■:W
iiitf
--Hi
-•;!!)

499994515 

ICINI NATIONAl LIIIAIT OF MIOICINI NATIONAl IIIIAIY OF Mil


0I1VN INI3I0IW JO AlVafll IVNOUVN INI3I0IN 40 AIVIII1 1VN
#S{<^
  r»   ^   a      n
IICINI NATIONAL IIIIAIY OF MIOICINI NATIONAl IIIIAIY OF MM
                    0
/> !
\MZ\4
3uvn inisioiw 40 aiviim ivnouvn indioiw to aiviim ivn



              a

ICINI NATIONAL IIIIAIY OF MIDICINI NATIONAl IIIIAIY OF MID
ICINI NATIONAL IIIIAIY OF MIDICINI NATIONAl IIIIAIY OF MIC
 
\K/  \  V«
LIIIAIY OF MIDICINI NATIONAl LIBRARY OF MEDICINE  NATIONAL II
LIIIAIY OF MIDICINI NATIONAL IIIIAIY OF MEDICINE  NATIONAL II
O AIVIII1 1VNOUVN INOIOiW 4 0 A I V « I II 1VNOUVN  INOIOiW 41

 
 
THE
DUBLIN  PRACTICE
MIDWIFERY.
BY
HENRY MAUNSELL, M.D
           WITH NOTES AND ADDITIONS


                    BY


      CHANDLER R. GILMAN, M.D.,

L  PROFESSOR OF OBSTETRICS, AND THE DISEASES OF WOiJn AND
\       CHILDREN IN THE COLLEGE OF PHYSICIANS
 y            AND SURGEONS, NEW YORK
             NEW YORK :

W. E. DEAN, PRINTER & PUBLISHER, 2 ANN ST.

                 1845. 
» ^
WQ.
                    Entered
  According to the Act of Congress, in the year 1842, by
             CHANDLER R. GILMAN,
In the Clerk's Office of the District  Court for the Southerr
                 District, of New York. 
  EDWARD  DELAFIELD,  M. D.,
LATE PROFESSOK OF OBSTETRICS AND THE DISEASES OF WOMEN AND CHILDREN
      IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK.


  AS AN EXPRESSION OF HIGH PROFESSIONAL RESPECT


        AND AN ACKNOWLEDGMENT OF MUCH


                PERSONAL KINDNESS,


      THIS WORK IS RESPECTFULLY DEDICATED,


                           BY HIS FRIEND,
THE EDITOR. 
 
AUTHOR'S PREFACE.
   Those who are conversant with the  teaching of
 obstetric medicine must  have felt the difficulty of
 satisfactorily answering  a question  commonly put
 to them by students: What book do you recom-
 mend me to take to the Lying-in room ?  Yet there
 is, perhaps, no department of the healing art which
 can boast of more elaborate and valuable elemen-
 tary systems than Midwifery.  The works, how-
 ever, of Denman  and  Burns,  Ramsbotham  and
 Merriman,  though excellent in the  study, do  not
 supply the want  indicated in the question  of the
 student.  Their size and price (if there were noth-
 ing  else) disqualify  them for this  service;  and
 giving, as they do, the history and  principia  of the
 science,  conclusions  and  rules cannot be obtained
 from them with the facility and quickness so desira-
 ble to the student and practitioner during the bustle
 of actual business.  In addition, as an Irish teacher
 of Midwifery, I must say, that though, in general
principles, there can  be little room for disagreeing
with the distinguished authors just  named, still in
many points of practice the lessons of the  Dublin
School differ materially from those  inculcated in
          1* 
vi                   PREFACE.
their books.  Of those  publications  upon the sub-
ject  specially  intended as  manuals, it does  not
become me to speak ;  and I shall, therefore, merely
state shortly what I have wished  to do, and what
to avoid, in the construction  of the  present work.
My object, then, has been to give a concise, but, at
the same time, sufficiently full and  perfect account
of practical Midwifery ; not merely to furnish an
index of hard-named  diseases  and a jumbled cata-
logue of discordant remedies, but to supply an avail-
able knowledge  of all  appliances and  means  that
are known to be requisite for the safe conduct of a
patient through  the perils and accidents of child-
birth.   In attempting to attain this object, it has
been my endeavour to state honestly my own prac-
tice, which, I believe, agrees  pretty  closely with
that generally taught  in the schools of  this city, and
upon important  points will not be  found to differ
much  from  that recommended by  the  standard
authorities in Midwifery.  I have, however, given
few or no references, as these can be easily obtained
 from the larger  works, and here would  have served
 merely to swell the  book and  dilute the matter,
 which it is desirable  to offer in a form as concen-
 trated  as  possible.  In  a word, remembering the
 strictures of Lord  Bacon, it has been  my wish, not
 so much to give  " a history large of bulk and pleas-
 ant for variety, but to weed  out fables, quotations 
PREFACE.
Vll
needless  controversies  and  flourishes, which are
more proper for table talk and stories in a chimney
corner, than for an institution in philosophy."  It is
next to impossible to write a Preface without ego-
tism, and on that account a Preface should be brief:
this  shall, therefore,  be  concluded  by the simple
statement that the material for the following pages
was drawn exclusively from a syllabus of my lec-
tures, without any works being at the time consulted
upon the subject.  By the adoption  of this plan I
hoped that the language and style might be found to
possess  a freshness  not  to  be expected  in a mere
compilation.  How  far this and  the other ends al-
ready alluded to may have been attained, must now
be left to the judgment of the profession. 
 
EDITOR'S PREFACE.
   The work of which an American edition is now
presented to the medical public, came, rather acci-
dentally, into my hands,  soon after  its publication.
I was much struck with  its  clearness, and  its emi-
nently practical character.
   Within the last two years I have loaned my copy
to quite a number  of medical  students,  and from
them I have had but one opinion,  viz. that it was
"just what they wanted."  Believing, as I do, that
intelligent medical  students are the best judges of
what a text  book  ought  to  be, I was induced, by
their request, to superintend  the  publication of an
edition, chiefly  for the use of my class,  but,  at the
same time,  not doubting that  it would  meet  the
wishes, and  supply the wants of  very many obste-
tric  students throughout the country.  From  the
high opinion I have expressed of  this work, it will
readily be believed, that I would make additions
and  alterations  to it with great  caution;  a  few,
however, seemed necessary, and have been made.
The  chief of these is  the chapter  on pregnancy,
(Chapter vii.) which has been  almost entirely re-
written.  In other places I have ventured to make 
X               EDITOR'S PREFACE.
a few additions, chiefly amplifications, they are  in-
dicated  by brackets  [thus].   On one  or two occa-
sions I  have felt  compelled  to dissent from  the
opinions of the Author; in such  cases my views
are expressed in  notes,  which are  distinguished
from those  of  the author by  the signature,  Ed.
Hoping that the work may prove  useful to medical
students, and especially that my own class may re-
ceive this attempt  to promote  their improvement,
with the same kindness with which they  have  re-
warded  my  previous labours, I  commend the work
to the candid consideration of the profession.

  P. S.—The Anatomical descriptions in Chapter I,
are condensed from Knox's Translation of  Cloquet. 
CONTENTS.
                                                   Page
Chap. I. The Pelvis.......13
     II. The Fcetus      ......       28
    III. Mechanism of Parturition    ....     35
    IV- Organs of Generation      ....       43
     V. Functions of Generative system    ...     53
    VI. Gravid Uterus......       60
   VII. Signs of Pregnancy.....19
   VIII. Natural Labour  ------      108
    IX. Duties of Accoucheur.....118
     X. Varieties of Natural Labour     ...      136
    XL Difficult Labour......140
   XII. Obstetric Operations.....158
   XIII. Preternatural Labour.....1~4
   XIV. Hemorrhage......188
   XV. Convulsions       ......215
  XVI. Plurality of Children.....224
 XVIL Presentation of Funis      ....      227
XVIII. Rupture of Uterus......229
  XIX. Management of Puerperal Women    -    -      233
   XX. Puerperal Fever......245
  XXI- Ordinary Fevers of Puerperal Women     -      263
 XXII. Phlegmasia Dolens      .....269
XXIII. Puerperal Mania.....2~5 
 
              THE

     DUBLIN PRACTICE

              OF

MIDWIFERY.
                 CHAPTER I.

                  THE PELVIS.

  It is customary to commence the study of Mid*
wifery with the consideration of the bony structure
of the pelvis ; a  knowledge of the anatomy of this
part being, in fact, essentially requisite for the under-
standing of the  mechanism wThereby the  foetus is,
either naturally or artificially, transmitted into  the
world.  At present I shall strictly confine my obser-
vations to such of its properties as may be of obste-
tric interest, other points being sufficiently  noticed
in surgical and anatomical works.
  The pelvis, then, is a firm osseous case, formed in
the  adult of four bones,—the  two ossa innominata,
sacrum, and coccyx.
  [The  os  innominatum, called also  the iliac, the
coxal or haunch bone,  is a tdouble, unsymmetrical
bone, of a quadrilateral  form, and very irregular
        2 
14        DIT.I.IN PRACTICE OF MIDWIFERY.
figure.  It is the largest of the flat bones, and forma
the lateral and anterior part of the pelvis.
   It has two surfaces, the external  or femoral, and
the internal or abdominal surface.
   The external or femoral surface is of no great in-
terest to the accoucheur ; superiorly and posteriorly
it forms a wide fossa,  convex  above, concave  be-
low, called the dorsum  of the  ilium, or  sometimes
the external iliac fossa.   Downwards and forwards
from this surface is the acetabulum or cotyloid cavity,
in which the head of the femur is lodged.  Before and
below the  cotyloid cavity, is observed  the foramen
ovale, called also the thyroid, or obturator foramen.
This perforation is  oval in the male, triangular in
the female, though  the angles are more or less round-
ed off.  At the upper edge of this hole posteriorly,
there is a groove, in which the obturator vessels and
nerves pass. In the recent subject the obturator fora-
men is closed, except at the groove before spoken of,
by a dense fibrous membrane, the obturator ligament.
   The internal or  abdominal surface of the iliac
bone, is at the upper part directed forwards, at  the
lower backwards ;  at the upper  and posterior part
there is a rough, irregularly oval  surface,  corres-
ponding with the lateral  surface  of the sacrum,  to
which it is articulated.   The rest of the upper part
of this surface is occupied by a wide cavity of no
great depth, called  the iliac fossa, or  to distinguish it
from the dorsum, the internal iliac fossa.  It is limi-
ted below, by  a broad, and rounded prominent line,
called linea ilio peclinea, which  forms a part of  the
superior strait.  Beneath  this  line  is  observed a 
THE PELVIS.
15
smooth, inclined, nearly plain  surface, covered by
the obturator internus, and levator ani muscles, also
the inner orifice  of the obturator hole, with its
groove, and lastly, a second surface, narrower above
than below, which corresponds to the  bladder.
   The os innominatum has four edges.
   1.  The upper  edge,  called  also the  iliac crest.
This is thick, uneven,  convex, inclined  outwards,
except posteriorly, where it is directed  a little in-
wards, twisted upon itself like an italic s, thinner in
the middle than at the extremities, and longer in the
female than in the male, being six inches  in extent
measured directly and eight when its turnings  are
followed.
   2. Lower edge, shorter  than the  other, inclined
inwards, presenting below a  thin crest, more  ob-
lique and blunter in the female, bent outwards form-
ing with its fellow on the other side, the  pubic arch
or angle.  This crest is surmounted anteriorly by  a
vertical surface, of an elliptical form, which uniting
with a similar surface, on the bone of the other side
forms the symphysis of thepubes.
   3. Posterior  edge, very irregular, oblique from
above downwards, and from without inwards, at its
union with the upper edge it forms the posterior su-
perior spinous process of the ilium, a large project-
ing spine, which is  separated  by a notch from an-
other spine, called the posterior inferior spinous pro-
cess.   This latter is rounded, flat, sharp, and formed
by the posterior part of the  surface, which  articu-
lates with the sacrum.  Beneath  this process there
is  a deep notch, which with a  part  of the sacrum 
16        DUBLIN PRACTICE OF MIPWIKF.RY.
forms the great sciatic notch ;  it is terminated below
by a thin, pointed, triangular  spine, projecting more
or less inwards and  downwards, called the sciatic
spine.   Beneath this is a  notch or groove, round
which the  tendon of the  obturator  internus plays
like a pulley, and beyond  this  a  broad rounded or
oval eminence called the tuberosity of the ischium.
   4. Anterior edge, concave, oblique above, hori-
zontal below, uniting with the  upper edge it forms
the anterior  superior spinous process  of  the ilium.
Below, and a little forward of  this we have the an-
terior inferior spinous process, blunter and less pro-
minent than the other.  Proceeding downwards and
forwards we have, first the  ilio-pectineal eminence
and then the spine of the  pubes near the union of
the anterior with the lower edge.
   The os innominatum is developed  in three parts
or portions, the  ilium which is  uppermost  and  most
posterior, the pubes anterior and  the ischium below.
The upper and  horizontal portion of the pubes  is
called  its body,  the  lower its  ramus; so of the is-
chium, the posterior  portion constituting the  body,
the anterior the ramus.
   Sacrum.  This is a  symmetrical  pyramidal, tri-
angular bone, curved forwards  below,  situated  at
the posterior part of the pelvis,  having  one of the
ossa innominata on either side, the vertebral column
above, and the coccyx  below.
   It is perforated for  its whole length  by a  canal
called the sacral, a continuation of the vertebral.
   In the sacrum we remark  the following parts.
   Four surfaces, a  spinal or posterior, a pelvic or 
THE PELVIS.
17
anterior, and two lateral.   The spinal or posterior
surface is convex, rough and irregular ; in the  me-
dian line, are four or five eminences which appear
to be  imperfect or rudimental spinous processes ;
they are every now and then  united, and  form a
continuous ridge.  Beneath them is the sacral canal
in which is lodged the lower portion of the cauda
equina: the canal terminates in a triangular open-
ing, closed behind in the recent subject, by the sacro-
coccygeal ligament and limited laterally, by two tu-
bercles called the horns of the sacrum.
   On either side of  the sacral eminences are four or
five  holes  communicating  with the sacral canal,
through which the posterior  sacral nerves pass out.
   The pelvic or  anterior surface of the sacrum is
the part most interesting to  the  accoucheur.  It is
smooth, and concave, and its concavity is called  the
hollow of the sacrum ; it is traversed by four promi-
nent lines, indicating the points of the union of the five
different pieces of which this bone is composed in
childhood.   Between these lines we  see five plates
or surfaces slightly concave, most  so below which
answer to the anterior surfaces of the bodies of the
vertebrae.  Laterally from the  prominent lines are
the anterior sacral foramina, four in number, more
smooth and regular in shape than the posterior,
though like them diminishing  in  size  as  they go
downwards.  In the centre  of the upper surface of
this bone there is a  projection, which in the natural
position of the  parts overhangs  the hollow of the
sacrum, and diminishes  the  antero-posterior diame-
ter of the superior strait, this is called the promonto-
             2* 
18       DUBLIN PRACTICE OF MIDWIFERY.
ry  of the sacrum,  and is  one of  the  chief  land-
marks used by an  accoucheur.   The  two iliac or
lateral surfaces,  are  irregularly triangular,  very
rough, and  corresponding to the surfaces  of the
iliac bones,  to which they arc united.
  The base of the sacrum  is directed upwards, and
a little forwards, and by its oval central  portion is
united to the last lumbar vertebra.   The  snnnnit of
the bone is directed downwards and forwards, and
to it is attached the coccyx.
   The coccyx.  This little bone is developed in three,
four  or  five  pieces, whose  size diminishes  from
above downwards ;  it is attached to the sacrum by an-
terior and posterior ligaments. This union admits of
some motion early in life, but anchylosis (false) usu-
ally takes place about thirty, unless its occurrence is
prevented by child-bearing.  The coccyx  has a gen-
eral resemblance to the sacrum, being  convex and
rough behind, concave and smooth before, and pro-
longing the concavity or hollow of the sacrum.]
  These   different  bones  are  connected to  one
another by four articulations.
  Two serve to unite the sacrum with the os  inno-
minatum of either  side.   These are denominated
the sacro-iliac synchondroses, and  possess remark-
able strength, both  from the manner in which the
prominences and hollows of  the opposed surfaces
are, as it were, morticed into each  other, and  also
from  the strong bands of ligament stretched across
the posterior and  upper edges.  A ligamentous ex-
pansion further strengthens the front of the articu-
lation ; but this is thin and membranous, that it may 
THE PELVIS.
19
not, by its bulk, diminish the  capacity of the pelvic
cavity.  Two other remarkable ligaments on either
side  connect the sacrum and ossa innominata, but
seem rather intended to  complete the walls of the
pelvis than to add security  to the joint.   These are
the  anterior and posterior sacro-sciatic ligaments,
both arising from the sides of the sacrum  and coccyx,
and  attached, the former to the spine and the latter
to the tuberosity  of the ischium.
   The third  pelvic articulation is that between the
two ossa innominata themselves, and denominated
the symphysis pubis.  This differs from the  sacro-
iliac synchondroses in having an interarticular sub-
stance interposed between  the two osseous surfaces,
in addition to the fibro-cartilage covering each  of
those.   The joint is secured  by bands of ligament,
which, for the reason already assigned,  are stronger
and more bulky externally.   There is also a ligament
termed the  sub-pubic, which occupies  the apex  of
the arch formed  by the rami of the pubic bones.
   The last articulation  is that between  the sacrum
and coccyx.  In it the union is  effected by  an in-
terposed substance  analagous to that between  the
vertebra?, and is secured by ligaments anteriorly and
posteriorly.   The sacro-coccygeal joint  is  capable
of flexion and extension  to a considerable  extent,
 and is the  only one in the  pelvis naturally admitting
 of motion.   In certain animals, as the cow, the other
 articulations  become relaxed  about the period  of
 parturition ;  and it has been surmised  by some au-
 thors, but  without  sufficient proof, that a  similar
 relaxation always occurs in  the human female. 
20        DUUI.TN PRACTICE OF MIDWIFERY.

  Before preceding further we must observe, that
the entire pelvic case is divided into two  portions
by  the bony  ridge or angle  which, dividing the
body from the ahc of the os innominatum, is denomi-
nated the ilio-pcetineal  line.  The  space above this
line is termed the hypogastric cavity, or false; pelvis ;
that below it, the true, or lesser pelvis.  The hypo-
gastric ca\ itv possesses no bony wall anteriorly, but
is bounded laterally  and  posteriorly by  the  aire
ilii and the  lumbar vertebra*.  Its  dimensions vary
much, and are of minor importance to the  obste-
tric student; but the  distance  from the top of one
ilium to  the other, at the widest, is, in a  standard
pelvis, between ten  and eleven inches ;  and that
between the two antcro-superior spinous processes
somewhat more than  nine inches.
  We now come  to the  consideration  of  the true
or lesser pelvis, which, from its forming the unyield-
ing boundary of the canal through which the mature
fcetus is to be  transmitted, is more  closely allied to
our present  subject.  In describing and measuring
this canal, three portions are usually  specified : the
brim, called  also the superior strait or introitus ; the
cavity ; and the outlet, or inferior strait or detroitus.
  The brim formed by the  ilio-pectineal lines and
the  angle of union between the sacrum and lumbar
vertebra is  somewhat elliptical in shape, the  regu-
larity of the figure being interrupted behind by the
projection of the promontory or base of the sacrum.
The dimensions of this aperture  are measured by
four lines passing through its centre: the longest of
these, passing from side to side, and  denouunated 
THE PELVIS.
21
the transverse diameter, is usually about five inches
and  a quarter in length ; the  shortest, being  that
drawn from the centre of the base of the sacrum to
the symphysis pubis, and termed the antero-posterior,
or  conjugate  diameter, measures in the standard
female pelvis four inches and a  quarter.  The two
remaining  lines,  called the  oblique  diameters, are
those stretching from the sacro-iliac articulation on
one side, to the back of the acetabulum on the other.
The length of each of these is commonly five inches.
By many authors the last diameter is mentioned as
the longest, a mistake arising from the circumstance
of its actually being  so in the  recent pelvis ; the
length of the transverse diameter being then some-
what diminished by the prominence of the  psoae
muscles and great vessels and nerves.
   The  outlet, or  inferior aperture, presents in the
dry preparation  an extremely  irregular  figure, its
margin being interrupted by three deep triangular
notches ; viz. the two sciatic, and that between the
rami of the pubes.   In the recent subject, however,
the  two former are subtended by the  sacro-sciatic
ligaments,  in such a manner as to give the aperture
a quadrilateral character.   Its dimensions are de-
scribed by two lines: one, passing between the inner
margins of the tubera ischii, and called the transverse
diameter, averages in length four inches; the other,
denominated the long, or anteroposterior diameter,
is stretched between the inferior margin of the sym-
physis pubis and the tip of the sacrum, and measures
five inches.  In examining a pelvis, with the coccyx
attached,  it  will be  observed,  that  the distance 
22        DUBLIN PRACTICE OF MIDWIFERY.

between the same  point of the symphysis and  the
tip  of  this bone, is  not  more  than  four  inches.
Owing, however, to the mobility of the sacro-coccy-
geal joint, the space admits of being enlarged to five
inches, or to the full extent of the distance between
the point of the sacrum and the lower margin of the
symphysis.  In making these measurements it is also
to be noted, that the directions of the long and short
diameters  of the  brim and  outlet are  reversed; a
provision of which a beautiful and satisfactory  ex-
planation will appear, when we come to  examine the
relative dimensions of the  mature fcetus.
  While  considering  the  outlet  of the pelvis,  wc
may  conveniently  notice  the arch of the pubis.
This is  much wider, and assumes more  the  form of
an arch in the  female than in the  male  ; in the for-
mer also its rami are  bevelled in such a manner  as
to give a direction forwards to  any body  passing
through the canal of the pelvis.   A line subtending
this arch measures about three inches.
  The cavity of the  pelvis  being more  capacious
than either  the brim  or outlet, does not require  to
be accurately measured ; nor, from its peculiar form,
would it be easy  to measure it.   We may remark,
however, how  admirably the hollow of the sacrum
(for  this purpose  deeper in the female  than in  the
male), is adapted for the lodgment of the bulky face
of the child, while^ the convergence of  the point of
the sacrum and  spines of the ischia is well calculated
to second the bevelling of the rami pubis in directing
the vertex forwards.   The depth of the female pelvis
new remains to be ascertained, and we shall find it 
THE PELVIS.
23
to differ much in different parts.  At the symphysis
pubis it is seldom  more than  one inch and a half.
At the sides, from the brim to the tubera ischii it is
about three inches and a half, and  behind, a right
line drawn from the base to the tip of the sacrum
measures, generally, four and  a half or five inches.
From this  irregularity of depth in  different parts,
we may easily see, that a body may be close to the
outlet anteriorly, while it still  has to traverse a con-
siderable length of the back and  sides of the pas-
sage.
   The bearing  of the  pelvis  on  the  trunk claims
some attention.   In the erect  posture  of the body,
the  axis of  the trunk being perpendicular, there
would have been  constant  danger  of prolapsus of
the viscera, if the  axis of the pelvic passage  had
been continuous  with it.  This,  however, is  not
the case; but the line representing the latter  axis
bisects the axis  of the trunk so obliquely as to form
an angle inferiorly of  about thirty-five degrees.   In
other words, were the  axis of the trunk produced
downwards, it would   fall,  not upon  the  centre of
the pelvic aperture, but upon the symphysis pubis.
   [Difference between the male and the female pelvis.
 The general characteristics.  The male  pelvis  is
 deep, narrow and  conical: the sacrum being  long
 narrow and strait.  The linea ilio-pectinea proceeds
 from the sacro-iliac symphysis, nearly directly for-
 wards, and the  promontory of the  sacrum projects
 more.  The spine and tuberosity  of the ischium, are
 larger, rougher, and project more  inwards, and the
 pubic arch is narrower, the tuberosities which form 
21        DUBLIN PRACTICE OF MIDWIFERY.
the base being nearer together.  We have already
said that the thyroid foramen is in the mal - oval, in
the female triangular.  The female pelvis is shallow,
wide, and  cylindrical, the sacrum shorter and  more
curved, its hollow of course deeper.   The superior
strait is round in the male,  oval  in the female, the
inferior outlet is wide, and somewhat square in the
female, narrow and triangular in the male.]
   In the foregoing observations, we  have, to avoid
confusion, spoken of the axis of the pelvis in the or-
dinary sense of that term, as if it wen; a right line
passing through the centre of the passage.   No such
right  line, however, can exist; for the whole pelvis
is  so bent that both its brim and outlet look toward
the forepart of the body ; and the axis of the former,
or a right  line passing through its  centre, would, if
produced  downwards, fall  upon the point of the
sacrum; while  the axis  of the  outlet,  if produced
upwards, would  strike the promontory of that bone.
Hence it is obvious, that what obstetricians mean
by the axis of the pelvis must be a curved line, pass-
ing respectively through  the centres of both brim
and outlet, and nearly  corresponding in its curva-
ture to that  of the  sacrum.  The practical deduc-
tions  from these facts are, that a  body to get into
the pelvis  through the brim  must pass  downwards,
and backwards : and to get out of it, at the outlet,
must proceed downwards, and forwards.
   The foregoing are the  chief points  of obstetric
interest in a standard female pelvis.  Deviations are
occasionally met wkh, and  may consist  either in
deformity of shape ; in deficiency, or in  excess of
capacity. 
THE PELVIS.
25
   The most usual cause of deformity of the  pelvis
 is, doubtless, the occurrence of rickets during in-
 fancy, when the bones, not being  possessed of suf-
 ficient firmness, are pressed from their natural posi-
 tions by the weight of  the trunk and counteracting
 resistance of the lower extremities.  The same ef-
 fect is said to be produced, in a similar way, by the
 disease called mollities  ossium ; and deformity may
 also, sometimes, be occasioned  by fractures,  or the
 occurrence  of exostosis.   The  contraction of the
 passage from rickets  generally occurs  at  the brim,
 and oftener from before backward than in the late-
 ral direction.   It, however, may exist in a great va-
 riety of forms, and occasionally is  so extreme that
 the  canal is compressed into  a T-shaped slit.  In
 some cases  the capacity of the  aperture will be
 much diminished at one side, while, at the other, lit-
 tle or no alteration will be observable.  It is said,
 that in  many cases the deformity will actually in-
 crease after every successive labour, and that the
 act of parturition, which was, perhaps, at first only
 difficult, may, after some repetitions, become  abso-
 lutely impossible without artificial aid.
   The pelvis, without being deformed, is in some
 instances unusually small, and should the foetus then
 happen to be disproportionately  large, it is  ob-
vious that  the same  effects must be produced, as
 if the  passage was  morbidly   diminished in  size.
On the other hand, we have  said, that the pelvis
may deviate  from the  standard, in  having an ex-
cessive  capacity, in which case the  attendant in-
conveniencies will be, liability  to retroversion and
             3 
26        DUBLIN PRACTICE OF MIDWIFERY-
prolapsus of the  uterus, and  to sudden, unexpected
delivery.*
   The dimensions, and  other  characters just men-
tioned, can all  be  easily  enough ascertained upon
the dry bones,  but when  we  come to enquire into
them in  the living  body, we  find  it quite another
affair.  With  the  view of assisting  the  enquiry,
several instruments  have  been invented,  the  most
remarkable of which are—the  pelvimeter of Cou-
touli,  and the callipers  of Baudelocque.  The lat-
ter were to be  used externally, to measure the size
of the pelvis, in  a way precisely similar to that in
which they are employed  by  mechanics.  The for-
mer resembled a shoemaker's rule, one limb  of which
was to be thrust  into the vagina, and planted against
the  promontory  of the sacrum,  while  the other,


  • The Obstetric Museum of  the College  of Physicians and
Surgeons, contains  a pelvis, the diameters of which far  er*
ceed any that I have seen, and lam induced to put them upon re-
cord, as they are greater than those  of the large  pelvis spoken
of by Mr. Burns, in  the notes to his work on  Midwifery.
                    SUPERIOR STRAIT.
    Antero-posterior diameter,         5 inches.
    Transverse      do             5 inches, 9 lines.
    Oblique         do             5 inches, 7fc lines.
                    INFERIOR STRAIT.
    Antero-posterior diameter,         5 inches, 6 lines.
    Transverse       do             5 inches, 9 lines.
  This pelvis is remarkable also, for its excessive shallowness.
The distance from the top of the sacrum to the apex being only
3 3-8 inches—depth of pelvis at the sides 3 inches 3 lines.  It is
scarcely possible to conceive of a mal-formation  which would
more certainly expose the woman who possessed it to all the dan-
gers of a too large pelvis.—Ed. 
THE PELVIS.
27
moving upon a graduated rod, was  to  be brought
into contact with the  symphysis pubis, thus point-
ing out the measurement of the antero-posterior di-
ameter.  It is unnecessary to  do more than men-
tion those fantastic contrivances, their inefficiency
and inapplicability being fully recognized by British
accoucheurs.
  We can, however, generally obtain useful inform-
ation  by the employment of the fingers alone, and a
few remarks on the mode of using them will be ne-
cessary.  By passing the index finger into the vagi-
na, and carrying it upwards and backwards, we can
in many cases touch the promontory of the sacrum,
and if we then mark the part of the finger or edge
of the hand in contact with the arch of the pubis,
we can easily, by making a trifling deduction for
the thickness of the symphysis and  the obliquity of
the finger's direction, estimate the length of the con-
jugate diameter.  But sometimes, while this diame-
ter is  of sufficient extent, considerable contraction
may exist on  one or both sides of it.  In such a
case, a sharp angle must be formed  at the back of
the symphysis, and on this point we can satisfy our-
selves by introducing two or  three  fingers into the
vagina, and placing them in cpntact with the part;
if they lie evenly, side by side, there can be no very
acute  angle, and consequently no  remarkable  dimi-
nution of capacity on either side of the  conjugate
diameter.  By using the fingers, we are also enabled
to discover any irregular ridges of bone, or tumours,
that may have the effect of diminishing the capacity
of the passage. 
28
                 CHAPTER II.

                  tiii: Fa.Tts.

  We mav now advantageously turn our  attention
to the properties of the fa-tus, so  far as they relate
to its passage through the pelvic canal.
  While in the womb, the various parts of the child
are packed together in such a manner as to occupy
the least possible space, forming  a  mass somewhat
of  an oval shape.  The  head is flexed, so as to
bring the chin upon the thorax, the arms are applied
to the sides, and the forearms and hands flexed and
applied, often crossing each other, to the breast; the
thighs are flexed on the abdomen, and the  legs upon
the thighs, the feet often, like the  hands, crossing
each other.   In this way the head forms one ex-
tremity of the  oval we have  mentioned,  while the
other is composed of the feet and nates.
   The foetus, we are  to observe, is somewhat  flex-
ible in a lateral direction, very much so  anteriorly,
and but little posteriorly.  The parts of it requiring
to be particularly measured and  examined,  are the
head, the shoulders and the breech.  The first more
especially  demands our attention, both  as  being,
upon the whole, most bulky and least compressible,
and also as being the part which  is usually first en-
gaged in the pelvic passages.
   The head of the foetus, detached and without the 
THE FffiTUS.
29
face, is described as oval, with  the large extremity
posteriorly.   The  desire of pointing  out resem-
blances seems to be a besetting passion with  anato-
mists ;  but, in truth, in this as in many other instan-
ces, the likening of the head to any  known  figure
conveys but little  information.   The  student, then,
who desires correct notions upon  the subject, must
set before him a foetal skull of  the standard (or av-
erage) dimensions and shape, and carefully examine
upon it the properties which I shall now endeavour
to indicate.
  The first circumstance that strikes us in our ex-
amination is the great mobility of the bones upon
each other,  owing to  their incomplete ossification
and the cartilaginous  connection between them.
  [To these separations between the bones the term
suture is applied.  That  which   passes from  before
backwards, between the  parietal bones  is called the
sagittal suture.  That which separates  the parietal
bones from the frontal is called the coronal  suture,
while that between the  parietal bones  and the oc-
cipital bone behind is the lambdoidal suture.]
  The mobility of fhe bones  is also increased by
the prolongation of the  sagittal suture  through the
centre of the  os frontis, so as  actually to divide it
into two bones, and it can  be produced to such an
extent as to  admit of the  bulk of the  head being
considerably diminished  in one of its  diameters, and
proportionally increased  in another.   The  situation
and yielding nature of the sutures requires to be at-
tended to ; their general direction is the same as  in
the adult, but the sagittal is always prolonged, as we
               3* 
30        DUBLIN PRACTICE OF MIDWIFEHY.

have mentioned, to the root of the nose :  sometimes,
but rarely,  it passes backward into  the  occipital
bone.  At the junction of the lambdoid and sagittal
sutures, owing to the non-ossification of the occipi-
tal  and parietal  bones,  a triangular  space is left,
closed only by cartilage,  and  called the  lesser  or
posterior fontanelle.   A similar but larger space oc-
curs between the parietal and  frontal bones, at the
intersection  of  the  coronal  and sagittal  sutures.
This is termed the greater or anterior fontanelle, and
is distinguishable by being lozenge-shaped, and hav-
ing four concurrent  sutures, while the former is tri-
angular, and has only three  concurrent sutures.  A
knowledge of the differences between these  fonta-
nelles will assist us in a diagnosis of the situation of
the head during labour.
  We shall  now enquire into the dimensions of the
standard foetal head, which are usually measured by
lines, somewhat loosely denominated diameters.
  The shortest of these  is the bi-parietal, or that
stretched  between  the tuberosities  of the parietal
bones on  either side, and  is about  three  inches and
a half, or  three inches  and a quarter in length ; this,
it is plain, can meet  with  no obstruction in passing
through any part of  the standard pelvis, the shortest
diameter of the  latter  being nowhere less  than four
inches.
  There  are, however,  three  other measurements
to be considered, which, from  being all in the long
axis of the  head, are usually called the long diame-
ters.  One  or other  of these,  together with the  bi-
parietal diameter, may be considered as the measure 
THE FffiTUS.
31
of the bulk of the passing body, in every head pre-
sentation.
  The shortest, (called occipito  frontal), and that
which is most usually opposed to the long diameters
of the pelvis, is described by an imaginary right line,
extending from the upper part of the forehead to
the lower part  of  the  occiput.  This can only  be-
come the opposing diameter when the chin is very
much  depressed toward the chest, as it usually is,
the vertex being  the presenting  part.  The length
of this line  is about four  inches, which, it will be
remembered, is not greater than the  shortest diame-
ter of the pelvis, but as it  is  naturally opposed to
the longest diameters of that passage, there can, of
course, be no want of room in such  a case.  Such,
then, are the relations, as to dimensions, between the
head and pelvis under the most favourable  circum-
stances.
   The next in length of the great diameters, is  that
between the lower part of the forehead  and the up-
per part of the occiput, (called antero-posterior.)   It
usually measures four inches and a half, being about
half an  inch longer than the last.  This comes to
be the opposing  diameter in  that variety of head
presentation in which the head is extended upon the
neck  and the  forehead  applied  toward  the pubis,
called also   the fontanelle presentation, in conse-
quence  of  the anterior  fontanelle being  in  such
cases the presenting part.
   The longest diameter of the head, is that between
the point of the chin  and  the vertex.   It measures
five inches, and is the opposing diameter in another 
32        DVBI.IN PRACTICE OF MIDWIFERY.

variety of natural presentation, viz. when the face
is the presenting part: it must be obvious that  this
position of the head will materially increase the dif-
ficulties of  its transit.
  The depth of the head, from the sagittal suture to
the occipital foramen, may be  estimated at  about
three inches and a quarter.
  The dimensions, of course, vary in different indi-
viduals, but those we have given are about the aver-
age.  The   heads  of female  children  are usually
somewhat  less than  those of males ;  Dr. Joseph
Clark* estimates the difference at one twenty-eighth
or one thirtieth of the circumference.
  The movements of the head now claim a little at-
tention.  These are, flexion forwards and extension
backwards, both,  especially  the  former,  capable of
being carried to a considerable extent.   Direct lat-
eral inclination is only admitted to a  slight degree,
and rotation can be carried just so far as to allow
of the chin resting on the shoulder, but not farther
without endangering the child's safety.
   We have spoken of variations from  the natural
form and average  size  of the pelvic  passage, and
we shall also  be  able to detect  similar deviations
from the standard in the head of the foetus.  It may,
for  instance,  be  very  small, which  of course  will
have no effect, except to facilitate its expulsion.   It
may, on the other hand, be  very large, and if it be
so, disproportionately with  the size  of the  pelvis,
difficult labour will  be the  consequence, and it is
* Phil. Trans- v. 76. 
THE FQ3TU8.
33
even possible that the use of instruments may be
necessary.   On this point, however, it  is proper to
think with caution, as the extraordinary change of
shape which may be effected on the head by com-
pression, will often suffice to counterbalance  even  a
considerable disproportion of size.
  The head is occasionally  enlarged, while  in  the
womb,  by hydrocephalus,  and  may require dimi-
nution by  means of instruments: the head of  a
dead foetus is also sometimes swollen by the air dis-
engaged during putrefaction.  A peculiar form of
head is not very rarely met with, in which the upper
portion of the cranium  is  mal-formed, and partly
deficient, and the situation of the brain occupied
by a sort of fungous mass.   These are  denominated
acephalous,  or (by the  Germans) cat-headed foetu-
ses :  they may create confusion in our first exami-
nations by wanting the peculiar firm feel of the nat-
ural head, but they are not often themselves produc-
tive of difficulty  in the act of parturition.
   The  shoulders of the  foetus are generally about
five inches in breadth, but the  effect  of their size
is  counteracted  by their  possessing capability of
motion to such an  extent,  that one can precede the
other in their entry into the pelvis.
   From what has  been said it is obvious, that the
long axes of the head and shoulders  decussate, or
are at  right angles with each other ;  and  we can
now perceive the  value of a similar  arrangement
which we adverted to before, of the long diameters
 of the brim and outlet of the pelvis.   At  the mo-
 ment when the head is escaping in the most favour- 
34        DUBLIN PRACTICE OF MIDWIFERY.
able manner through  the latter,  the  shoulders  are
accommodated in the long diameter of the  former.
   We have next to say a word upon the pelvic ex-
tremity of the fetus,  as  it is packed  in  the uterus,
and sometimes presents in the pelvic  passage.  Oc-
casionally, the nates form the whole bulk of the pre-
senting part;  at other times the feet  arc assembled
with them ; and again, the feet or knees  pass first
into the world.  These differences  make  a good
deal of variation in the antero-posterior diameter of
the pelvic extremity, but it is  almost always less
than  the  transverse,  which pretty constantly mea-
sures four inches.
   Presentation  and  position.—Before proceeding
to the consideration of the mode  in which  the child
is propelled through the pelvis, or, as  it is called, the
mechanism of parturition, we  shall briefly explain
the meaning we attach to two  words  which we
shall  frequently employ,  and  which, indeed,  have
been already made use of in the preceding observa-
tions.   The words alluded to  are, presentation, and
position.  By  the first we wish  to designate  that
part of the child which, during labour, may be op-
posite the centre of the pelvic passage ; and by the
second, the relative  position of  the  child with re-
spect to the bones of the mother's pelvis.   Thus, if
we say the  vertex presents, we  announce  the pre-
sentation ; and if we add, with the occiput toward
the pubis, or toward the sacrum, as the case may
be, we describe the position. 
35
                CHAPTER III.

