteus maximus, gluteus medius and gluteus minimus muscles. This external or femoral surface has been called the external iliac fossa. * 3. The Ischium (from Greek unuz, the loin; so named because it is near the loin). The Ischiaticportion, or Os Ischium, also called FlG# 2. os sedentarium, or seat-bone is next in size to the ileum, and constitutes the most inferior portion of the innominatum. It consists of a body, neck, tuberosity and ramus. The body is the thick part of the bone; and like the ileum contributes rather more than one-third to the formation of the acetabulum, 2. Inferior to the body is a depression extending about two- thirds around the bone which is called the neck, 3. Jutting out from the posterior lateral portion of the neck is a sharp, lance- shaped spike of bone, called the spinous process of the ischium, of which more will be said hereafter. That portion below the neck is the tuber or tuberosity of the ischium, 4. It is a large strong structure, and supports the body when in a sitting position. Its most inferior border, 5, is very rough and uneven, and gives at- tachment to the long faciculus of the sacro sciatic ligament and ori- 44 THE PELVIS. gin to the semi-membranosis, semi-tendinosis, the long head of the biceps flexor cruris and quadratus femoris muscles. From the tuberosity we have the ascending ramus, 6, to meet the descending ramus of the pubis. The bone is smooth internally, and the exter- nal surface, which Is presented in the cut, is rough for the attach- ment of muscles. 4. The Pubes, pronounced pubes (from pubere, to begin to be covered with hair). Fig. 3. The pubic portion or os pubis, called for- l 5 merly picten from its resemblance to the ^^^^K^^*''^M6 ploughshare, is the smallest of the three \1f^S| ^ constituting the innominatum It forms the V " m anteri°r portion of the bone, and is divided Mm into body, neck and two rami. The body is ^* the thickest part of the bone, 1; and contributes PUBIS. rather less than one-third to the acetabulum, 2. The horizontal ramus, 3, extends from the body towards its fel- low on the opposite side, with which it forms the symphysis (from auv, syn, together, and