           MECHANISM OF PARTURITION.

  We have now to  consider the modes in which
nature essays to accomplish  the  transit of the ma-
ture foetus through  the bony canal  of the  pelvis,
and shall find, that of these  there are three grand
varieties ; viz.  presentations of  the  head ; of the
breech or lower limbs ; and  of the upper limbs, or
side of the body.
  In either of the two  first varieties  the foetus pre-
sents  an  extremity of its long axis, and a brief con-
sideration of the various measurements and charac-
ters described in the last chapter, will be sufficient
to explain, that in ordinary cases no material obsta-
cle to its  passage can  exist.  In the third  variety,
the side of the  child presenting, the long  axis lies
transversely to the pelvic aperture, and can only be
expelled under peculiar circumstances (afterwards
to be explained), to  the production of which nature
unassisted is rarely competent.
   In  a great majority of cases the head  is  the pre-
senting part; and we shall, therefore, first  examine
the mechanism of its transmission.
   Some varieties exist as  to the position in which
the head enters the brim of the pelvis ; and of these
French  authors have,  with their usual  ingenuity,
taken advantage, and  confused  the  subject by at 
36        DUBLIN PRACTICE OF MIDWIFERY.
least  seven subdivisions.  For practical  purposes,
however, such minuteness is unnecessary, and satis-
factory notions  upon the subject  may be  conveyed
by explanations of three varieties.  In the first and
most common, the head enters the brim of the pel-
vis with the sagittal suture in  the direction of either
of its oblique diameters, and the posterior fontanelle
applied to the back part of either acetabulum.  In the
second, the sagittal suture is  still in the same  direc-
tion, but the  posterior fontanelle is applied  to either
sacro-iliac synchondrosis.   In this variety  the head
occasionally, but rarely, is expelled with  the  face
toward the pubis.  In the third variety the  face is
the presenting part.
  In the first position, then, the head enters the brim
of the  pelvis  with its posterior fontanelle directed to-
ward either acetabulum (generally to  the left,) and
the forehead  directed toward  either sacro-iliac syn-
chondrosis (generally to the right).  The presenting
part, or that which we may touch  most readily upon
introducing a finger into the  outlet of  the  pelvis, is
the superior  portion  of one  of the parietal  bones
near its tuber ;  consequently, the head descends ob-
liquely into the  pelvis, neither the vertex nor the
sagittal suture being the lowest part, but one  of the
parietal bones ;  the right, when  the  posterior fon-
tanelle is directed toward the left acetabulum, and
the left when it  lies toward  the opposite side.   By
this oblique position of the head, its  transverse di-
ameter is rendered somewhat less than that  which
would be described by a line passing between the
two parietal  tuberosities, which, if the vertex  was 
            MECHANISM OF PARTURITION.          37

the lowest or presenting part, would be the moving
transverse diameter.  During  this stage of the pro-
cess, the  chin  of the foetus is depressed upon its
chest, so as to bring the shortest of the long diame-
ters of the head, or that between the lower part of
the occiput and the upper part of the forehead, into
the direction of the oblique or longest diameter of
the mother's pelvis.  At  this time the greater  fon-
tanelle or  the vertex  is lower  than the lesser, and
being situated anteriorly, can, from the  shallowness
of that portion of the pelvis, be felt very near the
external opening.  As the  head descends, the  face
turns somewhat into the hollow of the sacrum,  and
the vertex approaches the symphysis pubis.  It is,
however,  the   parietal  bone  which first  escapes,
and the vertex does not reach the  anterior central
line until in the very act of being expelled from the
outlet.   The mechanism by which  this turning is
accomplished is extremely interesting.   The hollow
of the sacrum is provided for the reception of the
bulky face of the  child, while the  convergence of
the point of the sacrum and  spines of the ischia,
and the bevelling of the inner  surface of the  rami
pubis form so many inclined planes, upon which the
round smooth cranium is guided forward under the
pubic arch.   The change  effected at the expulsion
of the head  brings, at the same- instant, the long di-
ameter of the shoulders obliquely into the brim of
the pelvis, thus  taking advantage of the wise adapt-
ation (already alluded to), by which  the long diam-
eters of the  brim and outlet are  placed  at right an-
gles with  each  other.   The head, soon after its ex-
            4 
38        DUBLIN PRACTICE OF MIDWIFERY.
pulsion, is again turned with the  face toward one
thigh of the mother, and thereby the greatest breadth
of the  shoulders  from  side to side is brought into
the direction of the long diameter of the outlet from
before backwards : the rest of  the body and  limbs
follow  without  difficulty.
   Second position of the head.—In this, which is of
much less frequent occurrence than the first position,
the posterior fontanelle is  directed  toward  either
sacro-iliac synchondrosis  (generally  to  the  right,)
and the forehead  directed toward either acetabulum
(generally to the left).  The presenting  part  is the
upper and fore  part  of one of the parietal  bones,
the head, as in the  first  position, descending  ob-
liquely into  the pelvis.  As the force of the ute-
rus continues to act upon the head,  the  round and
bulky vertex and  tuberosity of one parietal bone arc
directed against  the inclined plane formed by one
of the spines  of the  ischia, and  by it guided for-
wards toward  the neighbouring acetabulum, while
the less bulky but smooth forehead is, by the same
motion, passed  backwards  towards  the sacro-iliac
synchondrosis of its own side.   In this situation the
head is expelled,  the  case  being, in  fact, converted
into one of  the first position.   This, I believe, is the
usual course ; Professor Nagele of Heidelberg ob-
served it to occur in ninety-three out of ninety-six
cases.
   In some few instances, however,  the vertex  in-
stead of being  directed forwards, as has been de-
described above, is  turned toward the sacrum, and
the  upper and fore part of one of the parietals 
MECHANISM OF PARTURITION.
39
passes out first under  the arch of the pubis, consti-
tuting a presentation with  the face  to the pubis.
This is a less favourable position than the first, as
the head passes, not flexed, but extended upon the
trunk ;  and, consequently, the moving diameter  is
the second longest,  being  that between  the  lower
part of the forehead,  and the upper part  of the oc-
ciput.   It is said by some, that the head  occasion-
ally presents at the brim with the forehead directly
toward the pubis, and the vertex directly backwards,
which, I believe, never occurs, except in the case of
a very small head.
   Third position, or face presentation.—In this va-
riety the face usually enters the brim of the  pelvis
with the forehead toward  one sacro-iliac synchon-
drosis (generally the left), and the chin toward the
opposite acetabulum  (generally  the  right).   The
presenting part, then, is the upper  portion of one
cheek.   As the  labour advances, the chin is direct-
ed  under the pubic arch and passes first  out  of  the
pelvis.   Occasionally, but rarely, the forehead will
be, at the commencement, directed forwards toward
one of  the acetabula, and the chin  may turn back
toward  the  hollow of the sacrum.   In  one case,
however, in which  I distinctly ascertained this to be
the situation at the commencement;  the chin was
subsequently turned  forwards in the manner  de-
scribed above as happening in the  second position,
and was expelled  first under the pubis.  In face
presentations, the moving diameter of the head is its
longest, being that between the chin and vertex.
   Presentations of the  nates and lower extremities. 
40        DUBLIN PRACTICE OF MIDWIFERY.

—When the child is transmitted through  the pelvis
with its nates or  lower limbs foremost, its position
admits of two  varieties.  The first and  most fre-
quent, is with the back of the child inclined toward
the abdomen of the  mother; the  second, with the
back of the child inclined toward  the sacrum of the
mother.  The back of the child does not, in either
of these cases,  look directly forward or backward ;
but the presentation passes into the  pelvis with the
breadth of the  child in the line of one  of the ob-
lique diameters of the  brim.   When the breech is
the presenting part,  one of the isehia (usually the
most anterior, or that nearest to the pubis) descends
lower than its fellow, and  first meets the finger of
an examiner.
  The  breech  is  usually transmitted  through the
outlet with one hip directed obliquely toward the
pubis, and  the  other toward  the sacrum.   The
shoulders pass the brim with  their  breadth  in the
line of the oblique diameter, but, in passing the out-
let, have their position changed, being then inclined,
the one toward the pubis, and the  other toward the
sacrum: by this inclination the  head  is brought
through the  brim  with the forehead towards the
sacro-iliac  synchondrosis, and the occiput  toward
the opposite  acetabulum.  The  shoulders having
been expelled, the face turns into  the hollow of the
sacrum, the chin is depressed toward the chest, and
so escapes posteriorly ;  and, lastly, the vertex passes
out from under the pubis.
   In the second species, when the face of the child
is at  first  inclined  anteriorly, a  complete turn is 
MECHANISM OF PARTURITION.
41
most usually subsequently effected, so as to bring the
face into the  hollow of the sacrum,  as in the first
species.  Sometimes, however, in these cases, the
head,  instead of being flexed, is extended, the occi-
put depressed upon the nape  of the  neck, and the
vertex turns into the hollow of the  sacrum.   The
chin then rests  upon the pubis,  and the occiput first
passes out posteriorly.  The   above  observations,
with the exception of those relating to the passage
of the nates,  apply accurately to foot  and knee pre-
sentations.
  Presentations of the upper extremities, or side  of
the  body.—In  these  presentations  the child lies
transversely across the brim of the pelvis, with  its
head toward  one ilium, and its breech toward the
other.   A little consideration will show that almost
insuperable obstacles oppose its passage while thus
situated.  In certain  cases, however, in which the
foetus  is very  small, or rendered very pliable by
putrefaction,  the  power of the  uterus has  been
found sufficient to effect its expulsion. This pro-
cess has been termed by Denman, who particularly
noticed it, spontaneous evolution, and  was first cor-
rectly explained by Dr. Douglas of  Dublin.  It is,
in fact,  an expulsion  of  the  child  with its  body
doubled together.   During its  accomplishment, the
head  rests upon  one iliac fossa,  the shoulder  is
driven forwards entirely out of the pelvis, and rises
before the  pubis, thus making  room for the protru-
sion of the side of the chest into  the vulva; again,
as this is forced out,  the  side of the abdomen is
pressed after, the body is  very much  flexed  upon 
42        DUBLIN PRACTICE OF MIDWIFERY.

itself, until, finally, the breech is. by repeated ell'ort>,
expelled  over the sacrum.  The head, last of all,
passes out of the pelvis.

   ■. •  In describing the mechanism  employed in
head presentations, /have adopted the opinions of
Professor Magele, being  convinced of their general
correctness.  The student, however,  is not to be
disappointed if  he  should  find  himself  unable to
diagnose the exact position of the head in any indi-
vidual case.  It is, in fact, often extremely difficult
to do this, and, in attempting it, we are by no means
warranted in inflicting any pain  upon the mother.
A failure is of the less consequence,  as  the whole
tenor of the facts ascertained  by the  excellent ob-
server alluded to, goes to discountenance the idea of
its being ever necessary  or expedient to change the
position of the head. 
43
                CHAPTER IV.

ORGANS OF GENERATION.--EXTERNAL AND INTERNAL.

  A very brief description of these parts will be
required for the clear understanding of the steps
and accidents of labour ; it is not, however, neces-
sary to enter at all into their minute anatomy, with
which the reader is presumed to be  already suffi-
ciently  acquainted.   The organs  subservient  to
generation are divided into external and internal.
  External organs.—These consist of the mons
veneris, the greater labia, the  lesser labia, or nym-
pha.1,  the clitoris,  the orifice of  the  urethra,  the
hymen, the carunculae myrtiformes, the  fossa navi-
culars, fourchette, and perineum.
  The mons veneris is  merely the cushion of fat
and cellular  substance occupying the anterior sur-
face of the os pubis.
  The greater labia descend  upon  each side from
the  mons, become thinner as they pass back toward
the  anus, at about an inch before which they unite
together.  They are formed of fat and very disten-
sible  cellular substance, and  some fibres  of the
round ligament, and  are covered  internally  with
mucous membrane, and  externally with common in-
tegument, which, like  that covering the mons, is fur-
nished with hairs and  sebaceous glands.  The open- 
44        DUBLIN PRACTICE OF MIDWIFERY.
 ing between the labia is  termed the vulva, or geni-
 tal fissure.
   The. nymplup or lesser labia are two folds of  mu-
 cous membrane lying within  the  great labia ;  they
 are  united together superiorly immediately  above
 the clitoris, for which they form a kind of prepuce.
 They become narrower as they pass along the vagi-
 na, about the middle of which they are lost.   Their
 use appears to be to increase the dilatability of the
 genital fissure, by unfolding during parturition.
   The clitoris is placed immediately beneath  the
 junction of the  nymphae.  It is a  small  projecting
 body, having corpora cavernosa, and erector mus-
 cles, resembling those of the penis.   It is endowed
 with great sensibility, and is capable of a degree of
 erection.
   The orifice of the urethra is a small pit situated
 about three quarters of an inch below the  clitoris,
 and  immediately  above the vagina; a  small fold
 or flap of mucous membrane  sometimes projects
 from  the under  margin of the extremity  of  the
 urethra, and gives the orifice  somewhat of an  up-
 ward direction.
  While speaking of the orifice  of the urethra  we
 may conveniently consider the mode of introduction
 of the catheter.  If the  operation is to be performed
 while the woman is in  bed, she may lie upon  her
 back, or, what is better, upon her left side, with  the
 hips projecting over the edge of the  bed.  The  left
 forefinger of the operator is then  to be introduced
 to a  short  distance  (about  the  length of .the first
joint) into the  vagina, and carried forward to  the 
INTRODUCTION OF THE CATHETER.        45
symphysis pubis.   By this measure the urethra will
be easily discovered lying  between the  finger and
the pubis.  It resembles in feel the corpus  spongio-
sum of the male urethra, but is usually rather thicker.
The finger is then  to  be drawn lightly  forward
along the  urethra, until its  tip  sinks into the pit
marking the  orifice, in  contact with which it is  to
be held.   The catheter, held loosely  between the
right thumb and forefinger, is next  to be passed
along the front of the left  forefinger, in a direction
somewhat backwards, when it at once slips into the
orifice of the urethra.   The handle should then  be
slightly depressed, and the instrument passed  on into
the bladder ; during its introduction the point may
catch in some of the mucous lacuna?, upon which it
should of course  be withdrawn a  little, and  passed
forward with a slight variation  of its  direction.
The urethra is from an inch  to two inches long,  so
that in an ordinary case, where there is  no disease,
we should expect the urine to flow when the cathe-
ter has passed in to the distance of two inches.  If
it should be  necessary, the operation  may be per-
formed  while the patient sits  upon the edge of a
chair, the operator kneeling before her, and  passing
his hand between her thighs.  In either case, expo-
sure of  the woman's person should be  carefully
 avoided.  By adopting the plan  just mentioned, in-
 stead of that usually directed in books, we shall  get
 rid of the necessity for irritating the clitoris, which,
 for obvious reasons, is a very considerable improve-
 ment.
   The orifice of the vagina is situated  immediately 
46        DUPLIN PRACTICE OF MIDWIF1KY.

beneath that of the urethra,  and in the virgin is
usually closed by a  fold  of  the mucous membrane,
denominated the hymen.  This, in the natural state,
has a small crescent ie opening at the anterior part,
through which the menses pass.   Occasionally, this
opening is wanting, and the membrane is cribriform,
or even imperforate.
   ('arunculcc myrtiformes.—-These are three or four
wartlike excrescences  at the  orifice of the vagina,
by some supposed  to be the  remains  of the ruptured
hymen, but by others said to exist together with  it.
   The fossa navicularis  is  the  name  given to the
hollow immediately within  the  posterior  commis-
sure of the vulva.
   The  fourcheite is the point  of union of the labia
posteriorly.
   The  perineum is the space between the fourchette
and anus.   Its extent is from an inch to an inch and
a half.   It is lined  internally by the mucous mem-
brane  of the vagina, and externally covered by the
skin.   Between these there is  cellular substance,
and some  muscular fibres.
   Internal organs.—These consist of the vagina,
uterus, Fallopian tubes, and  ovaries.
   The vagina is the membranous canal leading from
the vulva  to the uterus.  It is curved  with a con-
cavity  forwards, to such an  extent  that its axis co-
incides with that portion of the curved line, already
mentioned,  as  descriljing  the  axis of the pelvis,
which  describes the axis of  the outlet.   It is formed
of dense cellular  membrane, surrounded throughout
by numerous nerves and vessels, and  at  the lower 
         INTERNAL ORGANS OF -GENERATION.       47

part by muscular fibres, forming a species of sphinc-
ter.  At about  an  inch from the orifice (which is
its  narrowest part), the vessels are collected into a
cavernous  erectile tissue, denominated  the  plexus
reliformis.   The internal surface is  lined with mu-
cous membrane, which, in the young subject, is ar-
ranged  into  transverse folds  or rugae : it  has also
many orifices of mucous glands.  The superior ex-
tremity of the  vagina passes up  nearly  an  inch
above the os uteri, before its  mucous membrane is
reflected upon  the  cervix;  this  reflection  takes
place higher  behind than before, so  that the poste-
rior lip projects more into the canal than the ante-
rior.  The anterior wall is connected firmly with
the urethra below ;  and  above, by looser cellular
substance,  with the back of the bladder;  this wall
in its undisturbed state measures about three inches.
The posterior wall (longer)  is united to the rectum
below : above, it is covered by peritoneum, which
forms a cul de sac separating  it  from the intestine.
   [This anatomical fact, that at its upper and poste-
rior part the  wall of the vagina is in immediate con-
tact with the peritoneum, should be  kept distinctly
before  the mind, whenever  we attempt to introduce
instruments,  or perform any operation in the vagina.
   This upper and posterior part is, so to speak, the
weak spot in the canal; any injury inflicted here
will, very probably, be followed by peritonitis, and
any laceration at this spot, where it is very likely to
happen, is  almost certain death  to  the  patient.
This spot  should  therefore  always be  carefully
avoided by the  operator.] 
13        DUBLIN PRACTICE OF MIDWIFCRV

  Tin- uterus is  a flattened pyriform  body, from
two inches and a  half to three inches in length, one
inch in  thickness from  before,  backward, and ono
inch and a half in breadth at its upper  (broad)  ex-
tremity.   It is divided  for the purpose of descrip-
tion into the fundus, which is the upper and broad-
est part; the cervix, or  lower extremity ;  the body,
which is that portion between the fundus and  cer-
vix : and, lastly, the os uteri or os tinea:, an opening
situated at the termination of the cervix,  and lead-
ing  from the vagina to the cavity.
  The substance of the  uterus  is from  one third
to three quarters of an inch in thickness, and is
composed of a peculiar dense,  greyish, fibrous tis-
sue, containing abundance of nerves, blood-vessels,
and lymphatics.  Upon cutting into" it,  we observe
that it contains numerous sinuses.   The  fibres of the
unimpregnated uterus cannot be observed to follow
any regular course :  they possess all the  powers, and
most of the appearances, of muscle ;  although it is
a favourite whim with  certain anatomists to deny
them  the name.
  Within the  solid walls of the uterus  a cavity is
formed, triangular in that  portion contained  in  the
fundus,  and with  its  lower angle  prolonged into a
narrow  canal, which  passes through the body and
cervix to the os  tinea?.   At  the  upper angles on
each side are situated the openings of the Fallopian
tube-.   The whole cavity  is lined by mucous mem-
brane, continuous with  that of the vagina.   In the
young subject, this is arranged into folds ; it has nu-
merous  mucous lacunae, particularly in the cervix. 
          INTERNAL ORGANS OF GENERATION.       49

   The os uteri is  a transverse slit  in the lower ex-
 tremity of the eervix, varying in length from three
 to eight lines.  It has  two lips, which  in the virgin
 are smooth, but, in persons who have had children,
 frequently present a tuberculated and irregular feel.
 In the neighbourhood  of the os are situated some
 follicles, termed  the glandulae Nabothi, which se-
 crete a tough sebaceous matter, and are supposed to
 be the seat of the cancer that occasionally attacks
 this part.
  The situation of the uterus is near the middle of
 the pelvis, between the bladder and rectum, its axis
 coinciding with that of the brim.   It is covered on
 both sides by peritoneum, and is held in situ by the
 following ligaments.  The broad ligaments,  which
 are merely folds of peritoneum passing off from the
 sides of the womb to the sides of the pelvic cavity.
 Each is formed by two  layers  of  peritoneum, be-
 tween which are  situated, at the upper  margin, the
 Fallopian tubes and  ovaries,  and, lower  down, the
 vessels and nerves of the organ.  The anterior and
 posterior  ligaments are  also  folds  of peritoneum
 passing off respectively upon the bladder and rec-
 tum.   The round  ligaments differ from any of the
 former.  They pass off on each side from the fun-
 dus uteri,  close to the insertion of the tubes, and,
 passing out  of  the abdomen  through the inguinal
 ring, are  lost upon  the  mons veneris  and  labia.
 They are composed of a number of blood-vessels,
lymphatics, nerves, and cellular substance, and form
a thick round cord.  The use of these  ligaments
5 
50        DUBLIN PRACTICE OF MIDWIFERY.

has been  much disputed.   By  Sir C.  Bell*  they
have been ingeniously supposed  to  answer the pur-
pose of tendons, and to furnish a fixed point for the
two circular muscles, which he has described as ex-
isting at the fundus of the womb.   Professor Jorg.f
of Leip<ic, believes that they communicate sensa-
tion from the  clitoris  to the Fallopian  tubes  and
ovaries at the moment of coition, so  as  to establish
a consent of all the parts concerned in generation.
   The Fallopian tubes  are two firm cords, about
four inches in length, formed of a spongy cavern-
ous tissue, with  blood-vessels,  lymphatics, nerves,
and  probably  muscular fibrcs.J   They contain a
canal, which opens into the fundus of the uterus
upon each side, by an opening merely large enough
to contain a bristle.   The  canal enlarges  as it runs
toward the opposite free extremity, and  opens  into
the cavity of the peritoneum, its termination being
surrounded by fimbriae, and  denominated the mor-
sus diaboli, (or fimbriated extremity of the Fallo-
pian  tube).   The tubes lie in the upper fold of the
broad ligaments in a very  tortuous manner.
   The ovaries also lie in the  upper  fold of  the
broad ligament, (or rather in a fold of the posterior
layer of the ligament), behind the  tubes.   They are
flattened whitish  bodies, from  an  inch to an inch
and a half long, resembling  in  appearance  and feel

   * Med. Chir. Trans, vol. iv.
   t Handbuch der Gebustshiilfe. Leipzig, 1833.
   X The muscularity of the tubes, or at least the identity of their
structure with that of the uterus, is abundantly manifest in case
of tubal pregnancy.—Ed. 
          INTERNAL ORGANS OF GENERATION.       51

 the male testes.   In the early foetus this resemblance
 is so remarkable, that we can sometimes with diffi-
 culty  distinguish  whether  the  bodies lying in the
 lower part  of the  abdomen  be actually ovaria or
 testes.  The ovaries are composed of a peculiar cel-
 lular  tissue, and  each contains fifteen or  twenty
 globular cells or vesicles, including a drop of albu-
 minous fluid,  and denominated the  vesiculce Graa-
fiance.  Each of these vesicles  is  supposed to con-
 tain an ovum, which escapes by the bursting of the
 peritoneal coat  of the ovary at  the moment of con-
 ception, leaving behind a small cicatrix.  At the
 same period an  oval glandular  body is observed to
 be formed in the ovary, about one third of an inch
 in diameter,  and resembling much the  secretory
 portion of the kidney.  This is named  the corpus
 luteum.  It continues  to exist from the time of con-
 ception until three or four months after parturition,
 but of its uses we are nearly quite ignorant.*
   In connection with  the foregoing  description of
 the hard and soft  parts  immediately concerned in
 the generative  function, it may  be interesting to
 reflect upon the effects likely to  be produced upon
 the other  organs contained  in the pelvis by the
 changes resulting from the exercise of this function.
 The uterus, we  have seen,  is situated  between the
 bladder and rectum, and accordingly, as might have
 been expected, its enlargement  frequently interferes
 with the action  of both  these organs.  If the  pres-

  * Sir E. Home supposed that corpora lutea might exist in the
 virgin ; but his supposition is not supported by the testimony of
 other observers. 
 52        DUBLIN PRACTICE OF MIDWIFERY.

 sure particularly aflect the former viseus, it will be
 found  to occasion  frequent micturition  and other
 symptoms of irritation ;  and when the part pressed
 upon is the urethra  or neck of the bladder, reten-
 tion of  urine  mav be  the  consequence.  In  like
 manner, pressure upon the rectum may cause either
 tenesmus, or constipation, and, by  interfering with
 the free  return of the blood, produce or aggravate
 piles.  The great  blood-vessels  which traverse the
 pelvis in their course to or from the lower extremi-
 ties, as well as  the numerous lymphatics, are also
 frequently subjected to  interruption of their func-
 tions from pressure; of the enlarged uterus, to which
 may be traced  the varices and edema of the limbs
so common in pregnancy.  The pressure, also, upon
the great nerves may satisfactorily explain the numb-
ness and cramps of the legs frequently complain-
ed of during labour, and at  the latter  periods  of
gestation. 
53
                 CHAPTER  V.

      FUNCTIONS OF THE GENERATIVE SYSTEM.

   Menstruation.—In every healthy woman, at the
age of puberty, a sanguineous discharge occurs from
the uterus, and  returns  regularly  every twenty-
eight  days, excepting at those  periods  when  the
woman is either  pregnant or  giving  suck.   From
the regularity of its return this is denominated the
menses or catamenia, and,  in ordinary  language,
" the monthly courses."  It commences in this  coun-
try usually about the  fourteenth  or fifteenth  year,
and ceases between the forty-fifth and fiftieth.  In
warm climates, it is said, but I think  upon insuffi-
cient authority, that it  commences  and terminates
much earlier than in these countries.*
  * Vide a paper by Mr. Roberton in the Ed. Med. and Surg.
Journal, vol. xxxviii.
  Out of 450 females Mr. Roberton found that,
   10 menstruated for the first time at the age of 11 years.
19	do	do	do	do	12 do
53	do	do	do	do	13 do
85	do	do	do	do	14 do
97	do	do	do	do	15 do
76	do	do	do	do	16 do
57	do	do	do	do	17 do
26	do	do	do	do	18 do
23	do	do	do	do	19 do
4	do	do	do	do	20 do
 
54        el'BLlN PRACTICP. of midwiftkv.
  The  menstrual  discharge,  although  sanguineous
in its appearance,  is  not  pure blood, but strictly a
sec ret ion from the  uterine  \essels.  It differs from
blood in being uncoagulable.  and 'containing but a
very small quantity of fibrine : although occasion-
ally retained in the  uterus  for  months, in conse-
quence  of  an  imperforate  hymen, it has  never
been observed to coagulate  or  separate  into  two
portions.
  Pure  blood may,  in consequence of increased
action, be  poured out  along with the  menses, and
detected by its coagulation :  also, eoagulable lymph,
as in the  false membrane of painful menstruation.
The  secretion may sometimes even be devoid of the
usual red color.
  The quantity of the  menses varies considerably
in different individuals,  and, from the  slow manner
in which  it  escapes, is not easily  estimated ; the
average .quantity, however,  in  this  country ap-
pears to be about four  ounces.   This irickles  from
the mouth of the uterus (as has been seen in cases
of prolapsus of the organ) during a period  varying
from three to five  days.

  Age at which menstruation ceased in 77 women.
   1 at the age of 35 years.      26 at the age of 50 years.
1	do	40	do
1	do	12	do
1	do	43	do
3	do	11	do
4	do	13	do
3	do	47	do
10	do	IS	do
/	do	49	do
2	do	51	do
7	do	52	do
2	do	53	do
2	do	51	do
1	do	57	do
1	do do	60 70	do do
 
      FUNCTIONS OF THE  GENERATIVE SYSTEM.     55

  At the period of the first occurrence of menstru-
ation, a remarkable change takes  place in  the sys-
tem  of the female.   All  the organs connected with
reproduction then assume a perfect condition.   The
uterus and vagina enlarge ; the external organs  be-
come developed and covered with hair,  and  the
breasts increase in  size and  in  perfection  of their
glandular structure.  The whole body  also assumes
a more  characteristically female  form ; and at  the
same time the mind ceases to  take interest in the
pursuits of childhood, and is more or less influenced
by the passions of the adult woman.
  The use  of menstruation  is,  obviously, closely
connected with the function of  conception, as it is
only during the menstruating  period of life that the
latter ever takes place.*  The  mode of its action,
however, is little explained ; most probably it results
from the internal  surface of the uterus being pre-
served in a condition capable of secretion, the latter
state being necessary to  the support  and develop-
ment of an  ovum.  The  causes  of its  periodical
returns, and of the uterine excitement  attending its
occurrence, appear to me to be  not in  the remotest
degree elucidated by any of the  numberless theories
that have been offered for its explanation.    It would
not, therefore, answer any practical end to enter at
present into farther examination of the subject.
  Conception.—This is  the  next  function of  the
generative system ; and  from its nature is  involved

  *  This rule is stated too broadly, exceptions to it are every
now and then met with.  Conception has certainly taken place
before menstruation.—Ed. 
56        DUBLIN PRACTICE OF MIDWIFERY-
in deep obscurity.  At present it will be sufficient
for our purpose  to state  simply  the facts known.
and indulge as little as possible in hypotheses,  which
must be more the  product of fancy  than of reason.
   In all animals, and  even vegetables, in which re-
production is accomplished by the  formation of an
ovum,"  the concurrence of two  distinct  sets of or-
gans appears to be required.   In the lower classes
of animals,  and in most  vegetables,  these organs
exist together in the  same individuals, constituting,
more or less, perfect hermaphrodites.  In the  higher
animals, on the other hand, and in some plants, there
is a sexual distinction ; the male  and female organs
being developed upon different and  distinct individ-
uals.  In these latter it is found  that  certain rudi-
ments of the new being arc prepared in the female,
and even brought  to a point of considerable perfec-
tion (as in birds and those animals which emit their
spawn  before impregnation),  but yet  require  for
their  full  development the stimulus  of the  male se-
cretion or semen.
   In the human  female, the existence of these rudi-
ments in the  vesicles of the ovaries, and their pas-
sage from thence, through the tubes, to the womb,
has been inferred  from the following circumstances.
In every instance  in which an examination has been
made shortly after conception, it has been observed
that the contents of one or more of  these vesicles
had been discharged,! and that a cicatrix,  marking

  '  The seeds of plants are perfectly analogous to ova.
  t It is usually found that a drop of blood is effused into the
vesicular cavity, which coagulates, and is subsequently absorbed. 
      FUNCTIONS OF THE  GENERATIVE SYSTEM.     57

the point of their exit from  the  ovary, existed on
the peritoneal coat of that body.   The formation,
at the same  period, of the corpus luteum in  the
neighbourhood of the cicatrix (although we are ig-
norant of its exact uses) also  indicates the perform-
ance of some special action.  Again, we have,  in a
morbid state, the occasional development  of  a  foe-
tus in the ovary, forming a variety of extra-uterine
floatation.   That the rudiments pass by the  tubes
into the uterus  may be  inferred from the occur-
rence of another example of extra-uterine foetation,
in which the ovum is arrested in its passage through
the tube and partially developed in its canal.  There
is also analogical proof to be derived from the  ex-
periments of Dr. Haighton,*  in which he complete-
ly stopped the progress of conception in a rabbit by
dividing the tubes within thirty hours from the pe-
riod of impregnation ; but failed in effecting  that
object when he postponed the division to forty-eight
hours from the same period.
  As to the  manner in which the rudiments escape
from  the ovary and effect their transit  into  the
womb, we have little information.  By some  it is
supposed that the vesicle  bursts, and that its  con-
tents are absorbed by the tube in a fluid state,  and
so conveyed  into the womb.   Mr. Cruikshank's hy-
pothesis was, that it escaped  in  the form of  a  per-
fect cyst;  and he  conceived  that he  demonstrated
this by opening and pouring  distilled vinegar upon
the tube of a recently impregnated animal, whereby
* Phil Trans, vol. lxxxvii, 
58        DUBLIN PRACTICE OF MIDWIFERY.

an egg-like cvst was  rendered visible.   This etlert,
however, might be produced by the mere coagula-
tion of the albumen probably contained in the fluid
rudiments.   It is  not improbable  that  the  matter
may  be absorbed in a fluid form, and furnished with
a cvst composed of the future  amnion  and chorion
during its transit  through the  tube ; in support of
which conjecture  we have an  analog)  in the ad-
dition of the shell to the ovum of birds during its
passage through the oviduct.
  As to the time occupied by these  actions, which
may be properly considered as constituting the pro-
cess  of conception, much uncertainty prevails.  It
may probably be  set down at about a fortnight, as
1 believe the ovum has  seldom been recognized in
the uteins  in  less than  two or three  weeks  from
the period of impregnation.
  In multiparient animals, and in the human female
who conceives of more  than one child,  the number
of cicatrices and of corpora luteain the ovaries ex-
actly corresponds  with  the number of foetuses in
the uterus.
  Conception has been  hitherto spoken of entirely
with reference to the operations  of  the  female;
with respect to the part borne by the male, but lit-
tle is ascertained with certainty.   We  are, in fact,
quite ignorant as  to the mode in which the semen
effects the awakening of the  ovum, which we have
already seen may be brought, in some animals, to a
state of apparent perfection, and expelled from the
body, without  its aid.   It  is  not  even certainly
known whether actual contact of  the male and fc- 
      FUNCTIONS OF THE 'GENERATIVE SYSTEM.     59

male products is an essential requisite of impregna-
tion, or whether this result may  not be  produced
by a mere exhalation or aura proceeding  from the
male semen.   In favour of actual contact are some
observations of Ruysch,  in which he says that he
detected  semen in the Fallopian  tubes of a woman
killed in  the  act of adultery ;  the experiments of
Dr. lilundell ;* and the  analogies of vegetable fe-
cundation, and of the generation  of  animals whose
ova are  impregnated after expulsion,  in  both  of
which, actual experiments prove  the necessity of
direct contact.   On the other side, we have the un-
explained difficulty of effecting contact, and the oc-
casional occurrence of  conception while the hymen
is perfect, and an  insuperable obstacle opposed to
the  entrance of the male  organ into  the vagina.
Upon the whole, the weight of evidence appears to
be in favour  of actual  contact;  but  where, or how
effected, we know not.   Such is the  scanty founda-
tion of facts upon which have been built the innu-
merable absurd, as well as ingenious, though fragile,
theories of  reproduction.
* Med. Chir. Trans, vol. x. 
GO
                 CHAPTER VI.

                 gravid i turus.

  Coeval  with,  and subsequently to conception,
many changes take place in the womb and its eon-
tents, all of which may be included in the consider-
ation of the gravid  uterus.  We shall first consider
the effects of pregnancy upon the womb  itself, and,
for the sake of a  contrast with the unimpregnated
state of the organ, shall examine its size,  structure,
<Sic,., at the  full period of gestation.
  At this time it is  of an  oval  shape,  somewhat
compressed from  before backwards,  and with the
smaller extremity pointed downwards.  Its average
dimensions are, twelve  inches in length, nine  in
breadth, and six or seven in depth ; these, however,
varying according to  the size of the foetus and sc-
cundines, and  especially  to   the  quantity  of the
liquor amnii.
  The steps by which it attains this  size are gra-
dual and regular.   Until the end of the third month
it remains within  the  pelvis.   In  the  fourth  it be-
gins to mount  above the brim, and then  measures
about five inches  from the fundus to the  beginning
of  the  neck.   At this  period the enlargement is
confined to the  fundus and body ; but in the fifth
month the cervix  begins  to  be distended, and be-
comes softer and  spongy. 
GRAVID UTERUS.
61
   Until the fifth month the weight of the uterus acts
 in depressing it into the vagina, so  that we can feel
 the  os tinea?  more readily  than in the unimpreg-
 nated condition :  but as the cervix becomes disten-
 ded, and  the  uterus rises into  the  abdomen, the
 vagina becomes more elevated, and the os more dis-
 tant from  the  finger.   In the  seventh  month the
 womb reaches usually to the  umbilicus,  and the
 cervix is so much developed  that we can often feel
 through it the head of  the  child.   In the eighth
 month the fundus gets to  about  half way between
 the  umbilicus and sternum, and  the  orifice is  on a
 level with the brim of the  pelvis.   In the ninth
 month  the upper  extremity of the womb  is  very
 near the ensiform cartilage, the cervix is  completely
 taken up into the general cavity of the uterus, and
 the  os changed  from a transverse slit  into  a round
 rugous hole, placed without  any projection in the
 lesser extremity of  the  organ.
   The situation of the full-sized womb  is oblique,
 with the os directed backwards toward the sacrum,
 and  the fundus  forwards, so  that its  axis  is nearly
 identical with that of the brim, being described by
 an imaginary right line passing from the scrobiculus
 cordis to the point of the sacrum,—a circumstance
 that  requires to be understood, when it is necessary
 to pass  the hand  into the  uterus.*  The gravid

  * In women who have had many children, this axis is often
deviated from, on account of the distensible parietes  of the ab-
domen allowing the uterus to depend forwards. Lateral obli-
quities also occasionally happen from unequal laxity of the pa-
rietes, or from deformities of the spine or pelvis.
              6 
62        DUBLIN PRACTICE OF MIDWIFERY.

womb lies  anterior to all the  viscera of the abdo-
men, occupying the whole interval between the iliac
bones, and  a corresponding space above as high as
the epigastrium.
  The structures of the uterus  continue essentially
the same as in the unimpregnated condition, but un-
dergo  a remarkable  development.  The  muscular
fibres, which appeared so irregular in the  virgin
womb, now exhibit a definite arrangement into lay-
ers.   The outermost of these  fibres arise from the
round ligaments, and, regularly diverging, spread
over the fundus until they unite.   According to Sir
C. Bell,' the round ligaments are the tendons of this
muscle, and servo as fixed points from which it acts
in bringing the womb  down into the pelvis at the
commencement of labour, and giving its mouth the
proper direction.  In  the substance of the organ,
internal to this layer, the muscular fibres have  a cir-
cular direction near the fundus,  and a longitudinal
near the cervix :  they  are, however, interwoven to-
gether in a very intricate manner ; and when they
act fully, must have a very powerful effect in con-
stringing the  blood-vessels, which pass between
them, and so preventing hemorrhage.  Their action,
during labour, is to open the os tinea', and draw it,
as it were, over the child's head.  The most internal
stratum of muscle is arranged with the fibres in two
sets of concentric circles, each having the orifice
of one of the tubes as its centre.   These two mus-
*  Med. Chir. Tranj. vol. iv. 
GRAVID UTERUS.               63
cles, if we may so call them, interweave together at
their  circumferences,  and  have  proceeding from
them, on each  side,  broad  longitudinal bands  of
fibres, which assist the external muscles in bringing
the fundus towards the os, and in drawing the latter
over the  child's head.   The  circular portions  are
supposed to corrugate and  diminish in size the in-
ternal surface of the uterus, after the child has been
expelled, and  so draw  it off, as it were, from the
placenta, which, having no power of diminishing its
own area, must, of course,  separate  from the sur-
face to which it is attached when the  latter is di-
minished in the way mentioned.
  The thickness of the  uterine  parietes is nearly
the same as in the unimpregnated state : in the part
to which the  placenta is attached,  it is perhaps  a
little thicker.*  Its  substance throughout is more
spongy and vascular, and has the sinuses much more
developed than before conception.
  The blood-vessels of  the  womb  are much  en-
larged during gestation, especially in the neighbour-
hood of  the site of the placenta, where the arteries
are sometimes as large as the point of the little fin-
ger.  The veins are proportionally large, and form
plexuses, with very free  communication.  The lym-
phatics are also very large and numerous.
  The nerves, which  are derived from the hypo-


  *  The walls of the uterus are sometimes unequally thin in
different parts ; a knowledge  of which circumstance ought to
make us particularly cautious when we happen to have our
hand in its cavity. 
64        DUBLIN PRACTICE OF MIDWIFERY.

gastric and spermatic plexuses of the gnat sympa-
thetic, and. from the sacral pairs, are said by some
(W. Hunter and  F. Tiedeman) to be  enlarged ;  a
circumstance,  however,  that  has been denied by
other observers.'
  Contents of the Womb.—These consist of the foe-
tus, liquor amnii, or waters, and the secundines ; all
together constituting the  ovum.  The secundines
consist of the funis, placenta, and membranes ; the
latter being three in number, viz. the  deeidua, cho-
rion, and amnion.
  The deeidua is the  outermost coat  of the  ovum,
and less properly belongs to it than to the uterus, as
it is formed in the latter during  the  process of con-
ception, and before the  ovum has descended into its
cavity.   It is  also to be found in the womb, in cases
of extra-uterine foctation,  appearing  to be, in fact,
a preparation made in the organ for  the  lodgment
of an  expected but  absent  guest.   The exact na-
ture of this  membrane has  been  much disputed ;
but it appears to be, at  first, a secretion of organiz-
able lymph, produced by the vessels  of the  womb
while under the stimulus of conception.!   ^ is soon
supplied with vessels admitting of being injected
from the uterine arteries, and then assumes the form
of a dense and thick, but friable  membrane.   The
deeidua is  not formed  in the cervix  uteri,  but
stretches across  its upper part,  so as to form  a  shut

  *  Iorg, Handbuch der Geburtshiilfe.
  t  In texture and mode of  formation it appears to resemble
much the false membrane thrown out in certain inflammations,
as croup, &c. 
GRAVID UTERUS.
65
sac in the body and fundus.   It  also closes up the
openings of the Fallopian tubes on each side.*
   When the ovum passes down, it must, to get into
the  womb, remove from the orifice of  the tube the
layer which  closes it, and  in doing so  (probably)
forms for  itself a little bag, having  a neck only
equal in diameter to  the perforation  of the  tube.
From the  plastic nature of the deeidua, we can
easily believe that this  bag  may increase in  a de-
gree  corresponding to  the  growth of the  ovum,
whilst its neck  remains of  its original size (that of
the tube) ; and it  is not  detached from any part of
the uterine surface, as some  have  supposed.  The
bag thus formed around the ovum, by the prolonga-
tion and growth of that portion of the "membrane
which covered the opening  of the tube, is termed
the deeidua rejlexa, in contradistinction to  the por-
tion adherent to the uterus,  which  is called the de-
eidua vera.   The arrangement of these  two portions
of the membrane resembles  precisely that of the
peritoneum ;  the  deeidua vera being  analagous to
the peritoneum lining the abdominal walls ; and the
reflexa, to the same  membrane covering the intes-
tines and other viscera.  It is only at the commence-
ment of pregnancy that the distinction between the
deeidua; vera and reflexa can be perceived, as they

  • Dr. Lee  supposes that the deeidua is perforated opposite
each tube ; but it is scarcely likely that an aperture so minute as
that of the tube would be preserved in a membrane of the kind.
His view also offers a great difficulty in the explanation of the
formation  of the deeidua reflexa,—a subject already obscure
enough.  Vide Med. Chir. Trans- v. xvii.
             6* 
66        DUBLIN  PRACTICE OF MIDWIFERY.
both coalesce when the ovum has attained a certain
size.  In one situation only are tin- two distinct at
the time of parturition, and that is where the pla-
centa intervenes between them: the  membrane (as
I have ascertained by repealed dissections) splits at
the edge  of the placenta ;  that layer which was the
deeidua vera passing over its  uterine aspect, while
the reflexa is attached to its foetal surface, interpo-
sed between  it and the chorion.  At this period, the
membranes being much condensed, and firmly ad-
herent to the placental  surface, it requires  some
care to demonstrate them.
   The use of the deeidua appears to be, in the first
instance, to afford  the means of establishing a con-
nection between the ovum and the uterus : the floe-
culent vessels of the chorion shooting  into it, and
(probably) anastomosing with the  numerous vessels
which it has recently  derived from the womb.  If
we may  adopt  the phraseology  of  germination,
which seems very  applicable, we may say that  the
deeidua furnishes the light  nutrient soil into which
the radicles of the ovum can strike at once, and ob-
tain for it, without difficulty, a supply of nourishing
particles  sufficient  to enable it to elaborate its  own
system.   Later, the deeidua assists in the formation
of the placenta, in a manner  respecting which wc
shall enquire when speaking  of that  organ.   The
membrana deeidua, or caduca, as its names import,
has but a transitory existence, and is always east off
either along with the ovum, or subsequently to par-
turition.
   The time at which the ovum arrives in the womb 
GRAVID  UTERUS.               67
is not exactly defined, and has been differently esti-
mated by observers : it has  not, I believe, been re-
cognized with  certainty before  three  weeks  from
the time of impregnation.*   When first visible, it
is simply a vesicle formed by two concentric mem-
branes, between which and  within the inner one is
contained a small quantity of clear gelatinous fluid.
The outer membrane is the  chorion.   It is, at first,
covered with a stratum of flocculent vessels, which
strike into the deeidua, and  are,  as it were, the rad-
icles of the ovum.  In the  later  periods  of preg-
nancy, it loses its shaggy appearance, and becomes
thin and transparent.  It is then adherent to  the
deeidua, covers  the  placenta (on its inner surface),
and is reflected over the cord.   Its  use appears to
be, to contain and strengthen the  other parts of  the
ovum, and to establish  a connection with the uterus
by means of the deeidua.
   The amnion  is a thin, pellucid, but  very dense
membrane, contained within the chorion, and at first
separated from it by the gelatinous fluid already de-
scribed ; but usually towards the close of pregnancy,
in close contact with that envelope.  It is reflected
over the chorion on the placenta and cord.f  Its use


  * I have known a perfect ovum to  be discharged from the
uterus exactly seven weeks after  menstruation.  The prepara-
tion is in the museum of the medical school at Park-street. It
contains an embryo and vesicula  umbilicalis with amnion and
shaggy chorion, and is altogether not larger than a hazel-nut.
  t At the umbilicus both  the chorion  and amnion pass insen-
sibly into the skin of the foetus, and are by some supposed to be,
in original formation, identical with the cutis and epidermis. 
68        DUBLIN PRACTICE OF MIDWIFERY.

appears to be as an envelope to the embryo, and to
secrete the liquor amnii.   Neither of these mem-
branes have been injected in the human  subject;
but their vascularity can be fully ascertained in ani-
mals, by injecting from the feetal vessels.
   The liquor amnii is the  fluid secreted by and con-
tained in the amnion.   It  is composed of water con-
taining small quantities of albumen, muriate of soda,
and phosphate  of lime.   It  is  of a light straw co-
lour,  ami has  a  very peculiar  smell.  The liquor
amnii varies in quantity, at the full period  of gesta-
tion, from half a pint to  upwards of a quart.  Its
use appears to be, to furnish  a medium in which the
foetus can enjoy a certain  degree  of motion, and at
the same time be most effectually protected against
external injury.   It has been supposed by some to
be a source of  nourishment to the foetus ; but, with-
out involving ourselves  in  the   intricacies of  this
question, it will be enough to point out the absurdity
of any animal being supposed capable  of  secreting
matter for its  own nourishment.  Such would  be
the case, however,  if  the liquor amnii  served  this
purpose, as it can only be produced  from  the foetal
vessels ;  the amnion having no vascular connection
with the mother.  We shall  now take a brief notice
of the foetus, the main object for which all this ap-
paratus  is  constructed;  and,  lastly,  examine  its
means of support while in  the  uterus, and the or-
gans accessory thereto.
   The Fa-tus.—After  the  lapse  of a period, not as
yet certainly ascertained,  the simple vesicle of early
pregnancy is found, upon close inspection, to con- 
GRAVID UTERUS.               69
tain a minute opaque body attached to its inner sur-
face by a slender and very short filament.  When
first seen,  this corpuscule appears  curved into  a
semicircle, and without any distinction of parts.   In
a short  time a distinction is evident between  the
head and body ;  but the  fundamental part appears
always to be the spine.   In  the second month, the
extremities begin to bud out, as it were, from the
body;  and between the  lower  ones the spine pro-
jects somewhat in the form of a tail.  At  the same
time the face and organs of the cavities sprout out
from the concave side of the corpuscule.  The eyes
also appear, and subsequently  the  mouth, nostrils,
and openings of the ears.  In the course of the se-
cond and third months, the genitals are formed, but
present very little difference in the different sexes,
the penis and clitoris being nearly of equal  size,
and the testes, which  remain in the  abdomen until
the seventh  or eighth month,  resembling much  the
ovaria.  Ossification commences about  the seventh
or eighth week.   During the third and fourth month
the nose, lips, eyelids, and ears are forming, and the
parietes of the abdomen are completed, so as to in-
clude the intestines, which previously formed a  sort
of hernia in the commencement of the funis.  The
extremities continue to grow in a branch-like man-
ner, and to  form  at their terminations  the  fingers
and toes.  About the end of the fifth month, the foetus
has nearly assumed  its perfect  form, and has then
chiefly to increase in size.  It still, however, differs
considerably from the child:  the testicles are in the 
70        DUBLIN PRACTier OF MIDWIFERY.

abdomen, the eyelids coherent, and the pupil closed
by a membrane called membrana papillaris.
  Fven at the full period, the fo-tus differs remark-
ably from the child  in  many of its organs, and es-
pecially  in those concerned in  circulation.   Into
these differences (which are  dwelt upon  in every
system of physiology)  it will not be necessary, at
present,  to enter farther than merely to call to mind
the peculiarities of the circulating system.  It  is to
be recollected, that, from  the want of atmospheric
air,  the  lungs are  incapable  of performing  their
function;  and, accordingly, a  vicarious organ is
supplied in the placenta.  From this  the renovated
blood is sent through  the  umbilical vein to the  in-
ferior cava, supplying,  as it  passes, large branches
to  the  liver.   The  portion of  the umbilical  vein
which passes through  the fissure of the  liver is de-
nominated the ductus  venosus, and exists merely as
a cord in  the  breathing child.   From  the inferior
cava the blood  passes  in the regular course into  the
right auricle, and from  thence part of it goes through
the  foramen ovale (which closes after birth) directly
into the left auricle ; from thence into the  left ven-
tricle, and so by the aorta into the general circulation.
 Another portion of the blood  in the right auricle
 passes in the ordinary course into the right ventri-
 cle, and thence  into the pulmonary artery ; but as
 the  uninflated lungs are not capable of receiving it,
 a passage, termed the ductus arteriosus (not previous
 after birth), conveys it into the aorta, where it joins
 the  blood which has  passed  through  the foramen
 ovale, and is  distributed along with  it through  the 
GRAVID UTERUS.
71
body.  . From  the iliac  arteries,  however,  two  #
branches,  denominated the  hypogastric, pass  off
upon the back of the bladder, ascend to the  umbili-
cus, and then become the arteries of the cord : these
convey a  considerable portion of  blood  from the
descending aorta back  to the placenta, for the pur-
pose of renovation.  The hypogastric  arteries de-
generate into cords in the breathing child.
   The body of the foetus is covered with a whitish
sebaceous matter, called the vernix  caseosa; the use
of this is, probably, to protect the  skin against the
effects of long immersion in the liquor amnii.   The
average weight  of the foetus at the  full period is
about  seven pounds ; it is  sometimes, however,  as
much  as twelve  pounds :  the  average joint weight
of twins is eleven pounds.  In the  gravid uterus the
foetus  is packed into the smallest possible space, its
chin depressed upon the breast, its  legs flexed upon
the thighs, and the latter upon the abdomen, and the
arms  crossed upon the chest,  or  placed with the
hands upon the  sides of  the face.
   The funis is composed of  three  vessels,  the two
 arteries just  mentioned, which bring the impure
 blood to the placenta, and the umbilical vein, which
 carries it back  from that organ  to the  body : the
 vein is considerably larger than the arteries.  None
 of these vessels  send off any branches  until they
 are entering the placenta, when the arteries anasto-
 mose  by a cross branch.  They do  not, however, run
 a straight course, but are twisted  spirally  together,
 and  also  arc  tortuous, forming  coils upon them-
 selves.   The substance  of the cord consists of a 
   72        DUBLIN PRACTICE OF MIDWIFKRY.

fc  cellular web. filled with a  gelatinous matter, called
   the Gelatine of Wharton, and covered firmly by the
   chorion and amnion.   In this gelatinous tissue the
   vessels are imbedded, and thus M-ry effectually pre-
   served from injurv.  Owing to this provision, knots
   are frequently formed  upon the cord, without in the
   least interrupting the circulation.   Uesides the arte-
   ries and vein, the cord  contains  a rudiment of the
   urachus and the omphalo-mesentcric vessels and vi-
   telline pedicle, structures which shall be  subsequent-
   ly alluded to.   The existence of  nerves  and lym-
   phatics in the funis has been denied by  most anato-
   mists; but Sir Evcrard Home has alleged that he
   discovered the former  by means of the microscope;
   and Dr. V. Fohmann,'  of Luttich, asserts that he
   has been able to inject absorbent vessels with  mer-
   cury, and that they are very numerous both in the
   cord  and placenta.  The  testimony of these gen-
   tlemen has not yet, I believe, been  corroborated ;f
   and,  I fear, that at least Dr. F's argument (like many
   an excellent one) is injured by too  much  proof, as
   he is not  satisfied with stating the existence of these
   vessels, but proceeds to show that,  except the vein
   and arteries, the funis contains nothing else but ab-
   sorbents.  The length  of the cord varies  (from six
   inches to four or even  five  feet), but is usually about
   two feet: it is  frequently,  when too long, twisted
   round the neck of the  child.

    * Zeitschrift fur Physiologie, 4ter, bd. 1832.
    t Since the above was written, Dr. Montgomery of Dublin
   has succeeded in repeating Dr. I'ohmiinn's injection  in the
   funis. 
GRAVID UTERUS.
73
  The placenta is the most important of all the ute-
rine organs of  the  foetus, without  which  neither
growth nor subsistence  can continue.   It has vari-
ous forms in  different  animals, but, in the human
subject, is a flat circular body,  about six  inches in
diameter, and about one  inch and a half in thick-
ness at the centre,  becoming thinner toward the
circumference.  Usually in the centre, but some-
times at or near the edge, we  find the  insertion of
the funis, whose vessels  immediately ramify  in a
divergent manner upon the surface of the  organ.
The placenta gives  to  the touch a  peculiar rough
fleshy feel, which the student will do well to make
himself familiar with,  that he may be enabled to
recognize it while in the uterus.
  The external, or uterine, surface is covered with
a thin layer of deeidua, intimately connected with
its  substance.  Under the deeidua  the  placenta
is divided  into  lobes,  the surfaces  of which have
somewhat of a rough,  spongy appearance ; and by
some it is said that  there  are defined openings to
be  observed, leading through  the deeidua into the
substance."   Much  dispute  has  arisen as  to  the
connection of this surface with the uterus.  Hun-
ter supposed that large vessels passed directly from
the mother into cells in the placenta.   A different
opinion was  entertained  by the  Monros,f and has
been lately very ably advocated by Dr. Robert Lee.


  * Dr. H. Ley in Med. Gaz. vol. xii.
  t Med. Essays, vol. ii.; and  Essays and  Observ. Phys. and
Lit., vol. i.
             7 
7-1        DIP!.IN PRACTICE OF MIDWIFERY.

These  gentlemen  deny that  any connection  exists
between the uterus and placenta,  except, perhaps,
by small nutrient vessels.   Later still.  Dr. H. Ley*
has had  an opportunity of accurately examining a
gravid uterus, and he  corroborates  the  account of
Hunter, which is also supported by the testimony of
Professor  Burns.   As  yet, I think, wo  must con-
sider the question as  unsettled,  although probabili-
ties certainly appear  to be against the  notion that
any  very large  vessels pass directly  between the
two parts.   The internal, or foetal,  surface of the
placenta is not, like  the  other, divided  into  lobes,
nor  has it  the same  spongy, glandular appearance,
but  is  formed of an  immense  congeries of vessels,
together with cellular  substance and a number of
white  filaments, the nature of  which docs not ap-
pear to be understood : it is covered by a thin layer
of deeidua, which is very intimately connected to
it; and by the chorion and amnion.
   The internal  structure  of the placenta has been
the subject of much  dispute.   It  can  be  injected
freely from the  vessels of the cord ; and it was sup-
posed  by William  1 [unter that  injections could also
be thrown from the  uterine vessels into  cells in its
substance.  From these  circumstances, and from
the  fact of distinct uterine  and foetal  portions ac-
tually  existing  in the placenta of many animals
Hunter  inferred, that in the  human  female it  is
also composed of two parts : the one cellular, com-
municating with the  uterus by a  direct passage of
• Med. Gaz., vol. xii. 
                 GRAVID UTERUS.               75

vessels ; the  other vascular, and being, in fact, the
ramifications of the umbilical vessels.  From  the
result of  his injections,  he  inferred  further,  that
these portions had no vascular communication.   By
others it has  been stated, that  no passage of injec-
tion can be effected  from the uterine vessels  into
the placenta, except as the result of extravasation,
and that there are no cells whatsoever  in its struc-
ture, but that it is entirely  composed of the foetal
vessels.  From the best consideration that I have
been able to give the subject, this  latter view cer-
tainly appears to me to be the most correct;  but I
am far from thinking that the  question has been ul-
timately set at rest.   It is probable  that the purpo-
ses of the glandulce uterince,  or  maternal  placenta
of animals, are effected in the human  womb  by a
peculiar development of that portion of the uterine
wall to which the placenta is  attached, and not by
any  contrivance in the substance of the latter organ.
The testimony with  respect  to the existence of
nerves and lymphatics in the  placenta is the  same
as was mentioned in favour of the  presence of  the
same organs in the funis, viz. Sir. E. Home and Dr.
Fohmann.  Dr. F. asserts that the  lymphatics con-
vey  nourishing material  from the  mother  through
the cord to the iliac glands, and  thence into the sys-
tem  of the foetus.
   The uses of the placenta appear to be  in some
degree analogous to those of  the lungs and stomach
of the breathing animal.   The blood passes into it
from the hypogastric arteries,  and, after a very free
circulation through it, returns  by the umbilical vein 
76        DUBLIN PRACTICE OF MIDWIFERY-

directly to the  heart.  This circulation  continues
until respiration is established, when it ceases spun-
taneously, and any  interruption of it, before  the
latter process has commenced, is  immediately fatal.
From these facts, we are warranted  in inferring
that a change  necessary to  life (probably oxygeni-
sation) is  produced  in the  placenta,  although  the
nature of that change is obscure, and  the  relative
properties of the blood in the umbilical arteries  and
veins not at all known.  That the organ in question
not only revivifies  the  blood, but  also  elaborates
new vital fluid, thus  performing  a function analo-
gous to that of the  stomach, can only be inferred
from the  absence of any other source from whence
the foetus could obtain materials for growth  and
support.
   With respect to the manner in which the placenta
is  formed, all  is  obscurity; but the  following ap-
pears to me to be a probable conjecture.  In speak-
ing of the deeidua  reflexa, I  have mentioned  the
probability of its being formed by the ovum, in its
entrance into the womb, pushing before it that  por-
tion of deeidua vera which covered the opening of
the tube, and so forming a bag,  the neck of which
would remain attached to the  tube, while it would
itself (from  its  plastic  nature) increase  in  a ratio
with the increase  of the ovum.  In  a short time
this bag of deeidua reflexa would be pressed against
some part of  the uterine wall (most probably in the
vicinity of the  fundus), and there meeting with a
membrane exactly  similar to  itself  (the  deeidua
vera), a vascular  union would  very  soon be estab- 
GRAVID UTERUS.
77
lished.  The result of this  union would soon  be a
minute anastomosis of vessels, and  a formation of
membranous tissue  to  support them, between the
two deeiduae, and, in process of time,  the elabora-
tion of a perfect placenta.
  We have now disposed of the principal  contents
of the gravid uterus, and shall merely allude to two
structures, to which great importance has been at-
tached by some, but which, in reality, are  very im-
perfectly understood.
  The vesicula umbilicalis is a  small body, not ex-
ceeding in size a small pea,  which lies between the
chorion and amnion, near  the margin  of the pla-
centa.  It is connected  with  the intestines  of the
foetus, by a duct denominated the vitelline pedicle,
which runs along the funis; and  is also connected
with the mesenteric vessels by an artery and vein,
called the omphalo-mesenteric,  which accompany
the  vessels  of the  cord  through the umbilicus.
The vesicle contains a small  quantity of a kind of
oily matter, supposed to perform a part in  the early
nutrition of the embryo : but the fact is, we know
nothing about the matter.
  Allantois.—By  some  persons a reticulated mem-
brane is described as existing between the chorion
and amnion, which they describe as analogous with
the allantoid of brutes, and from  which they say
the urachus proceeds along the cord to  the  fundus
of the bladder.   By others, the existence  of an al-
lantoid in the human subject is altogether denied,
and the urachus merely considered  as a rudimental
type of the same organ in animals.   The use of the
          7* 
78        DUBLIN PRACTICE OF MIDWIFERY.

allantoid has been  generally supposed  to be for a
reservoir for the urine of  those animals in  whom it
exists.   Velpeau, who admits the existence of some
structure of the kind in the  human subject,  suppo-
ses that it  serves some unknown purpose  in  the
early nutrition  of the foetus. 
79
                CHAPTER VII.

   PREGNANCY--STATE OF THE GENERAL HEALTH.

  Pregnancy is always accompanied with a state
of general health, having many analogies with fever-
Breschet (Etudes de I'ceuf) very truly says that the
reproductive process is nearly  identical with the
reparative ;  for nature, though multifarious in her
ends is exceedingly chary of her means.  Does she
intend to repair any lesion ? what is the process ?
Irritation, an  afflux of fluids—the elimination  of
eoagulable  lymph, which takes  sooner  or later  a
form  more  or less dense,  is  organized and then
adopted as part of the frame.   So, in the reproduc-
tive process, the irritation, the exaltation of vitality
the elimination of  a eoagulable fluid,  and its subse-
quent organization,—these are the  early steps.  If,
then, the analogy between the reproductive and the
reparative processes is so strict,  if  both partake in
nearly an equal degree of the characteristics of in-
flammation,  it is not to be wondered at  that the for-
mer, as well  as the latter, is  accompanied by that
exaltation of the vital  powers and disorder of the
vital functions, which  we call symptomatic fever.
Such is the fact; some of the symptoms of fever, as
heat, restlessness, alternate flushes and chills, a gen-
eral feeling of plethora, with an excited circulation,
and  a quick irritable pulse,  appear in almost all 
80        DUBLIN PRACTICE OF MIDWIFERY.

cases of pregnancy.   The mind, too, is often effec-
ted,  the  patient  becoming cross, fretful,  irritable,
and sometimes, exceedingly passionate.   In all these
respects there is a remarkable difference  in different
women ; in the feeble, the languid, and those whose
vitality is usually below  par,  the  corporeal excite-
ment is  beneficial, they  enjoy  better health while
pregnant than at other  times;  on the other hand,
plethoric women suffer  exceedingly  from  feverish
symptoms.   So of the  mental stimulation, in sonic
the activity of the mental faculties is increased in a
marked degree, so that  the dull and phlegmatic, if
at all effected, are only pleasantly so, while the ner-
vous, the  hysteric and the excitable are nearly, and
sometimes quite, driven  mad.
   Buff'y blood, in pregnancy, as indicating the inflam-
matory state, was formerly much insisted on ; that
the  blood was  buffy during  pregnane),  was  an
axiom in  obstetrics which no one doubted or  en-
quired about.  Of late years its existence, in all or
even in any large majority of cases has been denied.
Montgomery says it will be  found in the early
months in a great majority of cases, but  it is  lc>s
common as pregnancy advances, and very often ab-
sent during the eighth and ninth months.
   It is not, however, the presence or absence of
particular and individual symptoms, that  should es-
pecially attract  our  attention, but rather, the state
of system which these indicate.  The fact,  that a
tendency to febrile excitement is present  in a  de-
gree, in all cases of pregnancy, is a principle  in ob-
stetric physiology of great practical  importance, 
PREGNANCV.
81
ignorance or disregard of which is the cause of half
the errors which are committed in prescribing for
the diseases of pregnant woman, it is also the fruit-
ful parent of blunders innumerable, in their regimen.
How common is the notion, that because a pregnant
woman has, as they say," two to eat for," she must be
fatted up like a  prize ox, eat beef enough for two,
and drink ale, beer, porter, or wine, enough for half
a dozen !  Now how  absurd does all this appear in
view of the physiological fact, that the patient who
is thus pampered and stimulated, is all  the while in
a state near akin to fever.

        SYMPTOMS OR  SIGNS OF PREGNANCY.

  Absence of  the menstrual  secretion  is the first
symptom of pregnancy to which attention is direct-
ed, it is relied upon with great confidence by the sex,
with them it is the sign, and this confidence is shared
by some of the seniors in the profession—yet it is
open  to many  sources of error—let us  attempt to
appreciate with accuracy its value as a  diagnostic
sign of pregnancy.
   First then, as a general rule, if a woman who has
been regular, has the menses suddenly suppressed,
if this is neither preceded nor followed by ill health,
she is pregnant.  This is the general rule, but there
are some  exceptions and  besides  its  value  as a di-
agnostic sign of pregnancy is diminished because
in some instances the  menses do not  cease  immedi-
ately on the occurrence of pregnancy, of this there
is no doubt;  for though it is  vehemently denied by 
82        DUBLIN PRACTICE OF MIDWIFERY.

Denman and also by  Hamilton, we  have  on the
affirmative side of the question, Gardien,  Capuron,
Montgomery, Dewees,  Couch, and a host of others.
Again, pregnancy may  occur during a  suppression
of the menses, even when that is  caused by very
serious disease ;  of this Montgomery  gives a very
remarkable case, the patient bad disease of the heart
with dropsy, and the suppression was of two years
standing.   Again pregnancy may occur before the
menses appear, (Sir E. Home, Frank) or in women
who never have menstruated.   (Zachias, Moriceau,
Gardien,  Capuron, Fodere.)
   But the great source of error  on this  subject is
the irregularity of the function  about the turn of
life.  Women at that time are  very apt to pass one
or two periods, and then have an unusually profuse
discharge, even  a hemorrhage—an ignorant man
will here conclude that pregnancy  and  abortion
have both taken place, and  if, as is most likely, the
patient pass the next term she will  be put under all
manner of restrictions, perhaps subjected to medical
treatment, and  all to prevent  abortion  occurring
before pregnancy.   Still  it must not be forgotten
that pregnancy does every now and then take place
under these precise circumstances.
   The general rule to be deduced from all these facts
is, that the  suppression of  the menses, even when
not accompanied or followed by bad health, is not to
be relied on as proving pregnancy in a woman about
the turn of life—we must depend on  other circum-
stances.
  Irritable bladder.—This is one of the earliest and 
         SYMPTOMS  OR SIGNS  OF PREGNANCY.      83

most constant symptoms of pregnancy.   It is much
relied on by Blundell.  It occurs very early in preg-
nancy,  and is not  dependent  on the  mechanical
pressure of the uterus, but upon the state  of irrita-
tion common to all the pelvic organs at that time.
The same thing (micturition) occurs in piles  and
from the same cause, sympathetic irritation.
  Morning sickness.—This is a symptom  less con-
stant than you  would  suppose,  from its  being so
much talked about.   Some women never have it, a
patient  of  mine had nine children and  never knew
what it was to be sick.*  It usually appears  about
the third week,  though  sometimes earlier.  It has
many peculiar characteristics, as, it is usually felt on
the patient's making her first attempt to  assume the
erect posture, it comes on  suddenly and goes  off
as suddenly, the appetite is often good, food is taken
with a relish, then sudden nausea and vomiting come
on, the  food is rejected with instant and complete
relief.   Now and then the nausea is constant, and
the stomach rejects almost every thing.  Morning
sickness is usually most troublesome during the  first
half of  gestation, though it  may continue through
the whole  term, even to  the very hour  of parturi-
tion.  Akin to the  morning  sickness and like it de-
pendent on gastric  irritation, is the vitiated appetite,
of which so much has been said, real cases  of this

  * This  case contradicts a wholesale assertion of Ramsbotham,
who says, where nausea and vomiting are entirely absent, ges-
tation does' not proceed  with its usual  regularity and  activity.
This patient passed through nine prsgnancies, all with quite the
usual regularity and activity. 
84        DUBLIN PRACTICE OF MIDWIFERY.

sort are rare, and when they do occur  arc  usually
connected with hysteria in some form or other.
  Salivation is another  manifestation of  gastric
sympathy,  which  we  sometimes  see  in pregnant
women.   It has been thought mercurial, and the at-
tendant blamed for giving mercury.   (Montgom-
ery).
  Mammary irritation.—The  mammary gland  is
usuallv the seat of increased action very soon after
conception, marked by heat, pricking pain,  a sense
of distention, the breasts then enlarge, and frequent-
ly a little milk is  secreted.  This,  like the suppres-
sion of the menses, is much relied  on by the sex, as
a sign of pregnancy, it is, however, of little value,
being open to the following sources of fallacy :
  1st. Mammary-engorgcment is an almost constant
accompaniment  of suppression  of  the  menses,
whatever may be the cause of  that suppression.
  2d. It often occurs  immediately after marriage,
from  the irritation of first coition,
  3d. It is often felt just before or just after a men-
strual period especially if the woman have dysinen-
orrhoea.
  4th. Enlargement of the  breasts from fat may be
mistaken  for  hypertrophy of the  gland, dependent
on  pregnancy, the  knotted, lobulated  feel of  the
gland ought, however,  to guard us  against this error.
Hypertrophy of the breasts then is not of any great
value as a  diagnostic sign of pregnancv.
  Far different is it with the changes  in the nipple
and areola, to them great  value always attaches, and
in many cases they alone will  suffice to decide the 
SYMPTOMS OR SIGNS OF PREGNANCY.       85
question of pregnancy.   These changes begin to
manifest themselves as early as  the second month,
but are not perfected  till the middle of the third or
end of the fourth month.  The part then presents the
following characteristic symptoms.   The nipple is of
a decidedly darker colour than the skin  elsewhere,
varying, however, in different women,  darkest in
brunettes, lightest in blondes.  The colour, however,
is not to be relied on, especially if the woman has
had children before,  as  it is  never perfectly dis-
charged, the nipple retaining a dark shade  at all
times.   Besides the colour, we  find the  papillae of
the nipple turgid and  erect, the skin soft, puffy, and
moist over the nipple  and areola, and a  number of
glandular follicles, from  twelve to twenty, appear
in the areola.  They are  turgid,  project  about a
line from the surface, and are most numerous imme-
diately  around the nipple.   The  secretion  from
these follicles keeps the  part moist, and  sometimes
stains the patients linen.
  Such are the characteristics of the true areola,
when present in any degree of perfection they ren-
der the  probability  of  pregnancy  very  strong,
when entirely absent pregnancy must, be  considered
as quite out of the question.
  Secretion of milk.—This is of  little  value as a
sign of  pregnancy,  it  is rare before the fifth month,
but after that time it every now and then occurs.
  Enlargement  of  the   abdomen.—This  is a sign
which often excites  popular suspicion, but when we
come to speak of it  as  matter of science,  it obvi-
ously only proves that something bulky is being de-
             8 
86        DUBLIN PRACTICE OF MIDWIFERY.

vcloped in the cavity—whether this is the uterus or
some other organ, further investigation must deter-
mine.  Nay, even when  we get so far as to prove
that  the enlargement is dependent  on  the  develop.
ment of the uterus, it  may  still remain a question
whether this development result from pregnancy.
  The first of these facts, viz. that the enlarged ab-
domen depends on the increased size of the uterus,
can generally be  made  out by careful external ex-
amination,—to do  this,  place the woman  on  her
back, the  head and shoulders supported by pillows,
and  the thighs drawn up, then let her make a thor«
ough expiration, and if she  be not very fat, a care-
ful manual examination  of the hypogastric  region
will  enable you to detect the fundus uteri rising like
a firm, hard ball behind and above the pubis.   Take
care that the bladder  be  emptied.  Having satisfied
ourselves  that the uterus is enlarged, the next thing
is to decide, whether  it contains a foetus ;  this  can
only be satisfactorily  done  by vaginal examination,
and  ballottemcnt, of which we shall speak  further.
Reliance has, by some, been placed on depression or
prominence of the navel;  if, say they, the navel is
as deep as usual, the patient is not pregnant, if it is
effaced she  is.  Neither of  these affirmations  arc
true—the navel is often  effaced, the woman not be-
ing pregnant, and vice versa, it is  deep when preg-
nancy does exist.   A case of this latter kind occur-
red in New York recently, two obstetricians were
deceived by relying too much on this sign.
   Quickening.—It was formerly thought  that the
motions of the child were  always felt immediately 
        SYMPTOMS OR SIGNS OF  PREGNANCY.      87

after the rising of the uterus out of the pelvis, but
it is now known that these two things  have no ne-
cessary connection, when the womb rises, as it now
and then does, suddenly out of the pelvis, the change
is accompanied with certain nervous feelings, faint-
ness, a sense of fluttering, &c„  but this may, or may
not be followed by that perception of the motions
of the child, to which the term  quickening, or "feel-
ing life" should be restricted ; cases are recorded
where the uterine tumour was  quite obvious above
the pubis, some time before motion was felt.
   The time of quickening varies, not only in differ-
ent women, but in the same  women  in different
pregnancies.   It may occur so early as the twelfth
week, or be delayed to the sixth month.  As a sign
of pregnancy it has some value, but I  believe that
undue  reliance upon this symptom, has  been the
cause of more  blunders  in the diagnosis of preg-
nancy, than any other thing—as a sign of pregnan-
cy, then, let us try to appreciate  its true value.—
The motions of the foetus are perceptible to the pa-
tient, and  they may be felt by  the accoucheur ; we
have, therefore, two distinct sources of evidence—
the testimony of the patient, and our own sensations.
As to the  first, its value  is but small; even  if she
have no desire to deceive, (and women  sometimes
have motives which we little suspect)* abundant ex-
perience proves that, not  only the woman who has
never felt it, but also she, to whom in previous preg-
nancies it is perfectly familiar, may be entirely mis-
taken, and suppose she "feels life" when there is no
life to feel.  The evidence e>f the  patient,  then, is 
88        DUBLIN PRACTICE OF MIDWIFERY.

nothing worth—no  prudent man will  rely on  it.
But these motions are  perceptible to the  band  of
the accoucheur, here, surely, then; can  be  no  mis-
take ; any  one  who has lelt the convulsive start
which the foetus in utero gives, cannot  be mistaken
about it.   This would  seem so,  and yet  mistakes
have been made.   Dewees, with a candour which
does him infinite honour, confesses that  he was de-
ceived in one instance.   The best way to detect
these motions is to apply the hand, previously made
cold  by dipping it in water, or rubbing it with can
de Cologne, suddenly upon  the centre of the hypo-
gastric region, the child will give a start, often strik-
ing against the hand, this blow will, of course, be
stronger and  more  easily  perceived,  the  further
pregnancy  has advanced.
   Auscultatory evidence.—For the first idea of ap-
plying auscultation to the investigation of pregnan-
cy we  are  indebted  to  Mayer of Ceneva.   By ap-
plying the ear or the stethescope to  the uterine re-
gion of a pregnant woman,  two sounds may gene-
rally be recognized ; one a  cooing, rushing sound,
like that made by blowing over the neck of a vial;
it  is synchronous with the pulse -of the  mother, this
was  called, by  M.  Kcrgaradec, bruit  plaamlaire.
It is most frequently heard  on the anterior lateral
portion of the tumour, oftcnest on  the right  side,
(Montgomery,) left, (Dubois).  It varies  exceedingly
in intensity in different  cases, and  in the same case
from day to day, is  often detected  with difficulty,
and  in some  cases  it  has  not  been found at all,
even by practiced auscultators.   Some writers claim 
         SYMPTOMS OR SIGNS OF PREGNANCY.       89

to have detected it so early as the tenth  or twelfth
week, (Evory Kennedy, M. De Lens,) usually it can-
not be made out before the fifteenth, and often not
till the twentieth week, it becomes more distinct as
gestation advances.  It is always diminished, and
often entirely suspended by uterine contraction.
   The cause of this  sound is still matter of doubt;
it was supposed by Kergaradec to proceed from the
placenta, and to indicate the situation of that body,
this is now disputed.  Kergaradec  in proof of its
depending on  the placenta, asserted that it  was
heard loudest at one spot, and  that at  this spot it
would always be heard afterwards, if heard at all;
further observation has not confirmed this.  Laennec
thought it proceeded from the uterine arteries going
to the placenta, Kennedy inclines to this opinion.
Bouillaud asserts that it has no connection with the
placenta, but comes  from the  iliac arteries com-
pressed by the gravid uterus. The prevailing opin-
ion now is, that the so called  bruit plaeentaire is
nothing more  than an  arterial  bruit de soufflet, or
bellows sound, caused by the blood passing through
an obstructed artery.  This obstructed artery  may
be in the uterus, or in some other organ  or viscus,
an ovarian tumour, for instance; even if  the artery
be uterine, we have  still to decide whether its aug-
mented calibre depends on pregnancy,  or on some
other cause, and when we are sure  that pregnancy
exists, the so called bruit  plaeentaire, indicates the
position of the placenta, only so far that we know
that the largest branches of the  uterine arteries are
there.   That the placental circulation proper has
             8* 
90        DUBLIN PRACTICE OF MIDWIFERY.

nothing to  do with the production of this sound is
proved by the facts that it is sometimes  audible af-
ter the placenta has been expelled and also after the
death of the lotus, (Dubois).
   But we may have this bruit de soufllet  in the hy-
pogastric region when pregnancy does not exist, all
that is necessary  to its production is the existence
of a large artery so near  the surface  that it may he
compressed by the stethoscope.   Montgomery and
Churchill both detected very distinct  bruit de souf-
flet in a case where pregnancy did not exist, it came
from an artery on the  side of a large pelvic tumour.
The bruit plaeentaire,  then, is of no  great value as
a diagnostic sign of pregnancy, it is  not  always to
be detected when pregnancy exists, and it may be
very distinct and yet the  patient  be not pregnant.
   The second sound which we hear when ausculta-
ting the uterus, is the  foetal heart sound, this very
exactly resembles the  ticking of a small watch, it
varies in rapidity from 120 to 160 strokes in a min-
ute.  Its rapidity distinguishes it  from the pulse of
the mother, and its character is quite different from
that of any sound we  are likely to hear in the ab-
domen, it is not at all likely to  be mistaken for any-
thing else.   Here then we have a nearly perfect
diagnostic  sign  of pregnancy; by it  we learn not
only that pregnancy exists but that the child is liv-
ing ; nay more,  we can in many  cases ascertain the
presence of twins in  the uterus,  for if the heart
sound is heard with nearly equal distinctness in two
opposite regions of the uterus, and it  is not audible 
         SYMPTOMS OR SIGNS OF PREGNANCY.      91

at an  intermediate point,  we may say with confi-
dence that the woman carries twins.
  Rules for practising obstetric auscultation.  1st.
Never auscultate a woman who  is not supposed to
be at least four  and a half months  advanced in
pregnancy.
  2d. If you are in the habit of using the stethescope,
you may depend on it, if not the naked ear is better.
  3d. See that the bladder and the bowels are emp-
ty :  even flatus distending  the intestines will inter-
fere with your trial.
  4th. Place  the patient in bed, the shoulders sup-
ported, the thighs bent, press the stethescope firmly
down upon the uterine tumour,  kneading  away the
fat if there is much in the  abdominal walls.   Kneel
down and  apply the ear, do  not  bend over, or
bend  your head  down.  The spot first  examined
should be half way between  'the navel and the left
superior iliac  spine, here the sound is most frequent-
ly heard.  If, after careful and somewhat prolonged
listening it is  not heard, remove the  instrument to
some  other point, and if there unsuccessful, try an-
other and another, till the  whole uterine  tumour is
explored.   If after all the sound is not heard, the
examination should be repeated another  day ; one
who has  acquired that experience, which  all men
mayr acquire  by taking advantage of the cases of
undoubted pregnancy that come in their way, will
rarely fail to  detect the  heart  sound after two or
three patient  trials, if pregnancy does exist, and has
advanced beyond the fifth month.   Once heard,
pregnancy is  certain. 
92        DUBLIN PRACTICE OF MIDWIFERY.
   State of the os and cervix uteri.—It has been al-
ready shown that, about the fifth or sixth months,
considerable changes take place in the cervix ; and
accordingly it is about  this period that we  derive
the most certain information  from an  internal ex-
amination.  This part of the womb, not being dis-
tended by the ovum during the first months, is press-
ed downwards by the increased weight of the fun-
dus, and then projects rather more  than usual  into
the vagina; but, at the termination of the  fifth
month, begins to be taken up  into the general cavi-
ty7, and, therefore, becomes  shorter and less  promi-
nent.   The cervix continues to be shortened, until,
at the ninth month, its  canal is completely merged
in the general cavity  of the  uterus ; and we then
have no projection whatever, but  merely feel the os
uteri as a rugous circular opening in  the lower ex-
tremity of the womb, the wall of which  is  spread
evenly over the head of the  child.   From the first
periods  of gestation, the  os uteri itself undergoes
certain changes:  it appears to become the seat of a
more  active  circulation, losing  its  former  gristly
elastic feel, and becoming softer and more spongy.
During  the first  five months  it  is easily felt;  but,
according  as the  cervix shortens,  and  the  fundus
leans more forward against the anterior walls of the
abdomen, it is inclined  more backwards and up-
wards towards the promontory of the sacrum, and
at the termination of the  ninth  month is often out
of reach of the finger.   That the tumour felt in the
abdomen is identical with that felt per vaginam, we
may satisfy ourselves  by placing  one hand  on the 
         SYMPTOMS OR SIGNS OF PREGNANCY.       93

abdomen, and ascertaining that motion is communi-
cable from it to the fingers of the other hand press-
ing against the os and cervix.  This sensation, how-
ever, might be occasioned by a uterus morbidly en-
larged, or one which contained other substances be-
sides an ovum,  as, for example,  hydatids; and to
obviate such a deception, the mode  of examination
called by the French ballottement has been devised.
To perform this we must introduce one  or two fin-
gers per vaginam, the woman  being in  an upright
posture ; and while the other hand  upon the abdo-
men presses down the womb, we tap quickly against
the cervix, so as to jerk up the head of the foetus,
which floats for a  second or two in the liquor am-
nii, and then  falls lightly on the finger.   If this cir-
cumstance occurs, it is, of course, proof positive of
the existence of a foetus;  but  it  is not always that
we can succeed in the trial.
   From all that has been said respecting the indi-
vidual signs of pregnancy, it must be obvious that
none of them singly afford means for a certain di-
agnosis.   The most important information is cer-
tainly to be derived from internal examination, and
from  the employ ment of auscultation; but  even
these do not always furnish conclusive evidence, and
it  is only from a careful enquiry into all  the marks,
and a  collation of them with each other, that we
can usually be warranted in giving a  decisive opin-
ion, either negatively^ or affirmatively.   In  many
cases, also, the difficulties in the  way of the practi-
tioner will be much  enhanced by  the existence, at
the same  time, of pregnancy^ and disease, (for ex- 
94        DUBLIN PRACrii'B OF MIDWIFERY.

ample, ascites or morbid tumours,) he will then, per-
haps, have at once to deal with  both positive and
negative  signs, and should never give an  opinion
without the most patient, and,  if necessary,  pro-
tracted, consideration.
  Duration  of pregnancy.—h is very  difficult  to
come to perfectly exact conclusions  as to the dura-
tion of pregnancy, but  the most  generally received
notion, and which 1 believe  to be very correct, as-
signs nine calender months, or between 39 and 40
weeks, as the term.  It is not  improbable that, oc-
casionally, labour  may  occur  a day or two  earlier
or later; but there is no perfect certainty upon  the
subject.
  Reckoning, or the  computation of the duration of
pregnancy, is kept in three ways.  First, from  the
period of conception, which, if known, leads to the
most accurate results;  but, of course, can only be
ascertained  under  veiy peculiar  circumstances.
Secondly, from the cessation of the menses, which
is subject to a  trifling  inaccuracy, as the woman
may have conceived immediately after the last men-
struation, or immediately before  the next  period.
For this debateable time, they  usually allow two
weeks, and  so  reckon  upon  being  delivered 42
weeks from  their last  menstruation.   Thirdly, wo-
men frequently check   the last mode  of reckoning
by  the period of their  quickening, which they gen-
erally calculate to occur 24 weeks before labour. 
DISEASES OF PREGNANCY.            95
             DISEASES OF PREGNANCY.

   Most of the diseases of pregnancy are but aggra-
vations of the ordinary symptoms, any one of which
may be so in excess as'to constitute a truly diseased
state.
   Nausea.—This is sometimes so severe and so pro-
tracted as to destroy the comfort, endanger the
health and even to put an end to the life of the pa-
tient ; in the severest  cases  the patient has usually
some  respite, but now and then the distress is con-
stant, day and night;  food is rejected  the moment
it  is swallowed, and it is  only by taking advantage
of an  occasional lull  that any thing can be  kept
on the stomach.  Nausea is usually aggravated by
improper food,  by constipation,  and  by the pre-
sence of sores in the stomach or bowels.  If either
of these causes are suspected they should be remov-
ed.  If this  does  not  mitigate  the vomiting, we
resort to various means of checking gastric irrita-
bility.   If the tongue is  red and the pulse excited,
bleeding, or leeches to the epigastrium will do  good
(Burns).  If there are no such  indications for de-
pletion, we must, as Desormeaux  observes, adopt a
practice nearly empirical, trying first one thing, and
then another.  The effervescing  draught, simple, or
with laudanum,  or a bitter infusion, will often  do
good, strong coffee will benefit those who are accus-
tomed to  it, mint tea, or iced water may be tried.
Opium given by the mouth or per annum, will  often
do good after bleeding.   In  neither way must this 
96        DUBLIN PRACTICE OF MIDWIFERY.

remedy be continued for a long time.  A safe way
of using it is dipping a bit of hnt in  laudanum, and
applving  it to the epigastric region.   Counter irri-
tation  at this  point, by blisters or mustard  placer,
will often succeed  for a  time.   If acidity be  pre-
sent, charcoal. (10 grains  in a little  milk), or some
alkali, should be tried.  If nothing alleviate the nau-
sea, and, as has happened,  though very rarely, the
patient's life is  in danger, resort should be had to
premature delivery.   N utritive enemata ought t<»be
tried in  such cases.  It  is worthy of remark, that
the vomiting consequent on morning sickness very
rarely produces abortion, though that effect has not
unfrcquently resulted from the use of emetics.
   Heart  burn, or cardialgia.—This is very common
in pregnancy.  Bitter infusions, with alkalis,  effer-
vescing mixture with excess of soda, lime  water,
liquor  potassa-, may be  tried.  I have  given, sub.
carb. soda, in pills (5 or  0 grains after  each meal)
with advantage.  1 think it  does better than the so-
lution, why, I know not.   Dewees praises the infu-
sion of cloves, Baillie the mineral acids, others the
vegetable.   A  favourite  prescription  of Dr. Suns,
of which I think highly is
        R.   Aq. ammoniac,  z\.
              Magnesia calc., z\.
              Aq. cinnamon, _";i.
              — pura, fv. M. Cochl. max pro dos.
   Constipation.—This is  exceedingly common, es-
 pecially during the first months of gestation.  The
 means used for its removal should be mild laxatives,
 and  bland enemata.  Magnesia and  rhubarb, or 
DISEASES OF PREGNANCY.
97
 castor oil in small doses, answer a good purpose.  If
 the bowels are neglected early in pregnancy foeces
 may accumulate  in  the colon and rectum, causing
 great irritation, interfering with digestion, aggrava-
 ting nausea, and, perhaps,  by the straining efforts
 the woman makes to get rid of them, causing abor-
 tion.  If they remain till labour sets in the mass in the
 rectum may oppose  a  serious obstacle to  its  pro-
 gress.   When such accumulation is suspected (and
 it can  always be  ascertained by vaginal  examina-
 tion) means should be  taken at once to remove it.
 A purgative, such as Dinner pill, rhubarb, or a full
 dose of castor oil, should be taken at bed time, and
 a large enema of soap suds  or salt and water, ad-
 ministered early in the  morning.  If this does not
 succeed (it may  be  repeated once  or  twice), we
 must break  the mass  down by the finger, or the
 handle of a spoon.   One way or another  it should
 always be got rid of.  Extr. Hyosciani, and extr.
 Colocynth, aa 3L mft. pil. No. xv, two a dose, makes
 a good laxative.   Hyosciamus and aloes is a favour-
 ite with Burns.  The diet should be laxative, fruit,
 vegetables, veal, &c.   A great deal can be accom-
 plished by attention to diet in these cases, both in pre-
 venting and removing constipation and its effects.
  Diarrhoea.—This is every now and then observed,
 though  more rare than constipation.  In fact, very
 manyr of these cases  are consequent  upon constipa-
 tion ;  the accumulated, and  long retained foeculent
matter, acting as an  irritant, and exciting  the in-
testinal mucous membrane  to  excessive secretion,
and the muscular  coat to inordinate activity.  Un-
            9 
98        DUBLIN PRACTICE OF MIDWIFI:RV.
dcr these circumstances relief can be obtained only
by  a free  evacuation of the  alimentary  canal.
When; nothing  of this sort  is  suspected the  diar-
rhoea is to be treated on general principles.
  Salivation.—When this  is excessive, and the pa-
tient's strength  failing, it  should  be cheeked, and
may be without danger, though the contrary is as-
serted by  Baudeloque, and other  French writers.
Attention to the state  of  the  stomach  is very im-
portant in such  eases, after this has been regulated,
local astringents may be used, as infus. sumac, (Fah-
nostoch), turpentine julap,  (Geddings).   Blisters be-
hind the ears do good in some cases.
  Plethora.—We have already said that a certain
degree of vascular plethora and activity, is normal
in pregnancy,  especially  in the first months, and
should  not  be  interfered  with. To bleed merely
because a woman  is pregnant  was once a fashion
in medicine, but fortunately it  is now nearly explo-
ded.   Where plethora does  not  exist  it is absurd,
and even if there is  a degree  of vascular  excite-
ment  and fullness, we should  satisfy ourselves that
it has passed the normal standard,  and has produced
or is aggravating some disease, before we interfere
with it.  This  rule applies only to the first half  of
pregnancy ; towards the close  plethora is less com-
mon and more injurious,  in  fact,  women generally
do best when they fall in  labour with the  system a
little below par. and efforts may  well  be made to
bring them into this state  by low diet, laxative food
and even small  bleedings.  To low diet  and laxa-
tives, rather than to bleedings, will the judicious prac- 
DISEASES OF PREGNANCY.
99
titioner resort to remove plethora at any stage of
gestation.
  Among the diseases caused by plethora, we have,
  Headache.—This form must be distinguished from
the sick headache, which every now and then at-
tends the nausea  of -pregnant  women,  and also
from  the nervous headache, presently to  be spoken
of; it occurs most frequently after the sixth month,
is attended by fullness, and throbbing of  the tem-
poral arteries, ringing in the ears,  suffused eyes,
flashes of light  before the eyes,  indistinct vision,
&lc.  If these symptoms are attended with splitting
headache, apoplexy, or puerperal convulsions  are to
be apprehended, and instant means should be  taken
to remove plethora.  Bleeding,  not to the same ex-
extent, which would be safe if the woman were not
pregnant, but to 12 or  16 ounces, leeches to the tem-
ples, cold to the  head, a cooling purgative, and low
diet, are the proper means to combat these alarming
symptoms.
  Piles, varicose veins, and  cedema  of the legs.—
These all depend on obstructed circulation, and can
only  be palliated by  the horizontal posture,  and
other ordinary  means.  The excision  of hemor-
rhoidal  tumours  during  pregnancy, is  dangerous
and improper.
  Palpitation of the heart, and syncope.—-Both these
disorders of the circulatory system are met with in
pregnancy.   Delicate, nervous, and  hysterical  wo-
men are most apt to suffer from  them.  Such per-
sons should  take great care  to avoid  the exciting
causes on which these disorders depend; these  are, 
100       DUBLIN PRACTICE OF MIDWIFERY.

mental agitation, fatigue, long fasting, \-c. ;  it may
also be proper to invigorate the system by generous
diet, tonics and exercise.   Antispasmodics are some-
times  useful, the ammoniated tincture of valerian is
among the best.   Opium, and  the other narcotics
afford present ease, but it is* purchased  at  the  ex-
pense  of much  future  suffering.   Their  use is
pretty certain  to impair  the  digestive  powers,
and I  think  when long  continued  they do some-
times  destroy the child.   In every east; of repeated
syncope  the state of the heart should be most care-
fully scrutinized, as if organic disease be found there
the prognosis is very grave, life is often  terminated
in one of the attacks.
   Disorders of the nervous  system.  Nervous head-
ache.—This,  especially if it take  the form of heni-
crania, is one of  the most unmanageable of the  dis-
eases  of pregnancy.   It  is sometimes paroxismal,
and often confined to one small spot.   If the state
of the system indicate bleeding, it  will commonly
do good, local, should be preferred to general bleed-
ing.   If this is not indicated, we should first attend
to the secretions ;  when these are  corrected anti-
spasmodics, and anodynes come in well.   11 yosci-
amus  and camphor, a grain each, is a good remedy
also the vol.  tr. of valerian.  The external  applica-
tion of some  anodyne extract, as stramonium, bella-
donna, or cicuta may be tried, but with  caution,
lest they  produce the poisonous effects of the drugs.
   Odontalgia.—" Breeding with  a toothache" is so
common that it  has passed into  a  proverb.  The
ordinary means, as creosote, the essential oils, opium, 
             DISEASES OF FREGNANCY.           ] 01

 may be tried.  If they fail, the  woman had better
 bear the pain than run the  risk of abortion from the
 tooth being pulled.   The extraction of a large tooth
 is pretty certain to produce abortion.
  Insomnia.—A degree  of sleeplessnes  is not  un-
 common, it most frequently affects the weak,  ner-
 vous, and  irritable,  occurring sometimes  early  in
 pregnancy, oftcner towards the end  of the term.
 If the want of sleep continue for many days,  it is *
 commonly  followed  by  very  grave symptoms,  as
 restlessness, fever, mental disturbance, convulsions,
 &c.  Abortion has resulted from it, and some cases
 have terminated  in insanity, others have destroyed
 life.  Treatment.—If plethora exist a small bleeding
 will do good ; a cooling purgative  is almost  always
 proper ;  pediluvia, or what is better, hip baths, very
 often do good.   The diet should be cooling, and
 exercise  in the  open air  taken as freely as circum-
 stances will permit.  Anodynes should not be given
 too  freely, one of the best  is hyosciamus and cam-
 phor.  The hop pillow will amuse  the patient, and,
 perhaps do good.
  Disorders  of the respiratory  system.  Dyspnoea
 and cough.—Towards the  close of pregnancy  the
 uterus occupies  so much of the abdominal  cavity
 that the descent of the diaphragm  is  impeded, and
 dyspnoea or constant cough sometimes result.  The
dyspnoea is not  of much  consequence, though now
 and then troublesome, but  the cough is much more
important.  It is frequently violent,  and nearly in-
cessant,  and when it is  so  it will, if not  checked,
produce  abortion  in very many  cases.    If  the
             9* 
102       DUBLIN PRACTK 1. OP MIDWIFERY.

strength  of the  patient will admit of  it. a small
bleeding  will be  nd\antageous as  the  first remedy;
afterwards the bowels should  be emptied, and  the
secretions,  if vitiated, corrected;  for this purpose
blue pill,  followed by rhubarb and  magnesia, should
be given.  When  the  secretions  are normal ano-
dynes may be used liberally.  The diet should  be
carcfullv regulated, arrow root, barley and rice are
the best' articles.  A good  deal  can  be gained  by
confining the patient to one article, this, besides fa-
cilitating digestion, is  the most  effectual way of
guarding against her taking too much food.
   Mastodi/nia.—Women suffer most from this cause
in their first pregnancies.   Where  the  suffering is
great, fomentations or  anodyne linaments will be
proper.  If there  is much  inflammation a leech or
two may be applied, but putting on a dozen, as some
authors advise, I have  known followed by danger-
ous hemorrhage—the flow from the bite  is. in fact,
always checked with difficulty, from  the very great
vascular activity of the part.
   Incontinence of urine.—This is  very common to-
wards the  close of  pregnancy—it  admits  of no
remedy.   The old women say that  it. presages  a
good labour, and they arc probably right. .
   Puritus pudr.udi.—This  is an  exceedingly  dis-
tressing  complaint, to which  pregnant  women  are
liable, though it is not confined to  them.  It is often
so violent  as  to set decency at defiance.  We  are
indebted to Dr. Dewees  both for an accurate  ac-
count of the pathology of this disease,  and the sug-
gestion  of a  very useful remedy.  Examining  a 
DISEASES OF PREGNANCY.
103
case of this sort, by the eye, he found the vulva
covered with  apthoe.  This  suggested  the  use of
borax, so useful in apthse of the mouth,  the remedy
succeeded to a charm.
  It will cure very many  of these cases, probably
all in which apthae exist; where  they do not, dry
calomel sometimes will succeed.  If there is heat and
swelling, leeches  are proper.   Balsam capaiba cured
one in Dewees' hands.   Attention to  cleanliness is
all important.
  False pains.—Towards the close  of pregnancy
many, perhaps most women, are more or less trou-
bled by false pains.  They may occur at any time
after the sixth month, but  are most common at the
end of the eighth, and during the ninth.   They are
called false, as having no connection with labour.
It is not always  easy to  distinguish  between false
and true pains.   The history of the  case, and  the
time of the attack will  assist us.  False pains  are
rarely as regular  as the true, and very generally
they produce no  effect on  the os uteri, though now
and then they do.  They are rarely attended by
any show.  They can often be referred  to some ac-
cident, or act of imprudence, as lifting,  straining,  a
long walk, jumping out of bed, standing on the cold
floor, &c.  These circumstances facilitate the diag-
nosis.
  Treatment.—Anodynes, though apparently so ob-
viously indicated, should  not be given  till the  first
passages are well cleansed, and  the secretions regu-
lated, by rhubarb and soda, senna confection, or the
blue pill and rhubarb, then, morphia, hyosciamus and 
104       DUBLIN PRACTICE OF MIDWIFERY.

camphor, or other anodynes may be  tried.  Rub-
bing the belly with sweet oil and laudanum is good
practice.
  In line nee  of pregnancy  on the  susceptibility to
diseased action, and the development and progress of
disease.— Upon all these subjects facts are wanting.
As a general rule, pregnancy exercises a protecting
influence against epidemics.   To this rule, however,
there are exceptions, and the exact  reverse is said
to have obtained in some epidemics.
  The influence  of pregnancy on  most  acute  dis-
ease is so very unfavourable, that it is an aphorism
of Hippocrates, that pregnant women attacked by
acute disease, always die,  (Aphorism 30, lib. 5).
The danger in such cases, is not only from febrile
state, and the extreme irritability of the nervous sys-
tem, but also  because  the  disease very frequently
destroys the foetus, and then  the dangers of abor-
tion are added to  those  of the  existing  affection.
The life of the child is endangered also by the treat-
ment necessary for the cure ; especially is this true
of harsh purgatives, violent emetics, salivation, and
profuse bleedings.
  The practical lesson to be drawn from these facts,
as to  the  treatment of  acute diseases of pregnant
women, is one of caution and care.   Watch the first
symptoms of febrile disease, meet them in the out-
set with decided, but not violent remedies, above all,
be strict in your attention to regimen.
  It is by the prompt use of mild means, and  a per-
severing attention to small matters, that the patient
is to be conducted through the dangers that encom- 
DISEASES OF PREGNANCY.           105
pass her.  Above all, avoid the dreadful blunder of
treating a woman for acute disease, without discov-
ering that she is pregnant.
  On chronic disease the influence of pregnancy is
not so marked, nor is it always unfavourable.  In
some cases pregnancy  suspends the progress of a
chronic disease ; and in a few it absolutely seems to
exert a curative influence.  Phthisis is occasionally
checked  by  pregnancy ;  but  it generally  makes
more rapid  progress after  delivery".  It is  not al-
ways even temporarily suspended, but  goes  on as
rapidly during gestation as at other times.   It is a
curious  fact, that this  disease  very rarely, if ever,
produces abortion, nor indeed, does it interfere with
the perfect nutrition  of the child.
  Regimen of pregnant women.—This  is a most
important subject, but  physicians  are  not  as fre-
quently consulted about it, as  they might be with
advantage, perhaps  because  when consulted they
make light of it.
  Diet.—This should be light,  not  very nutrieious,
and rather laxative.  Nature in most  cases  points
out this course, the appetite is for fruits, vegetables,
and the lighter meats,  while gross food, as  goose,
pork, fat, <Scc, are loathsome.   Follow here the dic-
tates of nature, let the patient take vegetables, and
especially fruits, freely, and abstain from gross arti-
cles, from highly seasoned meats, and from stimula-
ting drinks.   These  rules  are most appropriate for
the first four  months;  after  quickening, when  the
digestion  improves,  a  rather  more nutrieious may
be allowed, but  as the patient approaches the term 
10G       DUBLIN PRACTICE OF MIDWIFERY.

of her gestation, the diet should again be light.  Dr.
Dehitield, my predecessor  in  the professorship ,,f
obstetrics,  gives it as  the  result of bis  experience,
that women generally do best, when before they fall
in labour, the system  is  reduced  to a  little below
par.  For this purpose he lowers the diet, and gives
occasional laxatives during  the  ninth month.  This
as has  been said before is excellent practice.   Arti-
cles likely to  produce flatulency are to be avoided
at this time.
   Influence of the atmosphere  on pregnancy.—Thi>
is well  established; cold,  rainy weather, and  low,
damp, miasmatic  localities, have been recognized
since the time of Hippocrates,  as disturbing preg-
nancy and causing abortion.   To  the  influence of
the atmosphere is to  be attributed the  frequency of
abortion, miscarriage, or other  mishap in pregnan-
cy, by which some years are signalized.   Miasm is,
probably, the unsuspected cause of many abortions,
and when this unpleasant accident recurs frequently
to a woman residing in a  low, damp, or miasmatic
district, she should remove during pregnancy.
   1'j.r.e.rcise.—This should be  strongly insisted on;
none of the means of preserving the health of preg-
nant women are more valuable than this.   It should
always be taken in the open  air, and carried so far
as to produce fatigue, but  not absolute exhaustion.
As to  the kind of exercise, walking is best, riding in
an open carriage will do well ; horseback exercise is
not to be permitted,  unless the patient be very well
accustomed to it, ride well, and have a gentle horse.
   Nothing  is so likely  to  overcome the persistent 
DISEASES  OF PREGNANCY.
107
insomnia, with which some women are troubled to-
wards the  close of pregnancy, as exercise  in the
open air, carried to fatigue ;  this, with the warm
bath,  will do more  than all  the anodynes you can
give.
  Dress.—The great thing  to  be  avoided is tight-
ness.   Anything that compresses the  body,  and ob-
structs circulation,  does harm.   Inflammation of the
mammae  is sometimes excited  by  the  exposure of
the part to cold,  in consequence of the dress  being
too low.  This should be  avoided, and the patient
induced to dress decently.
  Pregnant women should never be allowed to wit-
ness any  scene that will be likely, very powerfully
to excite, or alarm, or distress them—the evil influ-
ence of such impressions is well established.  Even
the more exciting pleasures of  life, they should par-
take of but sparingly, as balls, parties, theatrical
exhibitions, &c. 
106
                CHAPTER VIII.

                NATURAL LABOUR.

  From  the sketch which has  been given of the
anatomy and physiology  of the gravid  uterus, it
must bo obvious that the separation from  that or-
gan of the foreign substances (so to speak)  contain-
ed within it, will involve a difficult and elaborate
process.   Merc expulsion of these substances, how-
ever, is not  all that is required ; provision  must be
further made for a  perfect restoration of the parts
concerned  in gestation, to  their ordinary unim-
pregnated condition.   These  two purposes arc ef-
fected  chiefly by a series of involuntary contractile
efforts  taking place in the muscular fibres of the
uterus, assisted by voluntary action of the  abdomi-
nal muscles  and  diaphragm, and by  a disposition to
dilate,  which simultaneously occurs, in the birth
passages.   In natural parturition,  the  uterus, by
contractions frequently repeated, separah s the at-
tachment between its own walls and the ovum, and
completely expels the  latter ; at  the same time, its
fibres  constringe the  large vessels which pass be-
tween  them, so effectually, as  often  to  prevent the
escape of even a drop of blood.   Finally, bv a epiiet
continuance of the contracting  process, the organ
is in no very long time  reduced  to  its  natural size
and condition.   The contractions  of  the  uterine 
                 NATURAL LABOUR.              109

 fibres are invariably attended with suffering  to  the
 woman, and have thence been  called "pains;"  the
 whole process, from its difficulty, and the muscular
 exertions required  in it, has  been  appropriately
 termed  " labour."
   The determining cause of natural  labour cannot
 be explained ; it appears as if the ovum possessed a
 power of existence within  the  uterus for a definite
 period,  at the expiration of which it becomes to the
 latter as a foreign body.  This, however, is merely
 a form of speech, as we are ignorant of the changes
 which cause it constantly to become a stimulant to
 the uterine walls at the termination of nine  months:
 all  we know is,  that at this precise period gestation
 is completed and labour begins.
   Every author  upon  midwifery adopts  a  division
 of the subject of labour, and  definitions suitable to
 his own views ;  but, as I am  not aware that one of
 these is  much  more  practical than another, I shall
 content  myself with those of Dr. Denman, which
 possess the merit of simplicity, and of being at the
 same time sufficiently comprehensive:  we  shall,
 then, consider all the phenomena  of parturition,
 regular  and irregular, under the heads  of  natural,
 difficult, preternatural, and anomalous labours.*
  Natural labour  Dr. Denman defines to be, " one
 in  which the  head of  the child  presents, which is
 completed in twenty-four hours, and requires no  ar-
 tificial assistance."   Professor Burns adds,  the con-
dition of labour  not occurring until the full period
     * Vide Appendix, A.
10 
110       DUBLIN PRACTICE OF MIDWIFERY.

of  gestation.   Mauriceau requires  that  the child
should be  alive; and  Drs. Cooper and Power re-
strict  the time for a  natural labour, the  former to
twelve, and the latter  to six. hours.''
  Premonitory signs of labour.-  Some days before
the  commencement of labour, a  remarkable subsi-
dence of the abdomen and diminution in the size of
the  woman  ordinarily takes place.   This is occa-
sioned partly by  the  sinking  of the cervix uteri
(with its contents) into the brim of the pelvis, and
partly, perhaps,  by the gradual closure of the ute-
rine walls, previous to their  taking  on active  con-
tractile efforts.  It is  a favourable occurrence, as it
indicates room in the  pelvis, and a disposition to act
upon  the part of the uterus.   About the same time,
the woman  becomes  restless and anxious; if her
bladder or rectum be  irritable, she  perhaps sutlers
from  strangury or  tenesmus  in a greater or lesser
decree; an  increased mucous discharge lakes place
from  the vagina, and  she  may have flying pains and
stitches through the loins and abdomen.  This is a
common course, but in some instances labour begins
at once, without any warning whatsoever.


  *  In 839 cases of labour, which occurred in the Wi llesley
347 terminated in	6 hours.
300 do	- 12 hours.
h7 do	- ]H hours.
59 do	- 21 hours.
37 do	- 48 hours.
3 do	- 56 hours.
5 do	- CO hours.
1 do	- 7vi hours.
 
NATURAL LABOUR.              Ill
   The suffering from labour pains is usually referred
to the back and loins, whence it shoots round to the
upper  part of the  thighs;  or at first,  perhaps,  it
commences in the  lower region of the abdomen,
and darts backward to the loins through the cervix
of the uterus.  True pains recur with perfect regu-
larity,  the interval between any two of them being
equal, or gradually  and regularly diminishing as la-
bour advances."  If we place our finger upon tho
os uteri during a true pain, we  find that it is di-
lated in some degree, more or less, according to the
strength of the uterine action ; and when  the dila-
tation has somewhat advanced, the membranes can
at the same time  be distinguished pressing into the
opening.
   A marked difference exists in the character of
the pains, according to the period of the labour:  at
first their operation is chiefly to dilate the os uteri,
and for this  purpose  the  uterine fibres are  them-
selves sufficient;  accordingly there is no voluntary
muscular action.  From the peculiar suffering which
these pains occasion, they are termed " grinding" or
" cutting" pains, and during their occurrence, the
woman usually expresses her  sensations by shrill,
acute cries.  When the  os  tincse has been dilated
to a certain extent, the pains  (which are then termed
" bearing,") are accompanied by  a strong expulsive
effort, and to render this more effective, the woman


  * The interval between pains may vary in different cases from
one minute to thirty or  forty, according to the activity of the
uterus. 
112       DUBLIN PRACTICE OF MIDWIFERY.

instinctively  brings her  abdominal  muscles  into
powerful action.  In accomplishing this, she must
hold in her breath, and of course can utter no com-
plaint, until the  termination of  the pain, when  she
gives vent to her  suffering by a deep, protracted
groan.  An experienced ear will often  recci\e ac-
curate information, as  to  the  state of the labour,
from the character  of the  cries ; but, in many cases,
no expression of suffering will  escape the patient
until the moment at which the  head  is passing tho
external parts, when a scream of agony is usually
uttered, which no one who has once heard it will be
likely to mistake.
  When pains exist which differ remarkably from
the foregoing description, especially in having an
irregular interval, and  producing no dilating effect
upon the os uteri, we may safely consider  them as
" false," and as being no evidence  of  the existence
of labour.
  The course of a  natural labour has been divided
into stages—differently by different authors.   The
division we shall adopt is that of Dr. Denman, into
three stages, merely because it is the  most familiar,
and is not  less practical than any other I have met
with.  The first stage includes " all the circumstan-
ces which  occur, and all the changes made, from the
commencement  of  the labour  to the complete dila-
tation of the os uteri, the rupture of the membranes,
and the discharge  of  the waters;"  the  second,
"those which occur between that time and the ex-
pulsion of  the child;"  and the  third, "all the cir- 
NATURAL LABOUR.
113
cumstances which relate  to  the  separation and ex-
pulsion of the placenta."
  The premonitory  signs already mentioned  hav-
ing probably shown themselves, the first stage com-
mences  by the occurrence of sharp  pains  in the
loins or abdomen.  These recur,  as has been stated,
at regular intervals;  and, after they have lasted for
some time, the increased mucous  discharge from the
vagina will be observed to contain some slimy mat-
ter  tinged with blood.  This is denominated by
nurses " a show," or  perhaps, " a red  appearance:"
it consists of the blood discharged by a rupture  of
the small vessels connecting the sides  of the cervix
uteri to the membrana deeidua which  crosses it;
and of the plug or operculum of inspissated mucous
which  closes the womb during gestation : in some
instances, the latter will be discharged in its perfect
plug-like form.  The pains at first are " grinding,"
and have a long interval; but the latter gradually
shortens, while the pains themselves become longer.
If we examine per vaginam,  the os tincae will  be
found to open slightly during each pain, and by de-
grees to become more  and more permanently dila-
ted.   As this occurs, the bag  of membranes is pro-
truded into the opening, and, acting as a soft wedge,
materially assists in the dilating process.   Each pain
forces more  of the sac into the vagina, until at last
it presses upon the external  parts ;  when, the dila-
tation of the os tineas being complete, the  mem-
branes burst, and the liquor amnii is discharged ; so
terminating the first stage.
  During this stage  a slight degree  of febrile ex-
             10* 
lit       DUBLIN PRACTICE OF MIDWIFERY.

citemcnt generally  exists ; the  patient  is  anxious
and  desponding, with a  raised  pulse, and flushed
face: sometimes there is considerable fever, with
shivcrings, headache,  thirst, <Vc.  In  almost every
instance, there is nausea and vomiting, arising from
the close sympathy which exists between the stom-
ach  and  os  uteri.   Some xvoincn  sleep  between
every  pain throughout  the  whole course  of their
labour.
   In cases of first children, the dilating  stage com-
monly occupies several hours (from six  to thirty-
six) ;  but  in some  persons,  especially  those who
have had a number  of children, the os uteri opens
with very few pains and  little  difficulty.    Occa-
sionally the waters are discharged too early ;  an oc-
currence  generally  followed by uterine action  so
violent as to exhaust the patient  before the  mouth
of the womb is opened  sufficiently to admit  of the
passage of the  foetus,  thereby rendering  the sub-
sequent progress of the labour tedious and unfavour-
able.*
   Second stage.—After  the waters  have  been dis-
charged, the true bearing or expulsive pains  more
decidedly  set  in;  the  interval  becomes  shorter,
while  the uterine action continues a longer period,
and is accompanied with more voluntary exertion.
   The head of the child is now driven through the

  • This consequence would appear to follow only when uterine
action comes on immediately (say in twenty-four or  forty-eight
hours) after early rupture of the membranes.  1 have known  the
accident to occur days and even weeks before labour, and yet the
latter to be easy and natural. 
NATURL LABOUR.              115
os uteri into the vagina,  passing the brim with the
sagittal suture, corresponding to one of the oblique
diameters.   As the pains continue, the face is turn-
ed  into the hollow  of the  sacrum, and  the head
presses upon the  perineum, the uterine efforts  ap-
pearing to act upon the child as if they would force
it backwards through the latter part.*   At this time,
if there be any foeces in  the rectum, they are  ex-
pelled  during the  pain ;„or if the  intestine  be emp-
ty, the woman mistakes the pressure upon  it for an
inclination  to go to  stool.   By degrees,  however,
the head is guided along  the  inclined planes of  the
sacrum and ischia, until  the  vertex is forced under
the arch of the pubis, and appears externally be-
tween the labia.  From this position it recedes upon
the cessation of the pain, and is again protruded by
the next effort, the retraction and protrusion being
repeated a greater or  lesser number of times, ac-
cording to the more or less dilatable  condition of the
external parts, until at last a powerful pain steadies
the head, and effects its complete expulsion.  At this
moment (especially with  a first  child) the  suffering
of the woman is wrought to  the  highest pitch, and
she occasionally experiences a smart rigor, or even
becomes temporarily delirious.
  After the expulsion  of the head, there is com-
monly an interval varying from  one minute to  ten
or fifteen :  the pains then again recur, and by them
the face of the child, which, at the moment of ex-
pulsion, looked toward  the  anus,  is turned to one

        * Vide Mechanism of Parturition, chap. 3. 
116       DUBLIN PRACTICE OF MIDWIFERY.

thigh of the  mother: thus  bringing  the  shoulders
into  the long diameter  of the  \ulva.   By the suc-
ceeding pains these latter arc  expelled, one before
the other, and finally the body  and limbs are driven
out of the vagina, all being accomplished, in a natu-
ral case, by the unaided action of tin; uterus.
   It is not to be  supposed that every natural labour
is divided exactly into the stages we have laid down ;
on the contrary,  there  is au endless variety of tri-
fling circumstances.  In  many cases, for example,
the waters arc discharged before the os uteri is fully
dilated ; and again, the bag of membranes may  re-
main entire  until both it and the head within it are
expelled from the vagina.  There arc many varia-
tions, also, as to 'the length  of time and  number of
pains requisite for the expulsion  of the head, and
subsequently of  the  body and  limbs.   All  these
slighter differences must be learned from actual  at-
tendance upon  a great  number of  labours ;  and
when an acquaintance  with them is acquired, it con-
stitutes a main part of the  unwritten although most
valuable knowledge of the  practical  accoucheur.
   Third stage.—Immediately  after the birth of  the
 child, the uterus, contracted to  about the si/.e of a
 foetal head,  may be plainly felt through the relaxed
 abdominal  parietes.   After a short  interval, slight
 griping pains return,  and  the  placenta,  usually ac-
 companied by some clots of blood, is expelled, pass-
 ing through the  rent  in the  membranes  in such a
 manner as to invert the latter.   Sometimes one pain
 is sufficient  to accomplish this process, and it occa-
 sionally is  finished  by the  last  pain of the second 
NATURAL LABOUR.
117
stage.  This, however, is not usually the  case, and
according to the observations of Dr.  John Clarke,
which I believe to be tolerably correct, the average
time for the expulsion  of the  afterbirth is twenty-
five minutes.  Whether it  be done in a space of
time longer or shorter than this, it is always effect-
ed, in a natural case, solely by the  action  of the
uterus.  The third stage of labour being completed,
the uterus descends into the pelvis, and can be felt
there (through the  abdominal walls) contracted  to
about the size of the closed fist. 
118
                 CHAPTER IX.

 DUTIES OF T1IU ACCOUCHEUR  IN NATURAL  LABOUR.

  Having now described the physiological progress
of a perfectly natural  case of parturition, it will he
well to consider the duties of the practitioner under
such circumstances.
  In the first place, then,  it  is always advisable to
attend upon a patient as soon as possible after being
sent for;  we can  never depend upon the account
given by the attendants, and should always satisfy
ourselves as to  the progress  of the labour,  that no
opportunity for giving assistance (if such  should be
needed) may be suffered to (-scape.   The  only mat-
ters necessary to be taken to a patient's house are a
catheter, a lancet, and a little  tincture of opium;
these may be suddenly required, and it will be well
to have them at  hand, but all other obstetric appa-
ratus I would strongly advise to be left in the prac-
titioner's study ;  if accidentally seen in the lying-in
chamber,  they cannot fail to excite alarm, and I
think we should  never familiarize  our own minds
to the idea of their  being  ordinarily necessary in
practice.
  In approaching the  patient, some little  tact is re-
quisite ; we should always first let  her be apprized
of our approach, as the  unexpected appearance of
a medical man  has been  known to affect the  ner- 
DUTIES IN NATURAL LABOUR.         119
vous system of a timid woman  so  powerfully as to
cause a suspension of uterine action.   We should,
also, before seeing the patient, make enquiries from
the nurse as to the period when  labour commenced,
the nature of the pains, whether there has been any
discharge from the vagina, whether her  bowels have
been opened, or she has passed urine freely.   Hav-
ing ascertained these particulars, we may then visit
the patient, and enquire from herself how long  she
has been suffering pain ? what is the situation of her
pains ? how often they occur,  &c.   We may also
examine her tongue and pulse, and if she be in bed,
it will be well to place the hand upon her abdomen,
in order to learn if it has subsided, and if the uterus
be disposed to contract firmly upon its contents.   All
this should be done seriously, but  at  the same time
cheerfully, and without embarrassment  or unneces-
sary assumption  of solemnity.   If the  woman  has
had  children before, and the symptoms show deci-
dedly that she is in labour, we should not leave  her
without making an examination  ; but, if it be a first
case, and  the  labour only commencing, there will
be no necessity for doing so  at once.
  Young practitioners  often feel a difficulty in first
proposing an examination; but  the fact  is, that any
embarrassment  that  may arise  is generally altoge-
ther of their own creation.  The woman's delicacy
never should be aroused  by any  comments  upon
" the disagreeable duty  that is necessary to be per-
formed," ixzc. «fcc.; the thing should be done (with-
out talking about it) as coolly as if  we were merely
feeling her pulse, and our manner  should never be- 
 120       DUBLIN PRACTICE OF MIDWIFERY.

 tray any consciousness of the operation being in the
 slightest degree indelicate..  If we adopt  this plan,
 we shall seldom fail in getting an examination when-
 ever we  think it necessary : and the  only  intima-
 tion  we need  make of  our purpose is,  to desire the
 patient to lie in the proper position; or to ask  the
 nurse for a napkin, either of which expressions will
 be perfectly well understood,  and  we shall, in all
 probability, have no farther trouble.
   Before adverting to the mode of examination, wo
 may describe the  position in which  the woman is
 usually placed while  it  is making.   This is gener-
 ally  the same  as that  in which she is to be delivered,
 or what is commonly  called  " the obstetric posi-
 tion." and  differs in  different countries.   In (beat
 Britain the woman is always placed upon her left
 side, with  her thighs flexed, and her hips brought
 close to the right side of the  bed ; to prevent the
 latter from being wet, a dressed sheepskin or thick-
 ly folded  blanket  is  placed  upon it, and covered
 with  a doubled sheet,  immediately under the pa-
 tient's hips ; after delivery, the sheet can be  slipped
 away, so as  to make the woman somewhat more
 comfortable  without any  injurious  disturbance.
 This process is termed by nurses, " guarding  or pre-
 paring the  bed."  On the Continent, the usual ob-
 stetric position is upon  the  back; and among the
peasants  of this country  women  are  placed occa-
sionally (but not always) upon their knees, both f"i
examination and during labour.
   The patient being  properly placed, we stand at
her back and pass the right or left hand (whichever 
            DUTIES IN NATURAL LABOUR.         121

vvc think  most convenient) under  the bed-clothes,
with as little delay as possible, up to the vulva, into
the posterior extremity of which one or two fingers
are to be introduced.  If the  os uteri be not very
high, it will be sufficient to examine with  the fore-
finger  alone;  but  should the  latter  not be long
enough, we shall be enabled to make  a more satis-
factory examination by passing, at the same, time,
the second finger.   In either case,  our object is to
investigate accurately the condition of the os uteri,
and the nature of the presentation within it.*   In
searching for the former, we must  recollect that it
is situated  very much backwards towards the sac-
rum, and  that frequently the  cervix,  thinly spread
over the presenting part, will meet  our finger very
near the os externum, while the  os  tincae lies  con*
siderably  higher,  and almost  beyond our  reach.
Under such circumstances, I have  sometimes been
enabled to feel it, by making the  nurse place  her
hand upon the patient's abdomen, and gently press
down the uterus.
  The sensation  conveyed by  the mouth of  the
womb  varies very much  in  different  cases.   Very
frequently, when labour has been going on for some
time, we can pass our finger into it  and feel its edge
like a thin  free membrane  spread equally over the
child's  head; when this is the state of the part, it


  • It will be also well to take the same opportunity for forming
a general estimate as to the size and  formation of the pelvis, es-
pecially  in first cases, where we have not the experience of for-
mer labours.      *
             11 
122       DUIU.IN PRACTICE OF MIDWIFERY.

will probablv become thicker as  dilatation  advan-
ces, which will be likely to go on rapidly and fa-
vourable.   In other instances, the os tinea)  feels
from the commencement  thick and rounded, and
sometimes firm and hard, as  if tumefied  in conse-
quence of inflammation.   We should  always make
part of  our examination during  a pain,  and if wo
then find that the opening  is sensibly  increased by
the uterine action,, and especially  if the membranes
are protruded into it, we may safely conclude that
labour has set in.
   (Arrangement of the lying-in chamber.—The most
common  error we have to correct is, there being
too many people in the room.  More than two per-
sons should  rarely be allowed,  ne\er,  unless the
room be large.  N. B. Never allow the husband to
be present.   If he is a man of sense  and  delicacy
he will not  desire  it, and if he  is not, the  more
reason you should keep him out of your  way.
   Ventilation is all  important; this,  together with
a  proper temperature, can  best be secured in cool
or cold weather, by having a little fire in the grate,
and, at  the same time a window drawn a little down,
or a door partly open.  The temperature should be
rather cool than hot.  All perfuming by  flowers,
scented waters,  burning  of pastiles  and  the like,
should  be avoided ; the only true purifier is fresh
air.
   The  temperature of the room may vary as labour
progresses, during the second stage, while  the wo-
man's voluntary muscles are in action, and her cir-
culation excited, the room  should be  quite  cool; 
DUTIES IN NATURAL LABOUR.
123
when the child is born, the mother commonly falls
into a state of collapse, and is very sensible to cold,
then a draught of fresh air, or a too cold room,  es-
pecially when there are wet things about her, may
cause mischief.
  Dress.—The dress should  be simple  and loose,
no ligatures or corsets to impede the circulation or
interfere with the efforts.)
  As to the time that will  be occupied by the first
stage, we must draw our conclusions from the extent
of dilatation, and also  from the progress that may
be made in that process between  any two  periods
of examination; if the case be a first  one  (for ex-
ample), the os tincae only sufficiently open to admit
our finger, and  the effect of each pain very slight,
we  may expect  that the first stage will occupy a
considerable period ; on the other hand, if the open-
ing  be as  large as a half crown piece, and is in-
creased permanently by every  contraction  of the
uterus, we may look for a speedier result.  The  re-
laxed and apparently  dilatable  condition of the os
uteri, and of the vagina and external parts, will also
lead us to hope for a quick labour; while the oppo-
site  conditions warrant a contrary conclusion.  In
women who have had many  children,  however,  we
may be very much deceived, and should be constant-
ly upon our guard, as dilatation often occurs quite
suddenly, without any previous indications from the
state of the parts ; it should  therefore be a standing
rule with accoucheurs to deliver no positive opinion
as to the period when labour will terminate.
   Having  made our  observations  respecting  the 
121       DUBLIN PRACTICE OF MIDWIFKRT.

progress of the case, we must  next proceed to as-
certain the presentation.  This part of tin; examin-
ation should  always be conducted during the ab-
sence of pain and consequent relaxation of the bag
of waters, as we can then most readily feel what is
contained in  the  cervix, and  also  run less  risk of
rupturing tlu,  membranes, an accident that  should
be  carefu' y  avoided.   In natural  labour, we can,
under. f1*iese  circumstances,  usually  feel  the  head
from, ne very commencement:  we recognize it by
its  vjundness and firmness ; and also by the suture''
and the posterior  fontanelle, whenever wo  can dis-
tinguish the latter.   Persons who  have acquired a
tactits eruditus from frequent practice, will be often
able to  ascertain the  exact  position of the head,
with  regard  to the  bones of the pelvis ; but such
nicety is not  to be expected  by the  beginner, and,
in fact, is little to be desired,  as knowledge of this
kind should  have no influence  upon our treatment,
and is only to be looked upon as a matter of scien-
tific curiosity.'   In  making an early examination,
we shall be often enabled  to  feel  the presentation,
by having the uterus  pressed down by a hand on
the abdomen, in the way already mentioned.
   Having satisfied ourselves that  all is  right, and
that the labour is progressing, we may withdraw
from the room of the patient;  our presence there
during the first  stage  is not  needed, and, by oper-
ating as a restraint upon  the  woman, may even be
injurious.  When there is  any probability of tip:

         * Vide Mechanism of Parturition, chap. 3. 
DUTIES IN NATURAL LABOUR.
125
 case  terminating shortly, it  is  unnecessary to say
 that we should not leave the  house ; and the young
 practitioner should constantly  recollect that  it  is
 better for his reputation to give unprofitable atten-
 dance in  many cases, than to  run the risk of hav-
 ing one concluded during his absence.
   During the dilating process, it is not necessary to
 confine the patient to bed : she  may l ^  allowed at
 her pleasure to sit up or walk about  the room.  If
 she be disposed to eat, she may get any It food,
 as gruel, or tea and dried toast, or even a lit*-^ beef
 tea ;* nourishment of this description will  keep the
 stomach healthfully employed, and will  support her
 strength,  but no cordials or stimulating food or drink
 should, on any account, be permitted.
   Medical treatment is seldom required in a natural
 case : if the bowels have been confined, it will be
 useful, at  the commencement, to administer an ape-
 rient,! or if the labour has somewhat advanced, to
 clear out  the rectum with an enema.   The bladder
 should be  carefully attended to throughout the whole
 labour, and the  nurse  cautioned  to encourage  the

  • It  is  often advisable, when we  have to deal with dyspeptic
people, to give a little solid food, as slops are apt to produce de-
rangement of the stomach, which,  in  its turn, becomes  a fre-
quent cause of irregular uterine action.
  t Castor oil  answers very well for  this purpose,  if the wo-
man's stomach will bear it; or the following draught :—
  R  Pulveris Rhei, Sulphatis Potassaj,  aa 3 j. ;  Tincturee
    Rhei,  3 j.; Aquae Cinnamomi, |j. M. Fiat haustus.
For the enema we may use the following : —
  R  Decocti Hordei lb. j.; Olei Ricini, Muriatis Soda?, aa ?i
   M. Fiat enema.                                 ?J"
             11# 
126       DUBLIN PRACTICE OF MIDWIFIia.

woman to empty it from time to time ; if retention
occurs, it  must be relieved  by the introduction of
the catheter.
  (To introduce the catheter is not always easy—
the following  hints may be of use to the unexpe-
rienced.   You find the  orifice of the urethra with-
out difficulty, but  xvhen you attempt to pass  up-
wards and  backwards  into the bladder, the fixtal
head  which then  rests upon  it  interferes.   The
bladder is displaced, it may be pushed upwards and
forwards over the  pubis, or downwards  and  back-
wards so as to present,  a fluctuating tumour, in the
vagina.  Mad.  Boivin's directions  are  excellent:
" when the  point of the instrument  is introduced,
depress the  other end till the shaft is parallel to the
vulva, the convexity being towards  the pubis,  now
push  the  instrument  forward,  " avec management?
"humouring it," till it  has  penetrated  \\  inches;
then rotate  the  catheter and advance it slightly, it
will enter the bladder."  A flat catheter  is best.)
   During the entire of  the  first stage, the duties of
the accoucheur are more passive  than  active; his
object, in fact, should be, rather to watch that noth-
ing interrupts nature in her operations than to at-
tempt giving her any assistance.  When the second
stage commences  a  little more interference is  war-
rantable, but still nature should be allowed to do as
much of her own  work as  possible.
   There are two main  points  to which  our princi-
pal attention should be directed during  the second
stage : one  of these is the preservation of the  peri- 
            DUTIES IN  NATURAL LABOUR.         127

neum, and the other the promotion of an effectual
and permanent contraction of the uterus.
   Occasionally, when women are delivered without
proper assistance, considerable injury is done to the
perineum while the head of the  child is passing the
vulva:  a rent of more or less extent (sometimes
passing  into the rectum) may  take place ; or, in
some rare instances, the head (without injuring the
fourchette) may be driven through the perineum in-
stead of the natural opening, constituting what has
been  termed " a circular  perforation."  When we
consider the extreme thinness to which the part is
spread out, and the distension  which it suffers, we
may rather be  surprized that  accidents of the kind
do not very frequently happen: and, in fact, a slight
tear (at least of the mucous membrane) does occur
in almost every case of first labour.   To lessen the
risk of this injury, which (if it amount to any con-
siderable extent) is one of the most miserable that
can befall a woman, the  plan  of " supporting the
perineum" has  been devised.  To this duty the ac-
coucheur must attend as soon as the first stage has
terminated,  and the head of the child begins to press
upon the external  parts.*
   The most convenient manner of performing it is,
to sit at  the right side of the bed, and, consequently,
at the patient's back, and to  apply the palm of the


  • Beginners commonly fall into the  error of supporting the
perineum too soon. If pressure be made before the time spe-
cified above, it may have the effect of heating and inflaming the
parts. 
128       DUBLIN PRACTICE OF MIDWIFERY.

right  hand (covered xvith a towel') flat upon the
perineum, the fingers then passing upon each side of
the vulva.  The left hand may be employed in pre-
venting the woman  from suddenlv  withdrawing,
which she is apt to do during the suffering of a pain.
The degree of  pressure employed should be merely
sufficient to give steady and uniform support to the
part, but should never be so great  as to retard the
advance of the head.
   (The direction in which we apply our force when
supporting the  perineum, will often  decide the ques-
tion whether we do good or  harm.  Our  object
should be, by the hand to give to the  perineum the
same support which is given  further  back by the
coccyx and sacrum.  The hand should be so placed as
to continue the curve of the sacrum and coccyx, and
the force applied upwards and a good deal forward.
In this way, so far from hindering we facilitate the
progress of the  child's head, by impressing upon it an
impulse in the direction of the outlet  of the pelvis.)
   The employment of such a quantity of force as
would retard the head must of itself  tend to injure
the perineum by pressing it against the sharp edge
which  the  posterior margin  of the  frontal bone
often presents when  the  parietal  bones are  much
compressed together.  By gently keeping up a pro-
per degree of support, we can generally prevent
any serious mischief;  and the distended perineum

  ' This is a useful precaution, both for the sake of clennliness,
and as it prevents the heat of the hand from drying up and irri-
tating the perineum. 
         .   DUTIES IN NATURAL LABOUR.         129

at length slides uninjured over the child's forehead
and face.   When  this is accomplished,  the  great
danger is over; but still  the  sudden passage of the
shoulders may do harm, and it  is advisable to keep
up the support until they are expelled.   After the
head  escapes, we must  change the position of our
hand, and place it  across the perineum, with the ra-
dial edge applied close under the child's chin.*
  Several minutes often  elapse before another  pain
comes on ; and during the interval we should as-
certain  with  the  index  finger  of the  left hand
whether the cord is twisted round the child's neck.
If it be, we must draw it cautiously out, and pass it
over the head; or, if that be not possible, we  may
open the loop, so as to  allow the  shoulders to pass
through it.  After  this  has been  done, we  should
pass the same finger into  the mouth of the child,
and remove  any  mucus  or  membrane that might
obstruct the free  admission of air.  The  irritation
produced in the mouth by this process will often ex-
cite the  infant to breathe while its body is yet in the
uterus, and will thus much lessen the danger of suf-
focation incident to a delay in the completion of the
delivery.   No attempt should, under ordinary cir-
cumstances, ever be made to expedite the  passage
of any part of the child: all should be left to the
efforts of the uterus, which, when so much progress
has been gained, will very seldom indeed  fail in ac-
complishing the whole operation.  When the shoul-

  • At this period the  practitioner will generally find it conve-
nient to stand up, unless the bed be unusually low. 
130       DUBLIN PRACTICE OF MIDWIFERY.*

ders have escaped,  we are then  free  from all anx-
iety with respect to the perineum, and may remove
our right hand, and simply allow the  head to rest
upon its palm.
  It now becomes necessary to attend  to the other
point of practice which has  been mentioned : viz.,
to endeavour to ensure  a full and permanent con-
traction of the uterus.   For the accomplishment of
this purpose, we know of no more powerful means
than the employment of gentle friction and pressure
over the organ, through the abdominal walls.   Ac-
cordingly, as soon  as the perineum  is safe, the left
hand should be placed upon the  patient's abdomen,
under  her clothes,  and the uterus  followed  down
into the pelvis, as it contracts upon  and expels the
body and limbs of  the foetus.   In some cases, when
the uterine action  is slow, slight friction on the ab-
domen will at once  bring on a pain, which other-
wise might not return for several minutes.
   Next to ensuring a perfect contraction of the ute-
rine fibres, it is of the greatest importance to main-
tain them permanently in that  condition ;  and this
we shall best effect by keeping  up gentle pressure,
and allowing no interval for relaxation.   In order
to answer this intention, as  soon as  it becomes ne-
cessary for us to  attend  to the  child, we  should
cause the  nurse to pass  her  hand  over our own, in
such a manner as that, when  ours is withdrawn
from the abdomen, she may be enabled to grasp the
uterus, and  keep up as effective a pressure as we
have  been  employing.   Upon no  account  should
this pressure be discontinued, until an equal support 
DUTIES IN NATURAL LABOUR.        131
 is given by the adjustment of the binder in the way
 afterwards to be considered.
   Our attention is next  to  be  turned  to the child,
 which has now been entirely expelled,  and is pro-
 bably squalling and kicking lustily in the  bed.   If
 it be so, we may at once separate it from the mother.
 Before doing this,  however, we  must interrupt the
 vascular connection between the two beings, by ty-
 ing a ligature  (composed of six or eight housewife
 threads)  tightly upon the cord, about  two  inches
 from the child's abdomen.   A similar one is then  to
 be placed about two inches  nearer to the placenta,
 and  the funis  between them may be divided  with a
 scissars.   The whole of this operation should be
 conducted  fairly within  our view,  which  may be
 done by drawing out the  child a little, without  at
 all exposing  the mother.   But  even  if  exposure
 cannot be altogether avoided, the rule that we should
 see the part which we cut still remains  absolute,  as
 respect for its mother's  delicacy would  be a poor
 excuse to the child for the loss of its penis or  finger,
 —accidents which have been known to  occur in an
 attempt to separate the funis under the  bed-clothes-
 After the division, we should  carefully wipe the
 blood from the cut surface of the part  of  the cord
 attached to the  child,  to  ascertain that the  vessels
 are properly compressed, and that there is no dan-
 ger of subsequent hemorrhage.
   Should the child not have breathed perfectly after
birth, it is better to leave  it attached to the mother
as long as the cord continues to pulsate, and to en-
deavour to excite respiration by tickling the  mouth 
 132       DUBLIN PRACTICE OF MIDWIFERY.

 and  fauces, and  gently slapping and  rubbing  the
 chest.   If these means do not succeed, and the pla-
 cental circulation ceases, xve must divide the cord ;
 and  in this case, if the child's face be livid, it is bet-
 ter not to put on a ligature  in the first instance,  but
 to allow a few drops of blood to flow, which may
 possibly remove the state of asphyxia,  into which
 the child has fallen.   Other means for establishing
 respiration should also  be adopted, which we shall
 consider at a future  period.
   The cord having been  properly secured, the child
 may be given to an  attendant;  and the next step
 requiring the  attention of the accoucheur is the put-
 ting on of the binder.  This important  part of  the
 paraphernalia of the lying-in room should always
 be examined at the  commencement of labour, that
 we may not be disappointed in its qualities when
 we come to need it.  Those generally used consist
 of a  piece  of "pillow  fustian,"  or diaper, long
 enough to go round the woman's body, and bread
 enough to reach from the  ribs to the  trochanters.
 More elaborate contrivances, furnished with straps
 and  buckles, to facilitate their  application,  arc em-
 ployed by some gentlemen.   When we are at a loss,
 a very good substitute for the common  binder will
 be found in a long pillow-case or chock  apron.
 The mode of application is as  follows:—without
 allowing the woman to move, we slip, with one of
 our hands, an  end of the binder under her loins,
next to her skin ; this we  pass gently on  until it can
be laid" hold of by  an  assistant  (or by  our other
hand), at the  opposite side, when it can  be spread 
            APPLICATION OF THE BINDER.        133

out, and drawn downwards, until  iter lower edge is
below the trochanters.   The nurse should never be
suffered to withdraw her hand from  above the ute-
rus until we are ready to fasten the binder ; which
we  do with strong  pins, beginning at  the lower
edge.  The force  with which we  tighten it should
be  sufficient to give comfortable  support; and  it
will not be of much consequence  even if it be felt
a little too tight at  first, as it will  slacken upon the
expulsion of the placenta.  By beginning to pin at
the lower edge, and placing that below the trochan-
ters, we  prevent the binder from slackening by slip-
ping upwards, as  the  tapering form  of the  hips
would otherwise incline  it to do.*   When the binder
has been properly adjusted, a  soiled  sheet may be
pushed a short way under the hips, so as to prevent
the woman from being  annoyed by the wetness of
the bed ; and, having laid the divided cord upon this,
we must patiently  await the accomplishment of the
third stage.
  When the first two stages of a labour have been
conducted in the manner  already described, the re-
sult, in a very great majority of instances, will be a
speedy and safe separation of the placenta, without
any further  interference  whatsoever.  Sometimes,
the pain which expelled the limbs of the  child will,
  * That extremity of the binder which has been passed under
the woman, (she  still lying on her left side with her  back to-
wards the  practitioner,) should be pinned over  the other, by
which means we draw up the pendulous abdomen, and give it
more perfect support.
             12 
134       DUBLIN PRACTICE OF MIDWIFERY.

at the same time, drive the afterbirth  into the vagi-
na.  Generally, however, the  uterus  remains quiet
for ten or fifteen  minutes; after which the patient
will, probably, experience, a  slight griping  pain or
two  in the abdomen ; and if we then  pass  our fin-
ger along the cord, we shall, most likely, be able to
feel its insertion into the  placenta, and ascertain that
the latter is passing through the os uteri.  We need
not pull, or even  stretch, the funis, as  the contrac-
tions of the  uterus will almost always  effect the
complete expulsion.  But should this  not take place,
there appears to me to be, in  such a case, nothing
wrong in removing the secundines from the vagina,
provided there  be no appearance of such vascular
excitement as might lead us to dread  secondary Jic-
morrhage.   In  doing  this, it is still unadvisablc to
extract by the  cord, as  we  thereby  bring against
the opening the  broadest surface of the placenta.
On the other hand, we shall very much  facilitate the
operation if we hook one or two fingers on its edge,
and  then draw it sideways, and with  a  slow rota-
tory motion, through the os externum."
   Should  the case not  proceed  so  quickly as wc
have supposed,  and half or three quarters  of an


  • Immediately after the placenta has passed out, it is well to
turn it round upon its own axis two or three times, as we thereby
twist the membranes into a sort of rope, and so have a better
chance of extracting them entire: if any part remains behind,
it serves to collect clots of blood, which, in their turn, occasion
after-pains.  I always make it a rule to examine carefully the
placenta and membranes after  their expulsion,  in order to satisfy
myself that nothing has been left in the uterus. 
           MANAGEMENT OF THE PLACENTA.       135

hour elapse without any action of the uterus, it will
be well to stimulate it by a little  moderate  friction
on the abdomen, and by tightening the binder, or,
if necessary,  placing a  compress under it.  As a
general rule, I would  say, that no attempt  should
ever be made to extract by pulling at the cord.   By
doing  so, we always incur the  risk of producing
laceration  of the funis or placenta, or  inversion of
the uterus, or  even (according to the observations
of Dr. Douglas,*)  of indirectly causingj'etention of
the after-birth, by irritating the os uteri, and  thus
giving rise to the spasmodic contraction of the low-
er fibres  of its  body,  which  that gentleman con-
ceives to constitute hour-glass contraction.   We
may merely put  the  cord  gently on  the  stretch,
which will, perhaps, excite  uterine action; but if
this and the measures already mentioned  fail, the
case becomes one of retained placenta,  and must be
treated accordingly.
  After the delivery has been entirely accomplished,
it is always advisable to wait near the patient for at
least half  an hour; and  we should, on no account,
leave  her then if there be any disposition to hemor-
rhage, or  even an unusual  vascular  excitement.
Before  taking  our departure, we  should  always
carefully ascertain, first, that the uterus is properly
contracted, (the patient  not flowing too much,) and
the  binder well  adjusted ; secondly,  that the pulse
is regular ; and, thirdly, that there  is no danger of
hemorrhage from the child's funis.
* Med. Trans., v. 6. 
136
                  CHAPTER X.

          VARIETIES OF NATURAL LABOUR.

   Certain variations occasionally occur in the cir-
cumstances of a natural labour, of which the three
following require some additional  consideration:—
1. When the head is expelled with the forehead to-
ward the pubis, or xvhat  is  technically called  the
fontanelle presentation; 2. Face presentation; and,
3. Descent of the hand or arm together with the
head.
   The  first variety often eludes observation until
the head is  in the act  of escaping from the vulva.
We may discover it by the  presenting  part of the
head not being so conical as when the vertex pre-
sents, and  by its not so readily escaping under the
arch of the pubis; by the  direction of the sagittal
suture ; and by the facility with which we can feel
the  anterior fontanelle* near the  symphysis pubis.
By referring to what has been said in the chapter
upon the mechanism  of parturition, it will be seen
that this presentation will often  occasion a tedious
labour: in almost every case,  however,  nature will
be sufficient  to overcome the  difficulties.  Some


  * The anterior fontanelle is distinguishable from the posterior
by its lozenge shape, its  greater size, and its four'(instead of
three) concurrent suture:,. 
           VARIETIES OF NATURAL LABOUR.        137

eminent  accoucheurs* have recommended  an at-
tempt to change  the  situation of the head during
the first  stage of labour ; but  the  observations of
Nagele, already quoted,f prove  that nature,  in  a
vast majority of instances, effects the change  her-
self, and  that we  are  not warranted  in  any inter-
ference by the average  result of those cases that
are actually expelled with the  face forwards.   All
that is generally necessary is, a careful attention to
the perineum,  which incurs  more than ordinary
peril.
  When the  face presents, we shall  also generally
find the  labour  tedious, from the reasons already
laid down. J  A considerable difficulty often arises
in the  diagnosis of these cases: the marks are to
be  found in the features,  the mouth,  nose,  eyes,
&c.;  but, when the face is much swollen, as it usu-
ally is, it  is often by no means  easy to  recognise
these.  I have known the mouth to be mistaken for
the anus, and the case thought  to be a  breech pre-
sentation.  If we can feel  the mouth, however, we
always have the means of discriminating, by ascer-
taining the presence of the tongue.
  In the progress of  the case, the chin  is generally
expelled  first under the arch of the pubis, and na-
ture usually  accomplishes  the business unassisted.
It is neither  necessary nor warrantable  to attempt
any alteration of the  child's position in a face case:
all we have to attend to is,  to obviate the effects of

  * John Clarke, Smellie,  Burns.            t Vide p. 38.
  X Vide pp. 32, 39.
                  12* 
138       DUBLIN PRACTICE OF MinWIFFR\.

pressure upon the mother's bladder, which is said to
be more liable  t<>  suffer than in vertex presenta-
tions ; and to avoid injuring the features by frequent
and rude examinations.   The face is  usually fright-
fully swollen and discoloured, at the  time of birth,
but is restored to its natural condition, in  a  much
shorter time than we could at first expect.
  The hand or arm occasionally descends with  or
before the  head, and may cause delay and difficulty,
by the increase  of  bulk.  If the pelvis be narrow,
a necessity for instrumental  aid may even arise.
When the complication is discovered  before  the
head becomes jammed  in  the  cavity, it is possible
to prevent the descent of the arm, by holding it  up
during a pain, and  allowing the head  to descend be-
fore it:  but any attempts  of  this kind should  be
made with extreme caution ;  as, in endeavouring
to keep  back  the  arm, we might  be unfortunate
enough  to convert the case  into one of shoulder
presentation.
  Among  the slighter  varieties of natural labour,
may be mentioned very early rupture of the mem-
branes, without immediate  accession of labour.   I
have known this  to occur three weeks before de-
livery, and yet the latter to be good, and  the child
alive.  A  slight allusion to this  circumstance  has
been already made.*
  In the foregoing observations, I wish it to be un-
derstood as my opinion, that the exist* nee of any of
these varieties  of  labour should not of   itself  be
• Vide p. 114. 
          VARIETIES OF NATURAL LABOUR.        139

considered as sufficient to justify instrumental inter-
ference.  Such,  however, may be required ;  but
in administering it,  we  must  be entirely  guided
by considerations that will be  subsequently advert-
ed to. 
140
                 CHAPTER  XI.

                DIFFICULT LA1IOI It.

   Still following the division of Denman, we shall
include under this bead " every labour in which  the
head of the child presents, and which is protracted
beyond twenty-four hours."   Like every other arti-
ficial definition, it will  be presently seen  that this
does not perfectly apply to all cases, and that a la-
bour,  for  example,  which has  not  lasted  twelve
hours,  will sometimes be  more entitled to  the char-
acter of difficult, than  one which has lasted  forty.
As this class includes a great variety of cases,  we
shall subdivide it into  three  orders :—the first, in-
cluding those labours in which the time is protraeted
beyond  twenty-four hours, but which, if  properly
managed, may be accomplished by nature ; the sec-
ond, those in which instrumental aid  is  required,
but such as  is compatible with the safety of both
child and mother ; viz., the forceps and vectis: and
the third, those in which  the difficulty is  so great,
as to render it necessary either to  diminish artifi-
cially the bulk of the  child, or to provide for  it a
passage larger than the natural one.*


  * In this subdivision  we have not  followed Di-mnan, who
makes four orders, and founds them upon the different  causes of
difficulty. 
DIFFICULT LABOUR.             141
  Difficult  labour  of the  first order  may owe  its
origin to one  or more of a great number of causes,
which we  shall consider   as  divided  into  two
classes:—
  First,  those which increase resistance  to the pas-
sage of  the foetus.
  Secondly, those which lessen the force of the ex-
pelling powers.
  In any individual case, causes  from both classes
may be  combined.  The first includes,—
  a. Rigidity of the soft parts.—When speaking of
the various conditions assumed by the os uteri dur-
ing labour, it was mentioned that some were  much
more favourable to dilatation than others; we also
find the  same to hold good with respect to the va-
gina and vulva.   In some  instances,  especially  of
first pregnancy at a late period  of life, we find the
external parts rigid, hot  and   devoid  of   their
usual moisture; occasionally so much  so as to make
a common examination painful.   When  this is the
case, we shall probably find  the  os uteri puffy and
rigid, and very little disposed to dilate.
  This  condition will be  produced by any  cause
which  excites a febrile  state  of  the woman's
system ; and thus  sometimes follows  bad manage-
ment in a labour, that, if  left  to  itself, would have
proceeded  happily.   Thus,  rupturing the  mem-
branes  during the  first stage, will bring the hard
head of the child  into  contact with  the mouth of
the womb, instead  of  the  soft  accommodating
wedge,  formed by the bag of waters, and will ex-
cite a state of local fever, that frequently interrupts 
142       DUBLIN PRACTICE OF MIDWIFERY.

dilatation, and occasions  tedious  labour.   Stimula-
ting food or drink, the room  being too  hot, the pa-
tient remaining  constantly in bed, frequent exami-
nations, *fcc, may all be followed  by the same effect,
which  may7 also  be  produced  by the  fever conse-
quent upon neglecting to evacuate  the  bladder, or
to remove  costi\eness.  1 think  I have observed a
similar indisposition to dilatation  to depend upon a
jamming of the  anterior portion  of the cervix, be-
tween the head of the child and symphysis pubis,
in cases in which the os uteri was turned more than
usually backwards  and upwards towards the pro-
montory of the  sacrum.
   The treatment of these cases  must vary accord-
ing to  circumstances.  In the first place, every thing
likely to excite fever must be strictly avoided : the
room must be kept cool  and quiet;  if the woman
be disposed  to  speak, the  conversation of her at-
tendants should  be  cheerful ; she should be encour-
aged to walk about occasionally,  but not so much as
to fatigue her, or create any  febrile excitement; the
bladder should be carefully attended  to, and, if ne-
cessary, the catheter introduced :  if the bowels be
confined, an aperient should  be given, and, perhaps,
an enema  administered, as recommended in natural
labour:  she  should have  abundance of cooling
drinks, as tea, whey, barley water, lemonade, ev<\;
and if she take any food  it should be  of the light-
est kind.  Where  there is  much vascular excite-
ment, with quick pulse, flushed  face,  and heat  of
skin, in a plethoric  person, it is almost always advis-
able to  abstract blood.   The  quantity  must,  of 
DIFFICULT LABOUR.
143
course, be regulated by  circumstances;  but,  as a
general rule, I would say let it be the  minimum re-
quired.*  I think I have observed considerable ben-
efit to result in such cases as these from the employ^-
ment of nauseating doses of tartar emetic, in con-
junction with, or as a substitute for, bleeding; but
there certainly are circumstances under which the
latter cannot  safely be dispensed with.   Opium has
been much recommended as a relaxant; but it is a
medicine, the effect of which in parturition we can-
not accurately measure ;  and it may totally suspend
the pains, in place of expediting  labour  by its  re-
laxing effects.  Opiates should not be given when
the bowels are confined : but when these have been
opened, and  the woman is  teazed with ineffectual
pains, we may often procure for  her some hours'
sleep, and do much good by the administration of a
moderate  dose  (say  thirty  drops)  of laudanum.
There is one  rule which is very little attended to in
the administration of opium, yet it appears to me to
be of great importance : that is, when we want to
produce the sedative effects of the drug,  never to
give it, except at those times when  the  patient is
naturally disposed to  rest.   A  dose  of laudanum,
for example, that, at  night, would  produce  quiet
sleep, would, if given in  the morning, stimulate, and
increase febrile action.
  The  plans just  recommended,  together with pa-
tience, will generally remove any difficulty that may
arise from rigidity of the soft parts.   Other means,

   * Would that this rule were made absolute in medicine ! 
 1 14       DUBLIN PRACTICE OF MIDWIFERY.

 as fomentations, the introduction of tallow into the
 vagina, application of belladonna to the os uteri, in-
jections of tobacco, the xvarm bath, vVc.  have been
 n commended ;  but of their effects 1 know nothing
 from experience, and, a priori, see  no reasons that
 can  sanction their use.
   6. Tumours and Diseases of the  soft parts.—The
 hymen is sometimes ptetcrnaturally strong, and has
 been found in existence at the  time of parturition.
 There may be  also cohesions of  the  labia,  cither
 original, or the consequences of injuries.  Such ob-
 structions generally yield to  time and  patience ; but
 cases are upon  record in which it  was  thought ne-
 cessary to divide them  by an  incision ; and some
 are even described, that required  a division of the
 cervix uteri in  consequence of obliteration  of its
 natural opening.  Tumours  of various kinds, and
 herniae of the bladder or  intestines,  by projecting
 into the  vagina, have occasionally  interfered  with
 the passage of the child : they are fortunately rare,
 and  must be treated according to circumstances ; if
 we can pass them above the  head, labour may goon
 well.  At  other times, we may perhaps open tu-
 mours if  their  contents be  fluid, or  we  may bo
 obliged to lessen the child's head.   The only  gene-
 ral rule that can be laid down is, to take such steps
 as may enable the birth to be accomplished with as
 little injury as possible to the mother.
   c.  Disproportion between the passage and the body
 to be propelled through it.—A slight degree of dis-
 proportion may  exist and  render a labour difficult,
and  yet nature be sufficient to accomplish the busi- 
DIFFICULT LABOUR.
145
 ness.  In such a case the  head often bears great
 compression uninjured, and is expelled elongated to
 a most extraordinary degree.  We should remem-
 ber this,  and  not  think  of instruments  as long as
 symptoms do  not imperatively demand them.  The
 disproportion  may be  caused by the  small  size of
 the pelvis, or stiffness of the coccygeal joint, or by
 unusual size or deformity of the foetus.*  The treat-
 ment must be  very similar to that recommended for
 rigidity of the membranes ;  we must exercise  our
 patience,  and  avoid every thing likely to excite fe-
 ver.  Where  we can ascertain that there is  a mon-
 strous formation of the child, as, for instance, a hy-
 dro-cephalic head, we may, of course, give assist-
 ance earlier than  if we  supposed  the child to be
 alive:  in such a case, puncturing the  head, so as to
 evacuate the contained fluid, will probably expedite
 the labour much, and save the woman a  great  deal
 of pain and risk.
  The class of causes which lessen the  expelling
 force includes,—
  a. Original inertness of the  uterus.—This  may
 depend upon  weakness  of  constitution, produced
 by any cause,  or upon a deficient irritability of the
 uterine fibres.   It is  said also to be sometimes oc-
 casioned by over distension of the uterus, or by ex-
 treme thickness of the membranes.   We might ex-
 pect that persons in  the last stage  of debilitating
diseases would present examples of this want of ac-

  * The body of a dead foetus may be swoln by the air disengaged
during putrefaction, and considerable difficulty be thus occa-
sioned.
                   13 
1 16       DUBLIN PRACTICE OF MIDWIFERY.

tion ; but women in  phthisis,  fevers. \c. will frc-
quentlv expel their  children, without any difficulty,
a few hours before death.  There are no cases more
trying to the patience of the accoucheur than those
of inertness of the uterus.   In  midwifery, however,
patience is  always a safe  ally ; and,  by  merely
watching the woman, taking care that  her strength
is supported by light  food, and avoiding  all the Ur-
dentia already  specified, we shall find that, although
the labour may advance by very slow  stops, yet in
the end the  uterine action will not  often fail to  be
sufficient.
   Aperients and  enemata are  particularly useful in
this  variety, often (especially the  latter) exciting
effective pains.   Opium has been recommended in
verv  large  doses;  but, when given thus,  I  have
known  it to paralyse the uterus  completely ; and 1
should  prefer  using  it  merely in  the  way  advised
when speaking of rigidity of the membranes.
   It is in these; cases of inertness of the uterus, that
we most generally  have favourable opportunities for
the exhibition  of ergot of rye; and it  may  be well
now  to notice  that drug.
   It appears to  be at  present pretty generally ad-
mitted that  the secale cornulum, or ergot, docs  occa-
sionally at least produce uterine  action ; that it fre-
quently fails, however, cannot be denied, and this
has usually been  explained upon  the supposition of
its being liable to lose its active  properties,  and be-
come inert.   To try  it fairly,  then,  we should have
it recently powdered, and ascertain  that it possesses
its peculiar smell (resembling somewhat that of new- 
DIFFICULT  LABOUR.
147
mown hay), and that it  is not musty.  Even with
these  precautions it occasionally fails, certain con-
stitutions appearing not to  be susceptible of its in-
fluence.
  The mode in which I  have been  in the habit of
administering ergot is, to  infuse 3ss. of the powder
in a tea-cupful of boiling water for fifteen minutes,
and then give the whole of the infusion with a third
of the infused powder, adding a little milk.   If this
has no effect, it may be repeated in fifteen minutes ;
but I  think it unadvisable and useless to give a third
dose: if the  two  first produce no  pains, another
will not have a beneficial action.
  The circumstances which contra-indicate  the  use
of this drug should be accurately understood.   It
never should be given until the os uteri is complete-
ly dilated, nor xvhen there  is malformation  of  the
pelvis, or rigidity of the  soft parts.  If  used when
the os uteri is undilated, its effect would  be similar
to, and  equally injurious with, too early rupture of
the  membranes : under  the latter circumstances, it
might cause lacerations  of  the uterus,  or  of  the
other  soft parts.  It never  should  be given when
there  is  any preternatural presentation  that may
require to be rectified, nor in convulsions, nor when
there  is  any tendency to  head symptoms.   In the
first case, by increasing the uterine action, it would
of course increase the difficulties; and  in the two
last it would be unsafe, for reasons presently to be
mentioned.
  On the other hand, if the passages be well  pre-
pared and dilated,  the os uteri fully open, and  the 
148       DUBLIN PRACTICE OF MIDWIFERY.

head low down in the pelvis, with plenty  of room ;
in fact, nothing but the want of pains preventing its
expulsion, we  may safely use ergot in the manner
above mentioned.
   It may be supposed  that  greater  success would
attend the employment of larger quantities of the
medicine ; but I am fully persuaded that  these can-
not be employed without exposing the patient to
considerable risk.   In several instances, I  have ob-
served delirium to  follow the exhibition of large
doses of ergot: it almost invariably depresses the
pulse ; and I have known it to produce  coma and
stertorous  breathing, without  at all  affecting  the
uterus.'   If it produce these effects, it is manifestly
improper when any head symptoms or tendency to
them exist.
   The first notice paid to the secale  cornutum was
attracted by its poisonous qualities ; it having been
observed, when taken as an article of food, to pro-
duce  gangrene  of the  extremities,  and  death.
When given to animals, it acts similarly ;  and, from
two suspicious cases that came to my knowledge, in
which it had been largely exhibited,  and  sloughing
of the soft parts supervened (no instruments having
been  used), I am strongly  disposed to  adduce an
additional ground  for recommending its administra-
tion only in moderate doses.f
   When inertness of the  uterus  depends upon its

  • Perhaps even paralysing it.
  t Vide  Report of Wellesley Female  Institution, in  Dublin
Med. Journ., vol, v. 
DIFFICULT  LABOUR.
149
 over distension, or upon  extraordinary thickness of
 the membranes, the proper remedy will  be to rup-
 ture these with the finger-nail, or a  probe, intro-
 duced  during  a  pain.   I suspect that these  are
 causes of rare occurrence ; and, from what has been
 said respecting the evil  consequences  of too early
 evacuation of the waters, we  should be very chary
 of interfering in this way.
  b. Affections of  the mind,  as fear,  anger,  &c.
 powerfully affect some  individuals, and often so
 much so, as to cause a complete suspension of pains.
 Knowledge of  this fact furnishes, of course, a strong
 inducement to keep a patient tranquil and, as far as
 possible, free from all mental annoyance.
  c. Shortness of the funis is  said sometimes to re-
 tard labour, especially when it is  at the same time
 twisted round  the  child's  neck.   Such  extreme
 shortness  is of very rare  occurrence.  It might
 possibly be necessary, after the birth of the head,
 to tie and divide the funis;  but such  an  operation
 ought not to  be lightly  undertaken, and will very
 seldom, indeed, be required.
  [d.  Obliquity of the uterus.—This is  often a pow-
erful but unsuspected obstacle to the progress of la-
 bour.   Yet if attention be directed to it, and  it be
 examined for, there  is no  difficulty in detecting it.
 If the  obliquity be  lateral we shall find one  seg-
 ment of the os  near the centre of  the  pelvis, while,
 perhaps, the other cannot be discovered.   If,  now,
 we examine the abdomen, we find the  fundus uteri
 inclined to the side opposite to that of the os.  If
the obliquity be anterior, which  often happens to 
150       DUBLIN PRACTICE OF MIDWIFERY.
women who have had many children, and have pen-
dulous abdomens, one edge, the  anterior  of the os.
will be felt far back towards the  sacrum, while the
other is out  of reach.  On  examining  the  abdo-
men, we find the fundus uteri in the hypogastric re-
gion, projecting directly forward. To remedy these
obliquities, the French writers recommend dragging
the os uteri towards the centre of the pelvis, while
the fundus is pushed the other way.  This  traction
is always dangerous, often  ineffectual,  and rarely
needed.   It is usually sufficient to place the woman
in such a position that the  fundus will incline  by its
own gravity, to  rectify itself.  If the obliquity be
towards the right, let the woman be on her left side,
if towards the left, then on her right.  If anterior,"
on her  back.  This change of position  will often
facilitate labour  in a most surprising manner.]
   Second order of difficult  labours, or those in which
instrumental aid is required, but such as  is compati-
ble with the safety of both child and mother.— fa-
der this head are to be  considered certain instances
of the first order, in  which the modes of  treat-
ment advised have  not been successful   in promo-
ting efficient action of the  uterus,  and in which
symptoms of constitutional suffering  arc beginning
to appear.
  It is always one of the most difficult points in ob-
stetric medicine to decide upon the exact time when
we can no longer trust  to nature, but must have re-
course to artificial assistance ; and it is often equal-
ly difficult to determine upon the precise  means by
which we are to  assist.   In considering the first 
DIFFICULT LABOUR.
151
question, the practitioner must be very much guided
by his judgment in any individual case,  as to how
much suffering can be borne without  constitutional
or local mischief: no rule of time can  be  laid down,
as one  patient may be left unassisted for sixty hours
with greater safety than another can  for ten.   We
can now, therefore, only  state  collectively those
symptoms and  conditions which  indicate danger;
the general medical knowledge of every accoucheur
must inform  him as to the weight which ought to
be attached to  the occurrence  of one or  more of
these, in any particular  instance.
  The accession or continuance  of general  fever,
after the means of relief already suggested have been
employed, is always unfavourable : especially if the
fever assumes a low type, indicated by a quick, un-
steady pulse, tongue covered with sordes, muttering
delirium, restlessness, and despondency.   In persons
whose  constitutions  are weakened by  former ill
health, or by having had numerous children, &c.,
even without the previous existence  of fever, we
occasionally meet great debility  and  prostration of
strength, with a weak  failing pulse, and a counte-
nance  which  must be known to every person accus-
tomed  to see  bad cases, but that I cannot  describe
otherwise than  by saying that it bespeaks a want of
power to resist disease :*  such  a  set  of symptoms,
it is needless to say,   call for prompt  assistance.

  * The appearance of the  countenance alluded to, is one  of
those points which  can be learned only at the bedside: it would
be absurd to attempt describing it in words. 
152       DUBLIN PRACTICE OF MIDWIFERY.

The same holds good when there is any evidence of
local inflammation, such as  rigors,  occurring after
the dilatation of the os uteri, and when the  head is
not pressing upon the external pnrts ; vomitings of
brownish (coffee  grounds) matter  under  the same
circumstances; pain and  tenderness or tympanites
of the abdomen; heat and  soreness in the vagina;
and foetid olive-coloured discharges from the uterus.
Cessation or irregularity of pains taking place, after
the labour has been going on favourably for some
time, is always a bad sign, especially when connected
with any of the foregoing.  But though the  action
should sensibly decline, yet if the presentation show
some tendency to advance or even  merely to fill up
gradually the cavity of the  pelvis; and if the pa-
tient's strength continues unimpaired, and her free-
dom from fever  or inflammation  is evinced by a
disposition to sleep tranquilly, a  quiet  pulse, abdo-
men soft and tolerant of pressure, a cool, moist va-
gina, and a sufficient secretion of urine, we have no
grounds for apprehension.
  We may now turn to  the  next question,  as to
what circumstances render a case fit for the  use of
instruments not necessarily injurious to either child
or mother—the forceps and  veetis.
  The rules of Dr.  Denman, upon  this subject, are
excellent.  According  to him,  these  instruments
should never  be employed until  the  os uteri has
been completely dilated, the membranes broken, and
the ear become  capable of being felt.   The peri-
neum and soft parts should also be in a relaxed con-
dition, and there should not be such pressure upon 
DIFFICULT LABOUR.             153
the urethra, as will prevent the introduction of the
catheter.  Dr. D. advises that the head  should be
in a position suitable for the  use of the instrument
(that is, with the  ear to be felt), at least six hours
before they should be employed.   As this is a  rule
of time, it is, of course, not absolute, but must be
left greatly to the discretion of  the  practitioner.
The cases, in which we most generally have oppor-
tunities for using the forceps  or vectis, are, simple
inertness of the uterus  from whatever cause ;  sud-
den accession of debility ;  and convulsions.  They
are said to be employed by some gentlemen of rep-
utation when  there is a certain  disproportion be-
tween the head and the pelvis; and  by the  French
the long  forceps  are recommended when there is
obstruction at the  brim.  None of these practices
are (so far  as I am  aware), taught  or  adopted in
this country.
   One caution may be introduced here, which is
applicable to all circumstances requiring the aid of
instruments ; it is, never to  employ them privately,
without explaining their nature and  objects to the
patient's friends ; and, if possible, never to employ
them without the sanction  of a consultation  with
another practitioner.   In certain situations, the lat-
ter rule must, of course,  be  dispensed  with, but
never upon light grounds.

   Third order of difficult labours.—Those in which
it is necessary either  to diminish  the  bulk of the
child, or to provide for it a passage larger than the
natural one.   The general symptoms, indicating a 
154        DUBLIN PRACTICE OF MIDWIFERY.

necessity for instrumental aid. having been already
detailed, as xvell as those sanctioning  the use of the
forceps,  in particular, we have now to consider the
circumstances  which require other means of instru-
mental relief.   These are, in the first place, deform-
ities of the pelvis, or tumours obstructing its canal;
secondly, disproportionate  size  of the  fatal head;
thirdly, such  a degree  of rigidity or inflammation
of the soft parts, as would render them  liable to in-
jury7, during  the action of the  forceps or vectis;
and, fourthly,  similar liability to injury of the blad-
der in consequence  of retention of  urine, with an
impossibility of passing the catheter.
   Distortion of the pelvis may arise  from rachitis,
mollities  ossium, exostosis  or ill-united fractures;
most commonly  they are  occasioned  by  the  first
disease,  and exist, of course, in  very different de-
grees.   The means that have been devised for mea-
suring  pelves  have  been  already mentioned,  and
their insufficiency fully pointed  out.   In ordinary
cases the deformity is not so great as to bring them
obviously and  indisputably within this order,  and
we have therefore frequently  to canvass a great
many circumstances before we can come to a con-
clusion.*  If the  woman  has been  previously de-

  * According to  Dr. Osborn, the diameter from pubis to sacrum
must be more than two inches and three quarters to allow a living
child to pass.  He extracted a child- with the  perforator and crot-
chet through a pelvis that measured at  its widest part only one
inch and three quarters.  Dr. Joseph Clarke thinks three inches
and a quarter the  least conjugate diameter through which a living
child can pass. 
DIFFICULT LABOUR.             155
livered by the  crotchet, it is, of course, a justifica-
tion for earlier  decision upon its use in a subsequent
labour; and, on the contrary, if she  has  ever ex-
pelled a child naturally, we shall be inclined to hes-
itate.   Where  tumours, distention  of the  bladder,
or rigidity, or  inflammation  of the  soft parts exist
in any considerable degree, and  do  not  yield  to
milder measures, we have, I  think, generally, no al-
ternative but the perforator.
   Many persons think that a certainty of the child's
death should frequently determine us  at once : the
mere  death  of  the child, however, is no justification
for the employment of anyr instruments,  although,
if we were  sure that it had taken place, we would
then certainly not delay so long, as  to  run the wo-
man into  the least  danger.   Accordingly7, we act
upon  this  principle, when we have  to deal with a
hydrocephalic head, or one that, from its putridity,
or the looseness  and  overlapping  of the  bones, is'
beyond all doubt dead.  Excepting these signs, and
the accidental  prolapse of a pulseless  funis, I know
of none others  that positively determine the death of
the child, and, therefore, think it unnecessary to enter
into  a  lengthened  consideration of  those  usually
recited in books.   The chief, independent of those
 above alluded  to, are  first, rigors toward  the  close
 of gestation ;  secondly, sense  of coldness and dead
 weight in the abdomen;  thirdly, want of motion in
 the child ;  fourthly, flaccidity  of the  breasts, and
recession of the milk ; fifthly, the impaction of the
 head for a considerable  period (say  some days) ;
 sixthly, evacuations of meconium from the vagina, 
156'      DUBLIN PRACTICE OF MIDWIFERY.

the head  presenting;  seventhly, fetid  discharges:
none  of these, however,  can be  absolutely relied
upon, although they may afford a strong presump-
tion of death.  The sound of the  fiutal  heart is, of
course,  positive proof of life, but our  not being
able to hear it is no evidence to the contrary, as it
may exist and escape the observation of very expe-
rienced auscultators.  The placental soufflet is evi-
dence neither one way nor the other, as it does  not
constantly cease upon the death of the foetus.
   It appears to me, however, that it is not  of so
much importance as some suppose, to discriminate
the child's death ;  our reasons for operating should
be drawn entirely from  the state of  the  mother,
which ought, also, to influence our choice of instru-
ments, except in those cases, where the obvious signs
already mentioned free us from all anxiety respect-
ing the child.  But if there be the slightest chance
of saving the latter, or even  of avoiding its disfig-
urement, with due regard to the  woman's safety,
surely no person in his senses would think of using
a destructive instrument.
   In no case is the  advice already given, with re-
spect to the obtaining of a consultation, so appro*
priate as in those, which  are likely to come within
this third order of difficult labour.  The operations
alluded to in our definition, are  three: viz., first, di-
minution of  the  head ;  secondly, section of  the
symphysis pubis ;  and, thirdly, the Cesarean oper-
ation.  The merits of  these, and the  manner of
performing them,  shall  be  considered  in  the next
chapter. 
DIFFICULT LABOUR.
157
  [In all  cases  of difficult labours, whatever  may
have been the cause, especial  attention should be
paid to securing a perfect  and  permanent contrac-
tion of the  uterus, and  a discharge of  the  pla-
centa.   If the  uterus  has been  inert,  its  inertia
will be very likely to increase after the expulsion of
the child;  if the  resistance offered  by rigid  soft
parts, or a small  pelvis, has exhausted  its powers,
they will be  roused to action  after delivery  with
more than ordinary difficulty, and the chances are
very great that a uterus thus inert or exhausted,
will, if roused to action, contract  imperfectly, irreg-
ularly, or inefficiently: from imperfect contraction
we have hemorrhage,  from irregular  action, hour-
glass contraction and retained placenta.
  Another very unpleasant consequence  of difficult
labours, is  inflammation of the vagina  and vulva.
This is often  very great in women who have a first
child late in life.   The remedies are, leeches and  a
large poultice.]
14 
158
   CHATTER XII.

OBSTETRIC OPERATIONS.
  '• I wish that my present subject  permitted me  also to state
What I  have found  on dissecting the part9 after the use of the
crotchet, and in particular where the forceps had been used, as I
must presume, in  a case improper for them-  The  injury which
the seeming harmless instrument, the forceps, is capable of doing
might then be proved, and a wholesome admonition given to the
young surgeons."—AVVr to Sir C- Bell's l'tipcr on the Muscles of
the Uterus, in the Med. Chir. Trans., vol. iv. p. 336.
   Forceps.—It is not necessary here  to enter  into
a history of this instrument, nor a description of its
various forms, as  the  former  can be  learned from
any of the more elaborate  systems of midwifery,
and satisfactory ideas  respecting the  latter can be
best obtained in the shop  of an  instrument-maker.
The forceps in common use  in this  country are the
common single-curved, the  double-curved, and the
male and female.   The first  are  those  which  I  pre-
fer myself; but the exact  form of the  instrument is
of little  consequence,  provided  its application be
guided by judgment and caution.
   The position of the patient while we are opera-
ting should be the common obstetric one,  upon the
left side, with the knees a  little drawn  up,  and a pil-
low  placed between them;  she  should  also be 
FORCEPS.                 159
brought so close to the edge  of the bed, that her
hips may project over it, and in that situation should
be supported by an assistant standing at her back,
[The position  upon the back, the feet wide apart,
and resting upon two chairs, while the nates project
over the edge of the bed, is preferred on the conti-
nent of Europe, and in  America, and is obviously
the most convenient  for the accoucheur, the safest
for the woman, and therefore, the best.   The only
objection  that can be made to it is, that it renders
very considerable exposure  unavoidable, this, how-
ever, is a minor point, the case is  too serious to al-
low of our sacrificing a substantial advantage to a
mere regard for appearances.]   The first step should
invariably be, to pass a catheter, as extracting while
the bladder is full would expose that viscus to the
risk of rupture, or of such  injury as might  be  fol-
lowed by sloughing and fistula.*  It  is  also advisa-
ble to clear out the rectum by an enema.
   After  these preliminaries have  been settled we
are to sit down quietly by the side of the bed, hold-
ing in the left hand a  blade of the forceps, which
has  been previously  heated in warm  water, and
smeared with lard or butter.   The forefinger of the
right hand is  next  to  be introduced between the
symphysis and head of the child, and the ear to  be
felt for.   When we feel the latter, we may pass the
blade, held  still  in  the left hand, very gently be-


   * In difficult labour, we shall often have occasion to observe a
temporary suppression of urine, which is generally  secreted in
profuse quantity  shortly after delivery. 
 160       DUBLIN PRACTICE OF MIDWIFERY.

 twcen our finger and the head of the child, until it
 reaches the ear ;  after this  it must  be passed on
 with a wavv motion, keeping  its point close to the
 child's scalp,  until the lock  reaches  the  external
 parts.   After  the  blade has passed  the ear, as we
 are then deprived  of the guidance of our finger, we
 must be doubly cautious :  and if any pain is given,
 or obstruction met with, we  must withdraw for a
 moment (precisely as we would if any check occur-
 red in the introduction of the  male catheter), but
 never attempt to pass on  the instrument by force.
 The first  blade, having been  properly placed,  may
 be held by an assistant, and the forefinger of the left
 hand then  introduced  between  the  perineum and
 head along which  the second blade is to be passed
 as far, and with the same precautions as before men-
 tioned, taking care that it  is  exactly opposite to its
 fellow.   We may now proceed to lock, by holding
 the second blade stationary,  and withdrawing the
 first to  meet it, taking care that no hair or soft parts
 intervene, and  that  we cause  the  handles to pass
 each other with their locking sides  properly oppo-
 sed.  We may then tie the handles together with a
 running knot, which will admit of  being easily
 loosened.  When  the forceps are properly applied,
 with  the blades over  the child's  ears, and their
 points at the chin, their handles will approach to
 within one half or three fourths of an inch to each
 other; if they are more distant, it shows that the
 points have  not been passed far enough ; and if they
 approach  closer, the head has  not  been properly
grasped between them. 
FORCEPS.
161
  In working with the forceps we should take ad-
vantage of any pains that may exist,  and extract
during their occurrence ; or, if the  uterus be quite
inert, we must imitate nature, and allow an interval
of rest between  each of our  efforts.   Often, the
mere introduction will excite a pain, and we may
then move the instrument slowly and steadily from
the  perineum  towards  the  pubis,  using  at  first
scarcely any  extractive force.  When the  pain
returns, or (if there be no pains), after a short in-
terval, we may, in the same manner, bring the han-
dles back to their former position.  This  alternate
motion, backwards and forwards, is to be persevered
in, employing gradually a slight increase of extract-
ive force (which should be  always applied in the
direction  indicated  by  the  handles), and acting
always from one  blade  toward the other.  As the
head descends, and turns into the sacrum, the posi-
tion of the blades will,  of course, change, and we
shall have to act from side to side, instead  of  from
before  backwards.  To allow of this change, we
must let go the handles (or hold them very loosely),
between each of our efforts.
   The  time to be occupied by the  extraction will,
of course, vary according to the difficulties of the
case ; safety should  never be  sacrificed to speed ;
and we should always pay the closest attention  to
the  supporting of the perineum, which is frequently
injured by careless operators.  After  the head has
been extracted, the rest of the labour will probably
be accomplished  by nature, and, if possible, should
be left in her hands : if she be quite powerless, we
               14* 
162       DUBLIN PRACTICE OF MIDWIFERY.

shall be obliged to assist in the extraction of the
body.
  When the employment  of the  forceps  is advisa-
ble in the varieties  of natural labour, they should
be applied in the  same  manner over  the ears, the
same general rules applying to their management.
   Vectis.—This instrument, in its most simple form,
is nothing more than a single blade of the forceps,
deprived of its lock, and a little more curved than
usual.   The mode  of  introducing it is  precisely
similar to that recommended with the  first blade of
the forceps, and it should  occupy  exactly the same
situation upon the side of the child's head and face.
In acting with it, we convert it into a lever of the
first order, grasping  its handle  firmly with our right
hand, and making  a  fulcrum of our left: at the same
time using some extractile  force, and  taking great
care that  we do not allow the  labium to have  any
share in the office of supporting the centre of the
instrument.
  The vectis must  be  used at intervals, like the
forceps,  and, if  possible,  during  pains.    As  the
head descends, and gets with the face  into the  hol-
low of the sacrum, its position will of course  be
changed from the front to the side of the pelvis.
Dr.  Lowder contrived  an instrument  somewhat
more curved  than the ordinary  one,  and called,
from him, Lowder's  lever, which he recommends to
be introduced—first, over the  occiput, and subse-
quently, when the  face turns into the sacrum, to  be
withdrawn, and re-introduced over the  face and
chin.   I am not aware that this plan possesses any 
VECTIS.
163
real advantages over the ordinary mode of using the
vectis.
  By some authors, the propriety of using the  in-
strument as a  lever has  been impugned,  and  its
name has been  attempted  to be changed into " ex-
tractor."  This doctrine  has been of essential ser-
vice, so far as it points out the danger of using the
soft parts of the woman as  a  fulcrum ;  but a very
little reflection  must show, that, curve a vectis as
you  will, it cannot act simply  as  an extractor upon
a globular  body like the child's head, and that it can
have no other  action than that of a lever.   The
whole difference consists in making a fulcrum of the
left  hand,  instead  of  the labium, and this should
never  be forgotten.
  Much dispute has  arisen as  to the  comparative
merits of the forceps  and vectis. The safest con-
clusions appear to be,  that  either instrument  may
occasionally  be employed  by  competent persons
with perfect safety ; secondly, that the  forceps will
sometimes succeed (from giving a more powerful
purchase)  where  the  lever will  not;  and,  thirdly,
that, the vectis being more  capable of secret and
early use, there are more temptations  to its impro-
per  employment;  and, ergo (as we are all fallible), it
is less advisable for a practitioner to familiarize him-
self with it.
   The fillet is not now used in midwifery, except-
ing  occasionally in breech or  footling cases.

   V  Dr. Joseph Clarke found  it necessary to em-
ploy the forceps in the  Dublin Lying-in Hospital 
164       DUBLIN PRACTICE OF MIDWIFERY.

once in 728 cases:  lie estimates the necessity for its
use in  private  at  one in  1000.  In the Wcllesley
Female Institution, the proportion of forceps cases
has been about the same.
   [Merriman in  2917  cases  applied  the  forceps
twenty-one times.  Bland in  1897 cases only nine
times.   At  Maternite  in 20,:ii>7 cases the  forceps
were used in ninety-six.]

   Perforation  of  the   head.—In  performing  this
operation, the  same  rules are  applicable, with re-
spect  to  the patient's position, and emptying her
rectum and bladder  (if  possible),  as  have  been
stated  in  the  preceding pages.  The instruments
necessary are the perforating scissors and crotchet,
which  are to be heated in warm water, and placed
in a situation convenient to  the hand of the opera-
tor. The latter is then to sit down quietly and de-
liberately beside the patient, introduce  two or three
fingers of his left hand  into  the vagina, and place
them upon the presenting part of  the  head, ascer-
taining, by pinching the hair of the  scalp between
his  fingers, that  nothing  whatsoever  intervenes.
The assistant,  who stands  at the woman's back,
should press upon the  uterus, so as to steady it; and
the  operator may pass  up  the perforator,  with its
point  moving  along his fingers, until it  meets the
head.   Surrounding the  point with  two of his fin-
gers, he is then to  perforate the skull with a boring
semi-rotatory motion.   If the child be living, a con-
siderable  flow  of blood will  sometimes take place
from the  scalp, but as  it  is usually dead,  this sel- 
PERFORATOR.
165
dom occurs.   When  the skull  is  perforated, of
which the cessation of resistance makes us at once
aware, we are  to  push on the instrument steadily
until the stops meet the bone : we are then to grasp
one of the handles, and direct the assistant to sepa-
rate the other to its full extent.   This  having been
done, the instrument is to be again  closed, turned,
and separated in another direction, so as  to make a
crucial opening.  During  the separation  the stops
should  be kept firmly in contact with  the bone,
otherwise the points might be withdrawn  from the
cavity by the shortening consequent upon their  sep-
aration.  The  next step  is to pass the perforator,
stops and all, into the  brain, and turn it about in all
directions, so as completely  to break up  its mass.
This should  be carefully7 attended to, both for the
purpose of  lessening  the  bulk of the head, and to
prevent any chance of the child's being  born with
a spark of  life, an accident  which  occasionally
has happened, and given rise to much unpleasant
feeling.
  Some persons recommend a  delay of five or six
hours after perforation to let the  head collapse be-
fore finishing the delivery;  but,  unless in cases of
very extraordinary deformity, I can  see  no advan-
tage in this  practice,  and its  adoption has always
a depressing effect upon the mind  of the woman.
When the brain has been well broken up we  may
withdraw the perforator, and then, having removed
with the fingers any loose pieces of bone, and turned
the  torn edges of the scalp into the  opening, the
crotchet may be introduced, guided upon the fingers 
166       DUBLIN PRACTICE OF MIDWIFERY.

of the left  hand.  Its  point  is  to  be fixed in the
bone, and we may prepare for  extracting, which, if
pains exist, should be done during their continuance,
and by steady efforts, allowing  an  interval of rest.
While we extract we  should  place our fingers on
the head opposite the  point  of the instrument, so
that, if it slip, it  may rather injure our  hand  than
the patient's vagina.   We should also rest our elbow
upon the bed and act chiefly from the wrist, so that
a slip may not  be attended with any sudden jerk.
The amount of  force required  must vary much, ac-
cording  to  circumstances ;  the great  thing  is, to
employ it steadily, and in  the  direction of  the axis
of that part of the pelvis in which the head is situ-
ated at the time.  We shall sometimes have to per-
severe for a considerable period before we get over
the obstruction,  after which the rest of the busi-
ness will probably be speedily  effected.
   In cases of extreme distortion, the bones of the
cranium may come away piecemeal, and it may be-
come necessary to  perforate the thorax, and evis-
cerate it and the abdomen.  When an operation of
this kind is required, it is attended with  great dan-
ger, and all our care will  frequently be insufficient
to protect the vagina against injury from the broken
ribs.  Forceps intended  to supersede the use of the
crotchet have been devised  by Dr. 1).  Davis  and
others, and I think  may  often  be used  advantage-
ously.  I have,  however,  always found the  latter
instrument to  answer my purpose  without  ever
doing mischief, and I must confess myself to  be no 
SECTION OF THE SYMPHYSIS PUBIS.       167
lover of innovation, unless it be attended with mani-
fest improvement.
  After either crotchet  or forceps operations, the
greatest attention must be paid to prevent retention
of urine, which, as well as  incontinence,  occasion-
ally occurs.   It is often advisable to give an opiate j
and all the minutioe  of management,  of which we
shall afterwards speak, must  be attended to with
double strictness.

   *#*  Dr. Joseph Clarke found it necessary in the
Dublin Lying-in  Hospital to  use  the perforator
once in 208 cases.   In the Wellesley Female Insti-
tution  it was employed during the year 1832 once
in  2111,  and during  the year 1833 once  in 137
cases.
   [Of Merriman's 2947  cases,  nine required the
perforator ; of  Bland's  1897 cases it was  used in
eight;  at Maternite in 20,357 cases  only  in six-
 teen.]

   Section of the symphysis pubis.—This  operation
 was proposed by  M. Sigault of Paris  (in the year
 1768), as a substitute for both perforation  and the
 Cesarean section.  In performing  it, a catheter  is
 to be introduced into  the urethra, and the integu-
 ments and symphysis  of  the  pubis  to be then divi-
 ded with a scalpel, from  above  downwards to with-
 in a quarter of an inch of the lower edge of the
 joint.   The thighs are then to be separated,  and the
 bones  forced  asunder.   The symphysis cannot be
 separated to more than an inch without tearing the 
168       DUBLIN PRACTICE 01 MIDWIFERY.
 sacro-iliac joints (an accident always fatal), and aa
 this increase  of size  would  not answer any useful
 purpose, in a pelvis so  deformed as to require the
 Cesarean section,  of course the  Sigaultian  opera-
 tion cannot be a substitute  for the  latter.'   I hope
 no one now-a-days would  be mad  enough to pro-
 pose dividing the  symphysis, in a case where it
 would be possible to deliver with the perforator and
 crotchet.

   Ccesarean section.—In cases where the pelvis is
 so extremely deformed as  not to permit the extrac-
 tion  of a child diminished by the perforator to the
 greatest possible extent, the only alternative  is  the
 Caesarean operation.   From Dr. Osborn's observa-
 tion, already quoted, it appears  that a child was ex-
 tracted, by the  crotchet, through a pelvis measuring
 at the widest part  from before  backward only  one
 inch and three quarters; accordingly, it may be  laid
 down as a rule  that the operation is only required
 when the measurement of the pelvis falls short of
 this amount; and, as impregnation  under such  cir-
 cumstances is unlikely7, it follows that  a necessity
 for the section must be very rare.  The  truth is,
 that in Great Britain the operation  never did  and
 never will flourish.f  In Roman Catholic countries

  * Mr. Simmons, of Manchester,  proposed  that section of the
 symphysis and perforation should  be employed together in ex-
 treme cases; but surely the Caesarean operation,  by giving a
 chance to the child, must be preferable to this double murder.
  t Of twenty-five cases, twenty-four mothers perished.—JSkr-
riman on Difficult Parturition. 
CESAREAN OPERATION.       .    169
 it has had  better success, because in them it has
 been performed when, according to the rule above
 stated,  it was  not  required;  being patronized by
 the clergy, in opposition to perforation, from their
 unwillingness to  sanction the death of a  child  un-
 baptized.
   The mode of performing the operation is by an
 incision  through the linea alba, as semilunaris, six
 inches in length,  exposing the uterus; the  arteries
 are  to  be  secured,  and a second incision made
 through  the walls of the womb, merely large enough
 to admit the passage of  the foetus;  through this the
 hand should be  passed, the  membranes  ruptured,
 and  the child, and afterwards the placenta, quickly
 extracted.   During  this time  the  assistants  must
 carefully prevent the protrusion of the intestines, by
 keeping  the  abdominal  walls  pressed close to the
 uterus.   If the uterus does not contract,  the  hand
 must be passed  in  to  stimulate its cavity.   The
 wound in the womb is to be left to nature, that in
 the integuments  must  be secured with sutures and
 adhesive plaster.
  Before the commencement of the operation,  the
 bladder should  be emptied, and an attempt made
 to ascertain  the  situation of the placenta  by means
 of the stethescope.   If we succeed in learning its
 exact site, we must make our incision so as to avoid
 it.
  [The Caesarean operation has  of late  been per-
formed successfully7 in quite a number of cases ; by
Michoelis, of Keil, five times in the same woman ; by
Dr. Gibson,  of  Philadelphia, twice; by Dr. R. K.
             15 
170     .  DUBLIN PRACTICE OF MIDWIFE KY.

Hoffman, of New York, once, and  by other opera-
tors on the continent of Europe, and in the l'nited
States.  It. has, in fact, lost many of its terrors, and
is now contemplated every where  except  in Eng-
land, as one of the  recognized means  of  delivery,
and not as a reTi/srium miserabile, a mere  desperate
experiment, only to  be  thought  of  when every
other means have failed, and every rational hope of
life is lost.  The circumstances to which continental
and American accoucheurs own  their  success  ap-
pear to be, that  they have operated earlier, before
the strength of the  woman has been prostrated,and
her system rendered irritable by the  long  continu-
ance of labour pains, or by violent  and protracted
attempts at delivery,per vias nalurales.  When at-
tempted under such circumstances, and performed
with requisite skill and promptitude, the experience
of living  accoucheurs establishes the facts, that the
Caesarean operation, so far from being in the words
of a late English reviewer, "almost certain death,"
will succeed in a fair proportion of cases.  It is a
formidable, a very formidable operation, not to be
undertaken rashly, nor by an  incompetent surgeon,
but, on the other hand, if well timed and  well per-
formed, it is a valuable means of saving life, not to
be idly decried, nor yet restricted to desperate or
hopeless cases.
   A British writer  suggests the propriety  of divid-
ing the Fallopian tubes, when the  Cesarean opera-
tion is performed, that thus the woman being ren-
dered barren, might be guarded  against  the possi-
bility of requiring a repetition of the terrible (a 
INDUCTION OF PREMATURE LABOUR.      171
sarean section.  This  suggestion deserves mature
consideration.]
  When an individual woman has been frequently
delivered by perforation of the child's head,  it be-
comes an object to devise  some  means  for obviat-
ing these successive sacrifices ; and accordingly it
has been proposed in such cases to induce prema-
ture labour, at a period of gestation when the child
is sufficiently small to pass through the pelvis.
  This is a step  by no means to be lightly under-
taken, as there must always be a certain degree of
danger incurred by the mother ; and  the  act itself,
unless it can be justified by a powerful necessity, is
unwarrantable, and even criminal in the eye of the
law.  The mode of performing it is simply to rup-
ture the membranes  with a  sharp-pointed  probe,
and allow the  waters to drain off.  Dr. Merriman
has published some rules, the substance of which we
shall state as conveying all the information that is
useful upon the subject:—1. To give the child a
chance of life, the operation never should be under-
taken before the seventh month.  2.  It never should
be adopted, until we know from sufficient experience
that the mother cannot produce a  full-sized  child.
3.  The woman should be free from general disease.
4.  If  the presentation be preternatural, its  propriety
is  doubtful.  5. The  strictest precautions against
fever (varied according to circumstances) must be
adopted. 6. A wet nurse  should always  be  ready
for the child.   7. On no account should it be done
without a consultation as full as can be procured.
  [Ramsbotham has tried ergot as a means of indue- 
 1~2      DUBLIN PRACTICE OF MIDWIFERY.

 ing premature  labour, and finds, that  after a few
 doses of the infusion, given at intervals of four or
 six hours, the pains of labour set  in  and  the birth
 was completed without manual aid.   But  though
 the mothers recovered as well after  the  operation
 thus performed, as in any other way, yet a larger
 proportion  of  the  children were still-born.   This
 led him to modify the practice, and  he now gives
 four or five doses of  the infusion of ergot and then
 ruptures the membranes.  He generally  finds that
 the os uteri  has  become  soft and somewhat open
 under the operation of the drug.  The number of
 live births has  increased  in  his practice, since ho
 resorted to  this modified use of ergot.
   Another mode of bringing on  premature  labour
 is by separating the membranes for an  inch or two
 around the os uteri, and removing the [dug of mu-
 cus by which  the os  is usually closed.  This plan
 is advocated by Hamilton and Conquest, but Itams-
 botham sayrs he has found it fail in most of the in-
 stances in which he has tried it.   Kluge and Brum-
 minghausen  proposed introducing a sponge tent
 into the os,  and confining  it  there by plugging the
 vagina.  This plan is approved of by Velpeau, and
 adopted by  Dubois, and other French accoucheurs.
   This last method,  or the  removal of the  mem-
 branes from around  the os uteri, is  preferable to
 the immediate  rupture of the membranes,  as, by
 resorting to them we avoid the great source of dan-
 ger, pressure on the  funis and  the  child after the
evacuation of the liquor amnii.  If they fail, how-
ever, and we are compelled to resort  to rupturing 
          INDUCTION OF PREMATURE LABOUR.      173

the membranes, it is certainly good practice to pre-
scribe three or four doses of ergot.
   A curious fact relating to this subject is that the
proportion of cross births in  cases  of premature
labour, whether natural or  artificially  induced is
much greater than in labours at full  time.  Merri-
man met with fifteen  preternatural presentations in
thirty-four cases of artificially induced  premature
labour.  Ramsbotham reports fourteen in forty-one
cases,  and Dubois fifty-six  in one  hundred and
twenty-two.]

   *y*  Dr. Merriman relates forty-six cases of pre-
mature induction  of labour,  in all  of which  the
mothers recovered, and sixteen of the children were
capable of being reared; five  others  were alive at
birth,  but  died  shortly  afterwards.   Hamilton re-
ports forty-six infants born prematurely, of whom
forty-two were born alive.   Ramsbotham forty-one
children—twenty-three living.
15* 
171
                CHAPTER XIII.

            PRETERNATURAL LABOUR.

  The term preternatural is applied when any part
of the child, except the head, presents.  The  class
has two orders :—1.  Presentations  of the breech,
or inferior extremities; 2.  Presentations of the
shoulder, or superior extremities.
  In the common parlance of the lying-in chamber,
the term " cross-birth" is applied to  both these or-
ders ; but, technically and  strictly, it  is only used
for the second, when  the child  actually lies  trans-
versely  in the  womb.   Presentations  of the back,
abdomen, and sides, are  described by authors ; but
if they  ever  occur, at  the full term of gestation, the
same  principles apply to them  as to cases of the
second order.
  Various signs of preternatural labour  have been
mentioned, as,  peculiar motions of  the child and
shape of the mother; slow progress  of the first
stage  ; early  rupture  of the membranes, ccc, but
the only7 certain information upon  the subject is to
be obtained by examination per vaginam.  In some
cases, at the  very  commencement  of  labour, we
shall,  even by this method, be unable to detect any
part of  the child ;  and then, certainly, the presump-
tion is, that the head is not  presenting.   It is, there-
fore, incumbent upon us to watch the case carefully, 
PRETERNATURAL LABOUR.
175
 until, more  progress  having been  made, we may
 obtain the necessary information, and lose no time
 in affording any assistance that may be required.
   The marks of the different presentations  are as
 follows :—The  head  is known  from  every other
 part by its hardness, sutures, and fontanelles.   The
face is distinguished from the breech  by the fore-
 head, by its features, and especially by the tongue.
 Of these two presentations we have already spoken.
 The nates are  to be  recognized by their globular
 shape, softness, and elastic feel, by the cleft between
 the buttocks, the anus, and parts of generation (es-
 pecially in a male), and the free  passage of the me-
 conium.   In a first and hasty examination, the finger
 may meet one of the  trochanters, when the part is
 pressed firmly into the pelvis, and the skin tightly
 drawn over it; and I have known it, under such
 circumstances, to be, for a short  time, mistaken for
 the head.   The shoulder is to be distinguished from
 the hip by its smaller size, by the axilla and ribs, by
 the clavicle, scapula, and by the  arm, which is,  in a
 marked degree, smaller and more moveable than the
 thigh.  The foot and hand are to be  distinguished
 from  each other by the greater thickness and length
 of the former, by the projection of the heel, by the
 shortness and evenness of the toes, and by the great
 toe not being, like  the thumb,  separable from the
 rest.   The elbow can  be known from  the knee by
 its sharpness, and by  the small size of the arm and
 forearm.  All these things appear easy enough upon
 paper, or when we  have a child  quietly in its  cra-
 dle ; but when  it is in the uterus it  is quite another 
 176  .     DUBLIN PRACTICE OF MIDWIFERY.

affair,  and tolerably-experienced practitioners  arc
then not unfrcquently at a loss.  The way to  pre-
 pare ourselves  best against error is to improve  our
tact, and bv giving ourselves the habit of feeling the
different parts of dead or living children whenever
an  opportunity offers;  and  when we  have occa-
sion to exercise knowledge thus gained, we  should
proceed coolly and deliberately, without any affecta-
tion of extraordinary dexterity or greater skill than
 our brother practitioners.
   Iireech presentation.—The mechanism of parturi-
tion in these cases has been already fully explained.*
At the commencement of labour there may be two
varieties :—1.  With the front of the  child directed
toward the mother's  spine ; 2.  With  the  front  di-
rected  toward  the  mother's  abdomen : the latter
considered the least favourable.
   From the observations  of Nagcle  it is  fully es-
tablished that,  in a  great majority of instances, as
the labour proceeds, the latter variety is converted
by the pains (alone) into the former.   More  rarely
the child is expelled in the second position, and then
a degree of  difficulty, requiring artificial  interfer-
ence, occasionally occurs.
  The  first stage of a  breech case  must be con-
ducted precisely as in a  natural labour ; the practi-
tioner  should be even more  cautious  than usual in
his examinations, lest the parts of generation should
suffer injury.   If every  thing goes on well, nature,
unassisted, should be allowed  to expel the breech
• Vide p. 40. 
PRETERNATURAL LABOUR.
177
 and  feet.   If difficulty  arises,  it  must be treated
 according to  the rules  laid  down  in  the  chapter
 upon difficult labour.   The forceps  or  the perfora-
 tor, in short,  all  the means there spoken  of,  may,
 under certain circumstances, require to be employed.
 When the breech has descended to a certain extent,
 if necessity for interference arises, we may exert a
 powerful extractive purchase, by passing a fillet  (a
 common silk  handkerchief answers very well) over
 the  groins, between  the  belly  and thighs of the
 foetus,  and extracting with it as we would with  a
 forceps.   A blunt hook is also  sometimes  used for
 the same purpose.*   When the body is  expelled  as


  * This is the only practical precept in this work from which the
 Editor dissents strongly. The cases  are  exceedingly rare  in
 which it is necessary  to expedite the progress of labour before the
 umbilicus is born.  In the vast majority the  slower  the labour
 progresses  up to that point, the more perfect will be the dilatation
 of the soft parts, and the less the danger to the  child from pressure
 on the cord.  To this danger from pressure the child  is not ex-
 posed till the umbilicus has passed well into the  pelvis, and the
 danger is not great till the head fairly enters  the  cavity.   From
 these  facts the practical inference is plain, we should not hurry,
 nay,  within  certain  limits, we should delay  the  progress of
 the labour, till  the  umbilicus has passed the vulva, from that
 time  the  pressu/e on  the  cord is likely  to  be severe, and
 therefore, the remainder  of the labour should  be finished as soon
 as possible.  The application of a fillet in the manner spoken of
 in the text, we think  unnecessary, except in the cases of extreme
 and very urgent danger, as convulsions or the like,  and  to the
 blunt hook our objections are  yet stronger—the danger of break-
ing the child's thigh is extreme-  This use of the instrument is
 condemned by  the judicious Merriman, who says he has never
 found  it necessary.  The bringing down the arms will rarely
(Yelpeau, Desormeaux, and Mad. La Chapelle say never) be  re- 
 17.8       DUBLIN PRACTICE OF MIDWIFERY.

 far as the umbilicus, we should  draw down the
 funis a little, so as to prevent it from being stretched.
 If it continues to pulsate, we may still  leave every-
 thing to nature.    Should there  be any difficulty in
 the escape of  the foot or arms, we may bring  them
 down cautiously, taking care not to let them jerk
 out. so as to injure the  perineum.  To  bring down
 the arms, we  pass a forefinger successively into the
 bend of each  elbow, and then sweep the forearm
 slowly over the  breast.
   In many instances, the expulsion of the head will
 quickly follow that of  the  body,  the  face turning
 into the hollow of the sacrum, as in  natural labour.
 If it should  not, and the cord  cease  to pulsate, it
 becomes necessary to hasten the passage of the head,
 lest the child should  be suffocated.  The mode  of
 doing this is, to pass the fore and  middle fingers of
 the right hand round the back of the  child's neck,
 so as to give it a degree of support, and at the same
 time  to place the fore-finger of  the  left hand  in
 its mouth, and depress the chin : by  the latter man-
 oeuvre, we bring the head into the most  favourable
 position for passing,"  and at the same time, we per-
 haps  make a channel  along our finger,by which the
 air may have access to  the child's mouth and chest.
 I have frequently known a  child  to breathe,  with

 quired,runless the feet are pulled at; if the fcetus is pushed out
 by the efforts of the  uterus, the arms will remain folded upon
 the breast,  their natural position, it is only  when the child in
pulled ovX that they rise along side the head,  and present a for-
 midable obstacle to labour.—En.
  ' Vi.1l- pp.31. 41. 
PRETERNATURAL LABOUR.
179
 the greater part of its head in the vagina.   In gen-
 eral, by  depressing the chin we soon  succeed  in
 withdrawing the head,*  but sometimes  a delay oc-
 curs, fatal to the child, and it may even occasionally
 become  necessary to perforate the head, after the
 body has escaped.
 ■'_ [Where there is much delay in the passage of the
 head, especially if the cord begins to pulsate feebly,
 showing  extreme danger to the child, the forceps or
 the lever should be instantly applied.   It  is an ex-
 cellent precept of Professor Meigs, always to get
 your forceps ready when you  meet with a footling
 or breech case ; have them at hand, so that  if it be-
 come necessary to  apply them  it may be  done  at
 once.  This is one of the cases where it will not do
 to trust too  much to nature,  the  life of the  child
 may be saved or lost  as delivery is five minutes ear-
 lier or later.]
   The perforator can, in such  cases, be introduced
 behind the ear.  In all extractions of the head,  the
 perineum requires to  be carefully guarded.   When
 the belly of the child continues to  be  directed for-
 wards, up to the period of the head's  passing, some
 difficulty may arise from the chin hooking upon the
'symphysis pubis.  It  then  becomes necessary  to lay
 hold of the  body of the child (covering it with a
 napkin),  and to  give  it  a slight  inclination,-!;  so

   * The extraction is often facilitated by pushing up the  occiput
 with the fingers of the right hand.
   t In this manoeuvre we must recollect, that it is very possible
 to dislocate the child's neck, and we should  therefore  employ
 force with  suitable moderation. 
180       DUBLIN PRACTICE OF MIDWIFKRV.

as to  bring  the  head  into the  oblique  diameter
of the brim:  the  further steps  (depression of the
chin. &c.) are to be conducted in  the ordinary man-
ner.
  Footling Presentation.—This is to  be conducted
precisely  as  the  breech  case, and  is  liable  to the
same varieties.  It is  generally   more fatal to the
child, in consequence of the slow, wedge-like  dila-
tation  produced by the  limbs not permitting the
head to pass  as quickly,  as when the  large,  bulky
breeeh has prepared the  way for it.  The funis  is
consequently pressed upon  injuriously, before the
lungs can be supplied with  air.   The best way, in
any case,  to secure the  speedy passage of the head,
will be to allow the  body to be expelled  as slowly
as possible, and even not  to interfere with the head
so long as the circulation through the cord contin-
ues.   Efforts  at  disengaging the  head  should  be
made,  if  time permits, during a pain, but if the
child be dying, we cannot,  of  course wait for this,
[but apply the forceps at once.]

   '-.,.*  In 839 labours which occurred in the Wel-
lesley Female Institution, during the years 1832 and
1833, there were twenty  presentations of  the lower
extremities, or one in  forty-two.   In  both breech
and  footling  cases, a  considerable proportion  of
children are still-born.

   Second Order of Preternatural Lahonrs.—In pre-
sentations of the shoulder or arm, the  practice dif-
fers diametrically from  that required in the first or- 
TURNING.
181
der:  interference being in  the  one as universally
demanded, as it is in the other universally forbid-
den.  The mechanism of these cases,  and  of the
" spontaneous evolution," by which nature occasion-
ally relieves them, has been already explained,* but
it is very generally agreed, that when  the child is
mature, we cannot safely trust to the occurrence of
this natural operation, and that it is incumbent upon
us, in every such  case, to offer artificial assistance.
It is  equally agreed  upon  that our  interference
should, if possible, consist in the introduction of the
hand  into the uterus, laying hold of  the feet or legs,
and bringing them into the vagina, .in  place  of the
arm or shoulder ;  in other words, turning the child.
The circumstances of  the case, however, may make
a considerable difference  in the facility,  or even
possibility of doing this, and may require variations
in our mode of  practice.  The most favourable
case is when we see the patient at, or are enabled to
watch her until,  the arrival  of the  exact moment
when the os  uteri is fully dilated, the membranes
entire, or but lately broken, strong forcing pains not
having  yet  commenced.    If   we  are  fortunate
enough to find the patient in such a state, we  should
lose no time in turning.
  The mode  of performing the operation is  as fol-
lows :—The woman is to be  placed in  the usual
obstetric  position,! and the operator sits  or  kneels

  * Vide p. 41.
  t The French position, upon the back, the nates resting on the
edge of the bed, the feet upon chairs,  supported by two assist-
ants, while the operator sits between the patient's legs, is far
             16 
1S2       DUBLIN PRACTICE OF MIDWIFERY.

(as the height of  the bed  may render either posture
more convenient) beside  her.   Either  arm may be
used:  if we can  ascertain' that  the  child's face is
directed toward  the mother's abdomen,  the right
hand will probably reach  the feet more easily ; if
the face look backward,  the  left will  then usually
be more convenient.   The choice of the arm, how-
ever, must chiefly depend upon the operator's own
fancy ; but whichever  is  to  be  employed, it must
be completely baredf  (the coat being taken off, and
shirt sleeve turned up), and well greased or soaped
in every part, except the  palm of the  hand, which
should be  kept as  dry as possible, that it may re-
tain a better power of grasping  the  child's limbs.
These preparations having been  made, the fingers,
collected into a conical form,  are  to  be slowly and
gradually introduced into  the vagina.   This stage
of the. operation, until the  broad  part of the hand
has  passed  the  os  externum, occasions  consider-


more'eonvenient.  The English prejudice in favor of the "usual
obstetric position" is a  mere prejudice.  In all  these cases the
physician should take care to protect his own dress, and also the
carpet, by covering his knees with a sheet, and having plenly of
old rags or the like,  about his  feet  to receive the discharges.
Besides the  absolute importance of these things,  attention to
them has a good effect—it looks cool—and shows lhat the man
knows what he is about, and knows it too, in detail.—Ed.
  • The direction of the child's face can be known by that of
the palm of the hand and thumb, where these can be felt.
  t We should not be satisfied  with merely turning  up the coat
sleeve, as we can never know beforehand, how fnr it may be ne-
cessary to pass up the arm.  The muscles also will be cramped
in their action by the tight girding of the turned  up sleeve. 
ARM PRESENTATION.
183
 able pain, and should be performed with great cau-
 tion.   When  the fingers reach  the  os uteri, they
 must be  passed  in  the  same  conical form  into it,
 being guided upon the child's arm, when it is down,
 or otherwise upon the shoulder, to the  front of its
 body, where we  may expect to  find  the feet.  In
 doing this, of course we rupture  the  membranes,
 should  they  still  be entire ;  and our  wrist  then
 plugging up the os tincse, and preventing the escape
 of the waters, we have, in the  latter,  a  most advan-
 tageous medium, wherein to  move about our hand,
 and seek for the feet.  In searchig for  these, as in
 every step of the operation,  we should  be cool, and
 in no hurry, acting  with our  hand systematically,
 and according to an  imaginary  picture of the child's
 position, upon which our mind should be intently
 fixed.   If a pain comes on, we must  cease, for  the
 time, from moving our hand,  and  lay it  flat upon the
 child's  body,  lest the projections  of  the knuckles
 should   injure  the uterus.  If our arm becomes
 cramped, we may stop and rest for a little; a few
 minutes' delay making no difference in  the success
 of the  operation.  When the  feet or knees have
 been laid hold of we should carefully ascertain that
 there is  no mistake,* and then withdraw them slow-
 ly, and  with  a wavy motion, out of  the uterus.
 The subsequent treatment is precisely similar to that
 of a footling ; some  persons  tie  a garter upon  the


  * The second arm might be  brought down in mistake for a
leg; or, in twin cases, a  leg of a second child.   A little cool-
ness will prevent either of these errors, 
184       DUPLIN PRACTICE OF MIDWIFERY.

foot or feet as soon as they are 1 might down :  but
this  is not of  any  importance, as  there  is little
danger  of their returning again.   Dr.  lireen  of
Dublin recommends the knees to be brought down
in place of the feet, and they are certainly, in gen-
eral, easier to be found.   Other practitioners think
it preferable only to bring down one foot, suppos-
ing the  case  to be  thereby more assimilated to a
breech presentation, and  the chances of the  child's
being born alive to be increased accordingly.
   [The young practitioner will consult  his own in-
terest by  obtaining  the  advice of an experienced
friend, in  his first cases of arm  presentations.   On
no consideration is he to omit informing the friends
of the patient that the child presents badly and that
its life is in great danger.  The  operation of turning
will be much facilitated by having an assistant seat-
ed upon  the  tbed  by the  side  of the  patient, who
should, while the operator is searching for the feet,
grasp with both hands the uterine  tumour, hold it
steady, and gently  press  it  downwards  into  the
pelvis.  When  the feet are found,  and the extrac-
tion  begun,  this downward pressure may  be  in-
creased.   In  bringing down the feet care  should be
taken to make the heels present forward so that, tho
body and  head following  may pass in  the most  fa-
vourable way.   This is a  case  in which the  opera-
tor has to fix  the presentation, let him see  to it  that
it is the best.  If the child is  brought down with
the heels  to  the sacrum, and, of course, with its
back to the back  of the  mother, the chin will  be
almost certain to hitch upon  the symphysis  pubis, 
ARM PRESENTATION.             185
and the delivery be attended  with immense diffi-
culty.]
  In another variety of the circumstances  of pre-
ternatural labour, we may have the membranes rup-
tured early without much dilatation of the os uteri.*
If there  be at the  same  time no violent  forcing
pains, we may wait a  little, in the expectation  of
dilatation increasing.  Should the uterine action be
severe, means must be  adopted for lessening it.   If
the woman be plethoric, we may bleed her ; should
this not be successful or advisable, a  very excellent
plan is,  to administer  a full  dose of  tincture  of
opium, say forty drops,  and repeat it in half an hour,
if the pains do not cease.   By either of these plans,
or by a combination of both, the contractions of the
uterus will probably be  lessened, and relaxation pro-
duced, sufficient to admit of the introduction of the
hand.  [The  cautious  use  of  tartarized  antimony
will sometimes materially and  safely  expedite the
process of relaxation.   A large emolient enema will
contribute to the  same end.  The  enema must not
be stimulating, least it rouse the uterus to increased
action.  A mild  enema (simple warm  water  is as
good  as anything) will  produce relaxation, while at
the same time it  empties  the  rectum, a  matter  of
  * When the membranes rupture early, the shoulder present-
ing, it is proper to keep the woman in the horizontal position all
the time, in this way the  draining off of the fluid will be pre-
vented, and when we come to turn we shall still find a consid-
erable quantity in the  uterus by the presence of which the ope-
ration will be much facilitated.—Ed.
               16* 
 1S6       DUBLIN PRACTICE OF MIDWIFE!! V.

great importance, and  one which  should  never be
neglected.   Attention should always be given to the
state of the bladder.  Neither turning, n<»r, indeed,
any  other  obstetric operation should e\er be un-
dertaken, without the practitioner  having  first satis-
fied himself that the bladder is empty.  If there id
 the least doubt, the  catheter  should be  introduc-
ed.]   It  is  needless to  say, that  double caution is
required in  turning, under these circumstances.
   [It every now and then happens when  the liquor
amnii is  discharged, that the shoulder does not  pass
up, when the feet, or one of them, are drawn down,
in such a case a fillet (a broad  ribbon  well oiled will
do) should be passed round the foot, and  held fast
with one hand, while with t *vo fingers of the other
hand  placed in the axilla of the child  like  a crutch,
we push  up  the shoulder.]
   In certain unfortunate  instances, we cannot by
our treatment stop the labour,  or the foetus has been
impacted into the pelvis before we see  the patient,
or the latter may be d< formed,  and any of these
conditions may prevent us from attempting to turn.
We have then only the  alternative of awaiting the
chance of spontaneous  evolution,  or  of delivering-
the child by perforation of its chest,  and  eviscera-
tion.  In depending upon the former, we  must be
guided by the strength  of the woman, and by the
indications   of the presentation, as to whether  the
process is likely to take place or not: if we find the
shoulder  passing out and  forwards upon the pubis,
and the side gradually descending  more and more,
we may expect its occurrence.  If it be not likely 
ARM PRESENTATION.             187
to take place naturally, evisceration  will facilitate
it, by admitting of a more easy  doubling of the
child's body.   Some practitioners  recommend  in
these cases separation of the head from the body,
so as to admit of the extraction of the latter before
the former; the other operation,  however, is cer-
tainly the safest, usually answers very well,  and is
most generally adopted in this  country.
   Turning  is seldom  required before  the eighth
month of pregnancy, and never warrantable before
the seventh: spontaneous evolution usually taking
place easily, owing to  the  small size  of the child.
I have seen a living child born in this way about
the sixth month of gestation.

  V Four cases of presentations  of the upper ex-
tremities  occurred  in   the  Wellesley  Institution,
during the years 1833 and  1834, being one in two
hundred and ten.   The child is very generally  lost. 
188
                   CHAPTER XIV.

   ANOMALOUS LAIlOl R.--FIRST ORDER.--HEMORRHAGE.

     In the class of anomalous labour  are arranged
   a number of cases very  dissimilar, and  which,  in
   fact, have no relation to  each other, excepting that
,   of  not  coming  within any of  the  three former
   classes.   We shall divide it into the following fivo
   orders:—
        1. With hemorrhage.
        2. ■----convulsions.
        3.----plurality of  children.
        4. ---- prolapsus of the funis.
        5. ---- rupture of the uterus or vagina.
     1. Hemorrhage from  the uterus, in connection
   with pregnancy, occurs under  various  circumstan-
   ces  : it may be considered as divided into four spe-
   cies :—
     a.  In early  pregnancy7,  usually attended  with
   abortion.
     b. In advanced pregnancy, from the sixth month
   until the birth of the child.
     c. Between the birth of the child and expulsion
   of the placenta.
     d. After the expulsion of the placenta.
     Before going into these  particular species, it will
   be  well  to have definitely arranged  in our minds 
ANOMALOUS LABOUR—ABORTION.        189
the objects which we are to endeavour to attain in
the treatment of every case of uterine hemorrhage.
In the first place, then, we  should have in view the
general principle  applicable to  every form of he-
morrhage, of tranquilizing and keeping tranquil the
excited circulation ; secondly, we must look to the
peculiar operation by which uterine bleeding is re-
strained,  viz. contraction of  the  muscular fibres,
and consequent compression of the bleeding vessels
that pass between them.  Upon these two  princi-
ples our whole treatment in every case is to be based.
  Abortion.—When the  uterus  discharges its con-
tents  before the end of the sixth month, we  say that
the woman aborts or  miscarries ;  if  the  expulsion
takes  place after this period, but before the regular
term,  it is denominated premature labour.   Miscar-
riage  is always accompanied with more or  less dis-
charge of blood, and, as the  latter  is usually the
most prominent and perilous  symptom, the   subject
naturally falls under the head of hemorrhage.  It is
a very common accident, and occurs frequently, in
all ranks of life.*
  The causes, of course, must be various: those
which predispose to  it, are  sometimes general  or
local  plethora, but much more frequently general
or local debility ;f an unhealthy state of the uterine

  * Among  the women attended from the Wellesley Institution,
at least one  in eight has previously miscarried.
  t Debility in  these  cases (whether general or local) must be
understood as affecting specifically the generative organs, as the
extreme weakness produced by lingering diseases (e. g. phthisis),
is not usually followed by abortion. 
190       DUBLIN PRACTICE OF MIDWIPERY.
 functions: disease  or death of the  ovum; and not
 uncommonly an obscure  syphillitic  taint in the con-
 stitution,  in some women a kind of habit of abor-
 tion, at a particular period of gestation, seems to be
 established, which  has  been  ingeniously  explained
 by Mad. Boivin, upon the supposition, that  in such
 cases the uterus  has (in consequence of a former
 inflammation) contracted adhesions with the neigh-
 bouring parts, which prevent its  enlarging  beyond
 a certain limit.   The exciting cause of miscarriage
 may be any thing, corporeal  or mental, which pro-
 duces a sudden shock or disturbance in the  system,
 as, external injuries, unusual exercise, displacement
 of the  uterus, violent passions, severe cough, drastic
 purgatives.
   [Mercury, especially if pushed to salivation, will
 very often produce abortion.  Dr.  Davis  says sali-
 vation is as  certain to  produce abortion as the use
 of instruments.   This is  stating the rule too strong-
 ly7.  Cases have occurred where  no such  effect has
 followed, even profuse salivation,  but they are very
 rare.  The use of  opium in large or long continued
 doses,  is very apt to destroy foetal life, and produce
 abortion, this  is  not as  strongly  insisted  on by
 writers as it ought  to be ; from facts within my own
 knowledge, I have  no doubt that opium has such  a
 power, and, of course, should be used during preg-
 nancy with great caution.   Salivation should never
 be  resorted to with a pregnant woman, unless she
 have syphilis, under  no  other circumstances is it
justifiable.]
  When a woman  is  about to abort, she generally 
           ANOMALOUS LABOUR--ABORTION.       191

 feels, for some  time previously, a sense of weight
 and weakness in the loins and region of the uterus,
 followed by stitches of pain, shooting through the
 lower part of the abdomen, back, and thighs; occa-
 sionally, there  is frequent  micturition and  tenes-
 mus.*   Accompanying these symptoms, or immedi-
 ately following them, there is  always more  or less
 discharge of blood  from  the  vagina.  This  blood
 coagulates (thus differing from the  menstrual secre-
 tion), and is often discharged suddenly, and in quanti-
 ties so great, as to reduce the woman to a state of ex-
 treme debility.   When it occurs to any extent, we
 can  seldom hope to prevent  abortion; in fact,  it
 cannot be of any considerable amount without an
 extensive  separation of the  ovum  from the uterus,
 and consequent death of the former.  Our progno-
 sis, therefore, generally7, should be  unfavourable, as
 to the chances of preventing a threatened abortion,
 although by judicious management we may some-
 times succeed in doing so.
  In some instances the  ovum is  discharged with
 very little pain, and in  a short  period ; in others,
 the process  occupies some days, hemorrhage con-
 tinuing more or less during the whole time, and not
 ceasing  entirely until  the  ovum  has  been com-
 pletely expelled.   This latter fact makes us anxious
 to ascertain  when  complete  expulsion has been
effected, for which purpose we should  have all the
clots preserved and carefully  examined.  If  we

  * Dr. Ramsbotham thinks sudden disappearance of the morn-
ing sickness a very certain forerunner of abortion, 
192       DUBLIN PRACTICE OF MIDWIFERY.
open them w ith a little  attention under water,  the
ovum will be recognized as a semitransparent mem-
branous bag, containing the lotus floating in a clear
fluid/   Parts of the ovum, as  the deeidua or em-
bryo, will occasionally be expelled separately ; and
some mistake as to  the former may arise from  the
resemblance frequently  borne to it by a portion of
the fibrine of coagulated  blood.   When  the abor-
tion occurs at a very early period  of gestation,  the
ovum is so small that our best  directed attempts to
discover it will often be in vain.
   The  treatment  of abortions must be of  three
kinds.
   1st. Treatment for the prevention of a  threatened
miscarriage.—In certain cases, the  premonitory
symptoms already7 enumerated exist sufficiently long
and remarkably to  admit of our interfering in time
to prevent actual abortion.   In other instances, the
hemorrhage and  discharge  of  the ovum are almost
simultaneous with the  lumbar  pains, A-e.   In  the
former ease, our preventive  remedies  must  depend
a good deal  upon  the  condition of  the individual,
and also  upon the nature  of any  constitutional
symptoms  which  may  exist.   There is generally
some degree of febrile excitement,  and if it  run
high, with a quick bounding pulse, and severe pain,
and the woman be  plethoric and  young, blood-let-
ting is required, and will occasionally be of remark-

  • In very young ova the embryo  is so  gelatinous that it
readily dissolves in the  liquor amnii,  and consequently cannot
be seen. 
          ANOMALOUS LABOUR.—ABORTION.       193

able service.*  The quantity  to be  drawn  must
entirely depend upon circumstances, and should be
enough  to produce a  change in the  symptoms.
Generally accompanying a plethoric state, we. have
evidence of gastric derangement, viz. constipation,
nausea, foul tongue ; sometimes there are headache
and rigors.  These symptoms  indicate a necessity
for purgatives, which   should  be of a  saline and
cooling description.!
  In many forms of  threatened abortion, where
there are no symptoms  of general plethora, but the
patient  suffers considerably from pains,  we  shall
find great advantage from the employment of opium,
when the  bowels are free, or have been  opened by
an aperient.  A full dose, in draught or pill, may be
given at once, or five or six drops of laudanum may
be prescribed every hour, in an  ounce of infusion
of roses ;  or, what is perhaps better, a small opiate
enema may be administered.  In general, I think,
we shall find blood-letting less  frequently called for
than the latter plan. Under any circumstances, we
must remember  the principle  of tranquilizing the
circulation, and accordingly should enjoin perfect
rest in a horizontal posture ; a rigid avoidance of
every thing stimulating; a cool room ; cool drinks ;
and light bed-clothes.  In addition to these means,

  * It is only under  the circumstances  above mentioned that
blood-letting is admissible.  I believe  it  to be, in general, mueh
too freely employed in abortions.
  t A large enema of cold water often answers a valuable pur-
pose,  evacuating the bowels, and acting as a local refrigerant
and sedative to uterine action.—Ed.
             17 
19i       DUBLIN PRACTICE OF MIDWIFERY.

when there is any bleeding, we shall find advantage
from the application to the vulva of clothes wrung
out of  cold  water  or vinegar and water.   The
measures  just recommended,  should be  diligently
used while there is a chance afforded of preventing
the accident.
   [To decide whether there is any reasonable pro-
bability of preventing abortion in any given case,
or whether it is  absolutely unavoidable, is very im-
portant,  and in many eases  very  difficult.   The
following rules will be useful  to the young practi-
tioner :—
   If abortion is about to take  place, the  pains will
return at pretty regular, and gradually diminishing
intervals, and will increase in  severity7, and have a
decided  bearing-down character.   On  examination
per vaginam, which should  never be neglected  or
put off, as is too often done, wc shall find  the cervix
softened, the os  dilated,  the membranes  protruded
during  a pain;  this  protrusion of the  membranes
during a pain, is the best and a nearly unfailing diag-
nostic.  If the true waters are discharged abortion is
absolutely inevitable, but we must remember that a
free discharge of scrum  may  take place  from the
vagina, and yet the  amnion  be entire,  the water
being collected  between the chorion  and  amnion,
(false waters) or secreted by the glands  about the
cervix, which ordinarily  elaborate mucus.  If the
symptoms of threatening abortion have  been pre-
ceded  by those  which  indicate  the death of the
fcetus, the chance of arresting them  is,  of course,
diminished.   So, if they are  obviously  referable to 
           ANOMALOUS LABOUR.—ABORTION.        195

 some predisposing cause, especially  the habit  of
 aborting.   If,  on the  other hand, the  symptoms
 have arisen suddenly7, inconsequence of some injury
 or accident, and the woman has never before abort-
 ed, we must  not despair of saving the  embiyo—
 even though the pains be regular, and produce dila-
 tation of the  os, and  protrusion of the  membranes.
 Burns asserts that with  these  symptoms abortion- is
 certain, but the experience of Desormeaux and La
 Chapelle prove  that he is mistaken,]
   Second  Line  of Treatment, for the purpose  of
 bringing the  patient with safety through the  risks
 of abortion.   The same  general rules as to quietude,
 horizontal  position,  cooling  aperients, &c.,  apply
 when we wish  abortion to take place, as when we
 desire to  prevent it.  By some  persons, ergot  of
 rye is employed under these  circumstances ;  but I
 cannot  say 1 have ever observed  any benefit  to re-
 sult from its use.
   In  many cases, the plan above recommended, if
 strictly persevered in, will be attended  with happy
 results,  and nothing more will  be  required; but
 should there be  violent hemorrhage, and the assidu-
 ous application of cold cloths to the vulva and pubes*
 not be sufficient to check it,  plugging  must be re-

  * I must here interpose a caution with respect to the inordi-
nate use of cold;  where ^the woman is hot, and the circulation
excited, it is an invaluable remedy, but its employment may
be easily carried too far (especially in a weak person), and dan-
gerous eollapse produced by it.  The approach of this should al-
ways be attended to, when the cold amplications must be removed,
and heat applied to  the feet- 
196        DUPLIN PRACTICE OF MIDWIFERY.

sorted to.   This is an excellent remedy, especially in
early abortions, when the uterus is not large enough
to admit  of internal  hemorrhage.   It may be done
with  lint  or a silk  handkerchief, or (what, by en-
tangling the blood, and  promoting  its coagulation,
acts  better  than either) tow. or French wadding.
Any  one of these materials  is to  be sal mated with
vinegar or cold water, and then  passed gently into
the vagina, so  as to fill without  stretching it.   A
compress, wrung out of cold water, applied to the
vulva outside, will keep  the plug in its place, and in
all probability the bleeding will be  completely sup-
pressed for the time.  The plug should never be left
in the vagina longer than twelve hours, as the coag-
ula are likely to become putrid.   Sometimes it will
excite uterine action long before that period, and be
expelled, together with the ovum.   When  we  have
occasion to remove the  plug, if  the flooding contin-
ues, a fresh one  may be introduced.   In its use at-
tention must be  paid, lest  it  should press  upon or
interrupt the passage of  the urethra.*


  • Our method of using the plug is  different from lhat ad-
vised  in the text.  We use soft rags and saturate them with oil
instead of vinegar or water;  then, as to the manner of applying
them, we introduce the rags bit by bit, pushing the first up to the
os uteri, the next mass is to be crowded firmly upon this, and  so
on, till the vagina is full, till it  is literally plugged up. This
will usually excite some irritation, and very commonly provoke
uterine pain, which  is one of its advantages. Then, as to the
time during which it should be allowed to remain, if it cause no
irritation  or pain, we think twelve hours too short, it may be
kept, in silu, for double that lime, without the slightest danger,
from the putrefaction of the clots.  Iu fact if the plug be used, 
           ANOMALOUS LABOUR.—ABORTION.        197

   Frequently the embryo comes  away, leaving the
 shell,  or merely the placenta, in  the  womb;  and
 some  of the  severest hemorrhages I have seen  in
 abortions have been occasioned  by a  substance  of
 this kind preventing contraction,  and keeping the
 vessels open.   In such  a case  ergot may be tried,
 but  I  confess  I have  little  expectation of benefit
 from it. •  It is a standing rule never to attempt in-
 troduction of the hand into  the  uterus before the
 expiration of the sixth month of gestation, but oc-
 casionally, by passing up a finger or two, we  shall
 detect the  offending substance  sticking  in the os
 tincae, and be able to hook it away, when most likely
 the bleeding will instantly cease.
   [The placenta  hook of Dewees, which consists of
 a bit of stout wire,  bent at one  end, so as  to form
 a small hook, will often enable  us  to  bring away
 the placenta, or membranes, without the danger and
 difficulty which attend the  crowding  of even  one

 as above advised, there will be very little blood exposed to the
 air, almost all that flows will  be  confined to the  cavity of the
 uterus.—Ed.
  * The distrusfhere expressed of ergot is  not shared by Ameri-
 can obstetricians, to whom the use of the drug is more familiar,
and its  powers better known.  In all cases of  retention of the
placenta or membranes after abortion, ergot should be given and
that before many eflbrts at extraction are  made, either with the
ringers or the placenta-hook.  If used promptly, it will not often
disappoint the expectations of the practitioner.  One  great rea-
son why ergot fails in these cases is, that  it is not given till the
system is so broken down by the loss of blood, that the vital pow-
ers do not respond to any  stimulus, medicine cannot act; if, how-
ever, the article be given  promptly, and*be of good quality, it will
not often fail.—Ed.
                  17* 
198       DUBLIN PRACTICE OF MIDWIFF.R
or two fingers into the uterus.   This  instrument
should, however,  be used  very carefully, and  the
point should not be sharp.]
  In some instances, although there may be no  loss
of blood, there is the most distressing sickness  and
nausea  occasioned  by  the  distension  of the  os
uteri in this way, which  will be completely  and
instantaneously relieved by the manoeuvre just re-
ferrcd to.
   When the  abortion  is rather at an advanced
period of pregnancy, the placenta is  often retained
for some days, in spite of all we  can do to ellect its
removal.  It then  occasionally becomes the  cause
of putrid, fetid discharges, and 1  have  known it to
produce low  uterine  fever  and  death.  Wc shall
sometimes succeed  in bringing  away the placenta
when it is  retained  in this way,  by the  administra-
tion  of a  brisk  purgative or enema:  if  the  dis-
charges become  putrid,  injections into the vagina of
tepid water or  infusion of  chamomile* must be
frequently practised,  and cleanliness very. rigidly
enforced.      -^Z
   The quantity of blood which women bear  to lose
 in miscarriages  is very remarkable.  They  rarely
 die  from this cause, at all  (vents' before the end of
 the  fifth month, although the prostration of strength
 is. sometimes extreme.
   Third Line of Treatment.—Practitioners arc often
 consulted  as  to  the means  of  preventing  future

   ■<• Or, perhaps, injections  containing chloride <A lime might ba
found useful. 
ANOMALOUS LABOUR.—ABORTIOxV.       199
 abortions in those who have already repeatedly un-
 dergone them.   The  plan of treatment must,  of
 course, vary very much in different cases.   If pos-
 sible, we should ascertain the cause or causes which
 operated upon former occasions,  and remove them
 by suitable means.   The  great object  is, to bring
 the patient into a good state  of health—in the ple-
 thoric this must be  done  by  evacuations, exercise,
 low diet,  &c.—in the debilitated,  by tonics,  cold
 bathing or sponging, nutritious diet, good air, avoid-
 ance  of all  emotions, &c.   In some  individuals
 there is a disposition to abort at a particular  period
 of gestation ; and this may occasionally be  passed
 over with safety, by keeping them for a short time
 before and after in the horizontal posture, with per-
 fect rest.  This  plan, however, must be adopted
 with  caution, as the  injury to the general  health
 from  confinement would  in many cases be more
 prejudicial than allowing the patient to abort.
  A very common cause of repeated  abortions is a
 syphilitic  taint in either  parent.   If  this  be ascer-
 tained, the treatment is  obvious, but  frequently its
 existence  is very obscure.   We  very commonly
 meet with such a case as  the  following:—A  man
 and woman, apparently  both  healthy,  will  marry,
 and the woman will abort, or prematurely produce
 dead children several times ;  every variety of pre-
 ventive treatment is  probably tried,  until at last a
living child is born, which shortly after  birth shows
unequivocal signs of being syphilitic,  and the  case
is thus cleared up : all  this time,  probably, the wo-
man has never had a single venereal  symptom, and 
 200       DUBLIN PRACTICE OF MIDWIFKRY.

 the man not for years  before his marriage.   In
 some instances, there will be  a succession of abor-
 tions,  dead  children,  and  syphilitic living  oiks.
 The remedy, under  such circumstances, must be n
 steady,  slow mercurial  course, adopted.  1   am of
 opinion, with both parents—certainly with  the one
 known to have had the disease."
   In managing a case of this peculiar  description,
 it is needless to  say that the medical man has occa-
 sion for all his prudence in order to avoid being the
 promoter  of family  quarrels :  the  ascertaining of
 the history of the matter is particularly  difficult and
 delicate, and should be set about with the greatest
 caution.
   b.  Hemorrhage occurring from  the  end  of the
 sixth month  until the time of birth.  This  species is
 always occasioned by a  separation of a portion of
 the placenta  from  the  uterine  surface, and  conse-
 quently varies in quantity, according to the  extent
 of the disunion.  It has  two varieties.
   1st. Accidental Hemorrhage, when a  casual rup-
 ture of the connecting vessels takes place, the pla-
 centa being  in its natural situation, attached to the
 fundus  or  sides of the uterus.   This form may be
 occasioned by blows, falls, over-exertion,  evict but
 sometimes occurs without any reason being evident.
 The whole or a part of the placenta may be sepa-

  • In the present state of medical opinion, a man would scarce
be justified in mercurializing the parent known not to have had
the disease. — Ed.
  t  Dr. Ramsbotham believes that it is rarely attributable to any
apparent cause. 
ACCIDENTAL HEMORRHAGE.
201
 rated, and in some rare instances, the centre of the
 organ has been detached, and blood poured  out be-
 tween it and the  womb to a fatal extent, while, the
 circumference remaining in connection, no discharge
 or a  very slight  one has  been permitted to escape
 out  of the uterus.  Accidental hemorrhage may
 occur at any  period of advanced  pregnancy; if
 there be pains, the discharge will be diminished, not
 increased, during uterine  action, owing to the com-
 pression that is then exerted by  the fibres upon the
 bleeding vessels.
   As we are never sure that there may not  be in-
 ternal bleeding, our estimate of the  danger to the
 patient must  be entirely drawn  from  the  effect
 produced upon  her  system.   At this  period  of
 pregnancy,  the vessels are  so  very large,  that  a
 comparatively small actual loss  of blood will, from
 the  suddenness  of its  discharge, produce  more
 effect  than  a  much greater loss during the early
 months.
   If the hemorrhage be  slight, our treatment may
 in the first instance be  confined  to those means,
 already  specified,* which  have  for their  object
 tranquilization of the circulation.   Should they not
 succeed,  or the flooding be at first  considerable, an
 examination must be made, to  ascertain the  state
 of the os uteri  and the  presentation.  It is not ad-
 visable to be too  forward in examining, unless the

  * Cold, horizontal posture, saline aperients, mineral acids, &c.
vide p. 70.  Blood-letting, I believe, is seldom  or never proper at
this period of pregnancy. 
202       DUBLIN PRACTICE OF MIDWIFERY.

hemorrhage be of consequence, and actually going
on, as otherwise we may only reproduce  it by dis-
turbing the coagula, and the  information  required
is often extremely ditficult to be obtained by  the
finger during the seventh and eighth months, when
the uterus has not yet descended into the pelvis.
Should  the hemorrhage still continue, the further
treatment must be conducted  upon the principle of
promoting contraction  of  the  uterine  fibres  and
consequent constriction of the bleeding vessels.   If
we ascertain that the head or breech presents, it
will generally suffice for this purpose to rupture  the
membranes w iih  the finger nail or a probe, and allow
of the escape  of the  waters.   Pains will in  most
cases succeed this step, and effectually suppress  the
flooding:  if they do not,  or arc weak,  a dose or
two of ergol and friction on  the  abdomen may be
very useful in exciting or strengthening them.
  In former  times, the practice in accidental  he-
morrhage was, universally, to turn and  deliver  the
child by the feet.  Putting the hand into the uterus
is, however, always to be   avoided, if possible, and
is not required, unless the  uterus  be absolutely in-
active after the  rupture of the membrans (a very-
rare case) ; or the presentation be a transverse one,
which, on its own account, would justify the oper-
ation.
  When labour proceeds,  we must leave the case to
nature, only paying double attention to the securing
of  a  perfect  contraction  of the  uterus  after the
child  is  born.   Some  gentlemen recommend the
binder to be  put on  before delivery, but I prefer 
UNAVOIDABLE HEMORRHAGE.
203
trusting the  pressure  to my  own  hand, which
would  be only impeded in its access  to  the ab-
domen by the employment of the binder  at  this
period.
  The  Second Variety,  or unavoidable Hemorrhage,
is so called from the circumstance of the placenta
being unnaturally situated over the os uteri, where-
by a laceration of its vessels and consequent bleed-
ing is unavoidable whenever  this opening comes to
be dilated.  The centre  of the organ or a portion
of its circumference may be attached to the os tincae.
In  this form, the  bleeding generally first occurs
during the sixth or seventh months,  at  the period
when the cervix is beginning to be developed  ; and
may recur at intervals,  yielding, from time to  time,
to  the adoption  of general measures.   When la-
bour arrives, however  (and often long before), a se-
vere and dangerous flooding must take place, calling
for the promptest assistance from art.
   The unavoidable hemorrhage is to be distinguish-
ed from  the accidental by  the discharge being
 increased in it during a pain, in consequence of the
 dilatation of the os uteri rupturing additional ves-
 sels, while, on the contrary, in the other, it is  at the
 same period diminished, owing to the pressure then
 exerted upon the already open vessels.   We should
 always,  however,  satisfy ourselves  by vaginal ex-
 amination that the placenta actually presents.   It is
 to be known by its peculiar feel, and I know of no
 better way of instructing  a student in  this than to
 direct him to give himself the  custom of handling
 every placenta which  may come within his  reach. 
 204       DUBLIN PRACTICE OF MIDWIFERY.

 I5y doing  so he will in a short time  acquire a tact
 which it would be hopeless to attempt cons eying by
 words.
   The  principle  of treatment  in a  complete pla-
 cental  presentation decidedly  is, to  cflect a total
 separation of the  organ, by delivering the  woman
 as soon as  practicable.  Whenever,  therefore,  we
 ascertain a case to be of this nature,  we must care-
 fully watch  it, and seize  upon the proper time for
 artificial interference ; that is, when the os uteri is
 so far dilated or dilatable as to allow  of our pasMng
 up our hand, turning  the  child,  and delivering by
 the feet.   If the hemorrhage has commenced long
 before the period  of labour, we shall  probably have
 to wait some time before  this  state is arrived at—
 and  a  most  anxious  and  harrass'mg waiting it is.
 The patient must be closely watched, the ordinary
 hemorrhagic remedies employed,  and, if these do
 not  succeed,  plugging adopted.   I  think  I  have
 seen the latter  measure  do excellent  service, re-
 straining the flooding most effectually, and also  ex-
 citing the os uteri to a  speedy  dilatation.   The ob-
 jection to it is, that there may  possibly be  internal
'hemorrhage during  its use,  but, if the vagina be
 well filled, this does not  appear very likely to take
 place,  as  the  placenta  itself,  when covering  the
 whole os uteri, forms  an excellent plug upon that
 side.   At all events, when the plug is employed, the
 closest attention must be paid to  any effects that the
 bleeding may produce upon the constitution, where-
 by we shall obtain  timely notice of any  internal
 loss.  If the woman retains her  strength, we may 
            UNAVOIDABLE HEMORRHAGE.         205

wait until some  dilatation takes  place, but should
she be weak, it is our duty to attempt the operation
before she sinks, as soon as  we  consider the  parts
to be sufficiently7 relaxed, even though they  may not
be dilated.  When there  has  been much bleeding,
the probability is that the parts  will not afford  a
firm resistance, and the case  is always one requiring
prompt aid.
  In  performing the  operation, we introduce the
hand, as slowly as we  please,  in the  manner and
with  the  precautions  already  laid down,* until  it
reaches the os uteri ;  it must then either be passed
through the  placenta, or by the side of it, into the
cavity.  During this step,  the  operator has  need of
all his coolness and resolution.   There is usually a
frightful increase of hemorrhage,  the blood  gushing
in torrents  along  his  arm ;  if, panic-stricken, he
withdraws for a moment,  the woman is inevitably
lost;  but by pushing on boldly and steadily, he soon
brings his wrist and arm, as  an effectual  plug, into
the mouth of the womb, and  the  discharge imme-
diately ceases.  There is then  time for considera-
tion, and  the feet  must be  deliberately sought for
and brought down in the usual way into the vagina.
There will seldom  be any more  hemorrhage, and
the rest of the delivery is  to be accomplished as in
a footling case.  The placenta  will generally be
found loose in the vagina: I have  sometimes found
it to come along with  my hand and the child's feet
out of the vulva.   Great attention is necessary to
      • Vide p. 181.
18 
206       DUBLIN PRACTICE OF MIDWIFERY.

secure subsequent contraction of the uterus, and  if
the woman require it she should be  supported with
stimulants* during the operation.
  Where there is merely an edge of tin' placenta
attached over the os uteri,  it will often not be ne-
cessary to turn.  If we  can ascertain that the head
presents above it, rupturing the  membranes may
bring  the former, down so as  to  press upon the
bleeding vessels, and there may be no further danger.
It is often difficult to  decide which step should be
taken ; it is certainly very desirable to avoid intro-
duction of the hand into the uterus, but where any
doubt as to the practice  exists, it  appears to me to
be preferable to  turn.  In some case I  have known
the placenta to be expelled completely out of the
vagina before the child, which, being driven  by
strong pains into the os  uteri, effectually restrained
the bleeding.  In one case I saw a placenta com-
pletely separated and driven out of the uterus into
the vagina, at the posterior part of which it remain-
ed until the child was expelled past it.  Such cases
as these, however, are mere excepiions, and afford
no data for the establishment of any line of practice.

   *,* The average of placenta presentations in the
Wellesley Institution, during the years 1832 and
1833, was one in 167.  The child is very frequent-
ly  lost,  and  very great care  is required  by the
mother, especially when she has lost  much  blood.
•  One of the very best of these ia burnt brandy. 
         ANOMALOUS LABOUR.--HEMORRHAGE.     207

 Dr. Merriman thinks  that  phlegmasia dolens is a
 common sequela.

   c. Hemorrhage occurring between the birth of the
 child  and expulsion of the placenta.—The  surest
 means of preventing this accident will  be, to follow
 rigidly  the  directions  given in the chapter  upon
 natural labour for  the management of the  latter
 stages of the process.  The great secret is, to pro-
 mote  and keep up permanently a full contraction of
 the uterus:  if we can succeed in  doing this, we
 shall seldom have to treat either hemorrhage or re-
 tained placenta.
   The manner in which this form occurs is various.
 In some women, in whom will generally be  found
 an excited state of the  circulation towards the close
 of labour, flooding sets in  immediately after the
 birth  of the  child, and  by one immense gush quick-
 ly produces  syncope.  In  others, a slow draining
 continues from the same period, until a similar effect,
 or alarming prostration of strength, ensues.  Again,
 in a third case, the uterus contracts very well, and
 continues contracted for some time, when it relaxes,
 and flooding takes place with more or less violence.
  In all these cases, the two principles  already laid
 down must guide our  conduct; friction and  pres-
 sure must be  made  over  the  uterus,  to excite  its
 contraction, and the circulation must be quieted by
 throwing olf  the  bed-clothes (excepting a  light
sheet), removing the pillow from the woman's head,
so as to lay her  perfectly horizontal,  and opening
the window, to admit fresh  air and cool the apart- 
208       DUBLIN PRACTICE OF MIDWIPF.RY.
ment.   Cold cloths may be applied to the vulva and
pubes, with a view of answering  both intentions,
cold quieting the circulation, and  being a powerful
stimulant to the  uterine fibres.   When sent  for to a
case of hemorrhage. I have often succeeded in pro-
curing  immediate  uterine contraction, by placing
my hand (cold from having been  in  the open air)
upon the abdomen, which  the attendant, (heated by
his anxiety) has been in vain pressing upon it with
all his  force.   Where simple application  of cold
docs not succeed, accompanying it  bv a shock, as
by7 pouring a jug of water  from some height upon
the lower part of the  abdomen, will often  be very
beneficial.   Introduction of  ice  into the vagina has
been recommended by some ; but where  arc  we to
get ice  quickly  enough  to  be of  use  in a  case  of
violent flooding?"   Should  these  plans not  succeed
in checking the  discharge, we must, as a dernier rrs-
sort, introduce  our hand into the uterus, both for
the purpose  of  stimulating  it to  action, and  to re-
move  the  placenta, which,  being  partially or en-
tirely detached, may prevent contraction, and  keep
the vessels open.  The further management of this
variety  of hemorrhage we shall  consider in  the
course of our remarks upon retention of  the pla-
centa, which, from the close connection of the two
subjects, may be introduced  here.
   Retention of the Placenta  may be  occasioned by
three causes:—1. Want of  contraction in  the utc-

  * As has been before observed, we must beware  of going too
far with cold. 
           RETENTION OF THE PLACENTA.        209

rus ;  2.  Irregular  action of the  fibres, producing
hour-glass contraction ; and, 3.  Morbid adhesion of
the organ to the uterus.
  If the labour be  conducted  in the  way recom-
mended in the foregoing pages, the first two causes
will very seldom exist.   The  first very  generally
arises from interference  in  hastening  the birth of
the child's body, whereby the stimulus is withdrawn
too soon from the uterus, and it is left empty and
without any thing  to  excite  its contraction.  The
same effect often follows, when the womb  itself ex-
pels its contents  too rapidly.   On the other hand,
when a labour has been very tedious, the uterine
fibres are fatigued, and require rest  for some time
before they again act.  Irregular contraction is gen-
erally occasioned by injudicious attempts at extrac-
tion by the funis, which, without producing the de-
sired  effect, irritate the  fibres of the cervix,  and
excite them to contract  spasmodically7, thus impris-
oning the placenta.  This condition is termed hour-
glass contraction, on account of the chambers above
and below formed  by the uterus and vagina,  and
connected by the contracted cervix.   Morbid adhe-
sion is an occurrence over the production  of which
we have no control.
  Under ordinary  circumstances, we  need  not be
uneasy about  a delay of an hour  or two, in the
separation of the  after-birth.  But  if hemorrhage
should occur, or the retention continue longer than
we deem  safe,*  not yielding to  the  friction,  &c.

  * It is not easy to specify a precise amount of time, the  lapse
              18* 
210       DUBLIN PRACTICE OF MIDWIFERY.

already recommended,  we  must  proceed to intro-
duce the hand.  Before  resorting to this measure,
we may try the ergot, which sometimes succeeds.
The introduction  of the hand  is to be  conducted
in the  ordinary way,"  moderate  pressure  being
made upon the abdomen by an  assistant, while we
are doing  it,  and  the funis  put  upon  the  stretch
by7 one hand, so  as  to  serve as a  guide  for the
other.
   In any instances we shall find the placenta partly
expelled from the  uterus, but with a portion of its
edge  caught and  firmly grasped by the os  uteri:
sometimes it lies within  the cavity, quite separated.
In either case it is  likely that  the  mere irritation
excited by the hand, w ill cause both itself  and the
placenta to be forcibly expelled.  If the uterus  be
quite  inactive,  and flooding  exists,  we must not
withdraw our hand until some action has been ex-
cited ;  occasionally, it will be necessary to  promote
this, by moving about in the cavity, or even rub-
bing with the other hand, or employing an  assistant
to rub, strongly upon the abdomen.  When  there
is morbid adhesion, the  fingers  must be  spread out
from the funis,  towards the  edge of the placenta,
and insinuated between it and  the  uterus, so  as to
separate the  one  from  the  other;  every caution
must be used  to ensure the complete removal of the
mass.   When there  is hour-glass  contraction, the


of which warrants manual extraction.  I should be di<-pr>v t lo
say that two hours after the birth of the child would be quite
long enough to wait.                     '  Vide p. lsl 
           RETENTION OF THE PLACENTA.        211

spasm must be overcome, by introducing cautiously
finger after finger into the constricted part, until the
whole has been dilated so far as to allow of the re-
moval of the placenta.   The length  of time which
this requires is often very great, and no one whose
hand has not painfully experienced  the  power of
the uterine fibres, could believe that  so much resist-
ance would be opposed.  The  average occurrence
of retention is very small, if the latter part  of the
delivery  of the  child be  conducted properly, and
without any unnecessary interference.

  d. Hemorrhage  occurring after expulsion of the
placenta.—In some instances this is  occasioned by
the after-birth  being removed too  hastily,  before
the uterus is  inclined to contract.   In others, the
uterus relaxes, probably after  it has naturally and
very quickly expelled the placenta.  This  form of
flooding will be very generally prevented by avoid-
ing the first mentioned cause;  by preventing subse-
quent relaxation by friction, the use  of the  binder,
tfcc.; and by keeping the  circulation quiet, after
every labour, by the most strict enforcement of rest
in the horizontal posture.
  When it does unfortunately occur, notwithstand-
ing our precautions, the principle  upon which it is
to be restrained, is still  the promoting of uterine
contraction, which is  to  be  effected by friction,
pressure, cold, ergot of rye,  &c.:  or, if these do
not succeed, introduction  of  the hand.   Coagula
may have collected in the  uterus, keeping  it open,
and upon  their removal by the  hand, contraction 
212       DUBLIN PRACTICE OF MIDWIFERY.

may permanently ensue."   This should be kept up
by a very tight application of the binder, with a
compress between it and the lower part of the ab-
domen.
  In some cases, especially where  the binder  has
not been well applied, hemorrhage may go on into
the cavity of the womb, without a drop  appearing
externally.    Under  such  circumstances,  nothing
may,be known about the  matter until the  woman's
lips are observed to be getting pale, her pulse weak
and rapid,  and she becomes  restless, tossing  her
arms about, and complaining of want of light and
air.   The practitioner may  have left her, and things
have gone to this length before he  can be recalled,
AVhen he lays his hand upon the abdomen, he will
probably find sufficient cause  for the symptoms, in
the size which it has attained from the accumulation
of blood in  the uterus.  Pressure  may succeed  in
stimulating the uterus to  contraction  and expulsion
of the coagula ; but if it docs not do so immediate-
ly, we have no time to lose, and must instantly pass
up the hand and excite action.  When such  dan-
gerous prostration of strength as that described has
taken  place, it will  be  necessary to  support  the
woman's strength by stimulants.  Burnt  brandy or
whisky  I  have found to  be the best that I have

  *  The introduction of  the hand for any such purpose as exci-
ting contraction, or removing clotn, is condemned by many of the
best authorities; it will always do  some harm,  and very ran-ly,
a- I think, do any good.   If done at all it should only be in the
last extremi!<r.  The dashing of cold water on the uterine region
is a more tl^cient, and infinitely a safer remedy.—Ed. 
INVERSION OF THE UTERUS.
213
tried.  A tea-spoonful of it, with from five to ten
drops of laudanum, may be given every quarter or
half hour, until the patient  rallies.   Of course  the
strictest  rest must be enjoined, dangerous syncope
and even death having  been  known to follow  the
mere raising of the  head under such  circumstan-
ces.*
  In  the treatment  of  all  forms of hemorrhage,
large doses of opium  have been  very much recom-
mended.  Excepting  in small quantities, as a stimu-
lant, when collapse was to be dreaded, I have  not
been in the habit of  using it.  It may no  doubt be
useful in spasmodic contraction,  but  I apprehend it
is rather too much to expect from any  drug that it
will obey our pleasure, in relaxing the uterus when
we wish to turn a child,  and in causing  it to con-
tract when we desire the expulsion of the placenta.
  Inversion of  the   Uterus.—This  subject, being
somewhat connected  with that of hemorrhage, may
be considered  under the same head.  It  is  an  ac-
cident  that  occasionally occurs  spontaneously, in
consequence of extraordinary action of the uterus,
hut more generally is caused  by rude  attempts at
extraction of the placenta.   In a recent state it  can
scarcely be mistaken  for any thing else, except per-
haps a polypus ;  from which a careful examination
will distinguish it by its greater sensibility, its com-


   The extent of debility from which a woman may recover
is very remarkable : I have known a patient,  who ultimately did
well, to continue in a succession of fainting fits for twenty-four
hours, 
214       Dim.IN PRACTICE OF MIDWIFERY.

parative immobility, its want of a pedicle,  and the
manner in which the finger is prevented by its  re-
flection from passing upwards  by its side.  It will
also probably  have  the placenta attached to it, and
be bleeding profusely.   In a chronic state it may be
confounded with a  prolapsus of the uterus,  but can
be diagnosed from  it by its want of an os tinea1.
  The obvious treatment in inversion of the uterus
is to replace the organ immediately, as  re-inversion
becomes soon impracticable.  The mode of doing
it is to bare and grease the arm, and then place the
clenched hand against the fundus,  and  carry it  up-
ward until the organ is  completely replaced.   The
hand should not  be withdrawn until  the  uterus is
well  contracted.   Some  persons recommend  the
uterus to  be  returned without removing  the  pla-
centa, lest there should be  sudden and dangerous
hemorrhage  before that object  could  be  accom-
plished.   Dr. Merriman relates a  case  in which ho
was unable to replace the part  until he remuved the
placenta, after which he succeeded perfectly.  Hav-
ing never seen a  case  of recent  inversion,  I can
give no opinion as  to the relative merits of  the two
courses.  The consideration of  chronic inversion
of  the uterus does not come within  our  present
limits. 
215
                 CHAPTER XV.

  ANOMALOUS LABOUR.--SECOND ORDER.--CONVUL-
                       SIONS.

  Tins is one of the most dangerous, although  for-
tunately not a very common  complication  of par-
turition.   Convulsions may  occur,  either  before
labour commences ;  during its progress ;  or after it
has been perfectly completed.  The attack is some-
times preceded  by premonitory symptoms, indica-
ting congestion within  the cranium, as  headach,
vertigo, stupor,  flushed  face, numbness of  head,
arm, &c.; at other times there  is nothing whatso-
ever to give notice of its approach.*   They occur
equally in first and in subsequent labours, and are,
according to my observations,  particularly danger-
ous and fatal in the latter, f

  • I recollect once seeing a fatal case of convulsions, in which
the woman was seen three hours before the attack, and com-
plained merely of  pain in the epigastrium, without any head
symptom whatsoever.
  t Perhaps some explanation of this may be found in the sup-
position, that in first cases convulsions depend chiefly upon sym-
pathy of the nervous system with the unusual actions going on
in the birth  passages,  while  in  subsequent labours they may
more commonly have their cause in some organic disease.
  [Both the opinions here expressed are contrary to those of the
mass of writers, who generally assert that convulsions are more
common, and more fatal to primi-parient females than to others.] 
216       DUBLIN PRACTICE OF MIDWIFERY.

  The symptoms of  convulsions  resemble very
closely those  of epilepsy ;  the  face is  shockingly
contorted, either quite pale and leucophlegmalie, or
livid and  bloated ;  the  muscles  arc violently con-
vulsed, and sometimes become so rigid, that  1 have
seen a woman placed upon her side during a parox-
ysm remain in that position without  support;  the
tongue is  protruded and often  bitten in the spas-
modic motions of the jaw, so that the saliva, which is
blown in froth from the lips, becomes tinged with
blood ; there is sometimes a rattling  in the throat,
and generally a sharp hissing noise, produced by the
rushing of the air,  in breathing, through  the frothy-
saliva.  The patient  is quite insensible,  and when
(after an indefinite period) the convulsion ceases, a
deep sleep or rather coma succeeds, often with ster-
torous breathing,  and  continues  for some time,
when, if the paroxysm does  not  recur, she  slowly
recovers  recollection, and  complains of  headache
and soreness  in her  limbs.  The  countenance is
heavy and stupid, and the voice hoarse and altered.
The pulse differs in different cases, being sometimes
quick and strong, at others weak : before  the fit  it is
often remarkably slow.   As the  disease  increases,
the return to  sensibility  between  the  fits becomes
less marked, until at last there is no interval of per-
ception.
  Convulsion cases occur very much in groups at
certain times, and  Ur.  Ramsbotham  has  observed
that they  are  particularly  frequent in  hot sultry
weather, before thunder storms.
  The pathology of this affection is not well under- 
         ANOMALOUS LABOUR.--CONVULSIONS.      217

stood : morbid  anatomy has not hitherto  thrown
any certain light upon it.  In some instances it ap-
pears to  be a nervous affection, depending upon the
dilatation of the birth passages, and combined with
a state of plethora, and unhealthy condition of the
intestinal canal.  In other cases, it is probably con-
nected with organic diseases of the  brain.
  From  the state  of the pathology,  we  may infer
that the treatment is not well defined.  That which,
upon  the whole, appears to have had the best suc-
cess, is the depleting plan, but  it  certainly  is not
universally applicable.  When  the  woman is ple-
thoric and strong, with a quick and  bounding, or a
full, slow pulse, bleeding is unquestionably indicated,
and from  fxv  to fxxv of blood  should be drawn
from  the arm in a full stream :  if this appears to be
of service, and the blood is inflammatory, it may7 be
repeated as long as it is evidently required ; or the
temporal artery may  be opened.*    At  the same
time the  head should be  shaved, and a cold evapo-
rating lotion or an ice cap applied to it.  When the
patient is not plethoric, but  weak and rather hys-

  * The amount of bleeding advised in the text will not control
convulsions in plethoric women ;  and the experience of the best
writers and teachers, assures us that a very much greater quan-
tity of blood than here spoken of may be taken with advantage-
Burns  speaks of eighty ounces having been  abstracted with ad-
vantage.  Denman, seventy.  Dewees says, "I bleed till I abate
the severity of the fits, or arrest their repetition.  This may be
effected by taking 30 or 40 ounces,  or it may require  one hun-
dred."  In one case Dewees took 120 ounces in six hours, and
twenty ounces afterwards. Blundell took 70 ounces in three
hours.—Ed.
                 19 
218       DUBLIN PRACTICE OF MIDWIFERY.

terical, with a feeble, rapid pulse, the depleting sys-
tem cannot  be proceeded upon with so much confi-
dence.  Even then, probably, it will be well, to try
the effect  of a small bleeding, and the  appearance
of the blood will be a good guide as to whether wc
should proceed.  In a doubtful  case, 1  should  cer-
tainly be  disposed to lean  to the side of depiction.
I have never seen  a case of convulsions recover
unless the bowels have been got to act, and then the
secretions have been always depraved ; therefore  I
think the use  of purgative measures  never  should
be omitted.  A bolus of calomel and jalap* maybe
laid upon the tongue, and  followed  by a  purgative
mixture,f if  we  can get the patient  to swallow.
[Two drops of Croton oil, mixed with a  little  but-
ter or  sugar,   and  put  on  the  back  part of  the
tongue will generally find  its way down and oper-
ate well.]  At the same  time a  purgative enema,
containing  an  ounce of spirits of turpentine,  may
be thrown  up.  During the paroxysm  Dr. Denman
strongly  recommends  clashing the face  with  cold
water, and  it certainly often  appears to shorten the
fit.J   A solution  of tartar emetic has lately been

  * R Calomelanos gr. v., Pulv. Jalapae gr. i., Conservae Rosa-
rum q. s. ut fiat bolus.
  t R Fnf. Sennae 5 vj., Sulph. Magnesia?,  Tincturae Jalapae aa
3 vj. M. Sumatur gj. 2a quaque hora ad enectum.
  t A better plan is to allow a stream of water to fall from a
heighth (through a large funnel is a good way) upon the shaved
head.  The influence of cold water made to act in a constant
stream, and to fall with some force upon the head, in controling
the circulation in  the brain, is not  appreciated  by practitioners
generally.  I have sobered a man who was " dead drunk" in ten 
           ANOMALOUS LABOUR--CONVULSIONS.      219

  recommended, in nauseating doses, and I have some-
  times thought that it produced good effects.
    The foregoing plans apply to all varieties of pu-
  erperal convulsions ; but when they occur before
  or during labour, a question arises as to whether or
  not the woman should be delivered.  The solution of
  this question depends very  much upon circumstan-
  ces : if the woman be actually in labour, and suffi-
  cient advance made to admit of the application of
  the forceps, it will generally be advisable to deliver
  her; but I think no operation,  neither turning nor
  perforation, ought to be attempted while the os uteri
  is rigid, and a risk  exists of injuring it, and there-
  by increasing irritation.
   [Delivery sometimes  takes  place  very suddenly,
 during a convulsion,  and,   of  course, without  the
 consciousness  of  the  patient.   This  fact should
 teach us to make frequent  examinations per  vagi-
 nam, to note the progress of labour, lest the child
 should be born and perish from neglect, before we
 are aware of the accident.]
   Where all other means fail, and the case is evident-
 ly going from bad to worse,  it may be better to per-
 forate than  to allow the patient to die undelivered ;
 but I should feel  the less encouraged to adopt this
 practice from  the facts, that  convulsions  may get
 well, and the labour not come on for several hours,
 and  even  days,  after;  and  again,  that  they  may

minutes, by directing a stream of water from a small garden
engine upon his head. As  a  remedy ill  apoplectiform convul-
sions it is second only to bloood-letting.—Ed, 
220       DUBLIN PRACTICE OF MIDWIFERY

proceed to a fatal termination, even though delivery-
has taken place.*
  By some  persons it has been supposed that con-
vulsions always depended upon  mere  irritability of
the nervous  system ;  and, in pursuance  of  their
theory, they have  universally treated the  disease
with opiates.  As a general theory or practice, this
is decidedly wrong ; but 1 have already hinted at a
similar opinion with respect to blood-letting, and  it
appears  to  me  that, although a great  number of
cases  absolutely require the latter  treatment, still
that some would succeed  better under the former.
The  two plans,  also, may be used  conjointly with
great benefit.  Opium is indicated when the patient
is weak and debilitated,  with  a  quick unsteady
pulse, and is possessed of an irritable temperament,
and when, if blood  has  been drawn, it is evidently
not inflammatory.   After bleeding has  been  pre-
mised properly  and beneficially, and the  disease
begins to yield, an  opiate  will tranquilize the  sys-
tem,  and produce  great  benefit.   The medicine
may be used in  any convenient form.  When the
patient can be got to swallow it, I should prefer the
Dover's  powder, as likely to favour a useful deter-
mination to the skin.  The black drop answers very
well, as, from its small bulk,  it can be laid upon the
tongue.  The tincture of opium may be convenient-
ly given as an enema, should that mode of adiuinis

  *  I lately ruptured the membranes in a case of convulsions at
the sixth month of pregnancy, after all other means had failed.
Labour was completed ia four hours after, but the woman did
not recover. 
        ANOMALOUS LABOUR.--CONVULSIONS.     221

tration be thought advisable.   Should the  violence
of the disease abate, which may be known  by an
increase taking place in the length of the  interval,
and a decrease in that of the fit, we  may of course
diminish  the energy of our treatment;  still,  how-
ever, moderately continuing to act upon the  same
principle as  at first, and  adding, if necessary, the
application of blisters to  the back of the  neck or
head.   During  recovery,  the  use  of the  catheter
will usually be required.
  Convalescence  is generally slow, and it is often a
long time before the functions  of  the brain return
to their healthy state, the  disease  sometimes  even
passing  into mania.  Very frequently the woman
is quite insensible of all that has  occurred during
her illness, and I have known the want of  recollec-
tion to be extended to a period of some days before
the attack, when  there appeared to be no morbid
condition in existence.

  *#* It is difficult to strike any average  with re-
spect to the  relative frequency of  convulsions.  In
the  Wellesley Institution, during  1832,  there was
not a single case ;  while, in 1833, there were  three
—one before, one during, and one  after  delivery:
the  two latter recovered, the first was fatal.

  Sudden death after delivery  may be  here briefly
alluded  to.   It happens occasionally in  the  most
unaccountable  manner.   A woman, for  example,
will go through her  labour up to its perfect  com-
pletion without any remarkable  occurrence, and
                 19* 
222       DUBLIN PRACTICE OF MIDWIFERY.

shortly afterwards, upon moving abruptly, raising
her head to take a drink, or during the disturbance
necessary to admit of her evacuating  her  bowejs,
she will be seized with sudden faintness, and imme-
diately expire.   More rarely the same event occurs
some days after parturition.
   The pathology of this occurrence  is little  known:
it appears to be in some way connected with a sud-
den removal of pressure from  the  contents of the
abdomen, and  is  often  called " a shock upon the
nervous system ;" a form of words which, I appre-
hend, is to be merely considered  as  conveying the
negative information, that we cannot discover any
organic lesion to which it may fairly be attributed.
I once saw a woman die of apoplexy within twelve
hours  after  a  natural  and  good labour:  she fell
asleep a  few minutes  after  delivery, and  never
awoke.  On examination, several ounces of coagu-
lated blood were found in the ventricles, and a largo
quantity of serum at the base of the brain.
   Treatment in the former cases is  almost unneces-
sary to be spoken of, as we seldom have  time  to
employ any ; if we  meet an instance of dangerous
syncope,  we must  exhibit  stimulants,  ammonia,
ether, and, above all, burnt brandy or  mulled wine.
Should the patient rally a little, light  strengthening
nourishment should  be  given  in  small  quantities,
and all motion  or active purgation avoided  for sev-
ral days.
   The knowledge that such accidents now and then
happen, should make us doubly attentive about sev-
eral particulars in the treatment of lying-in  women : 
           SUDDEN DEATH AFTER LABOUR.        223

for instance, with respect to the proper application
of the binder, with a view  (in reference to this sub-
ject) of supporting the  abdominal viscera;  also as
to the observance of perfeet rest and quietude, in a
horizontal posture.   The necessity for  these  atten-
tions cannot be too rigidly enforced upon  the mind
of the young practitioner. 
224
                CHAPTER  XVI.

ANOMALOUS LABOURS.--THIRD ORDER, WITII PLURAL-
                ITY OF CHILDREN.

   The proportion  in which this  variety of labour
occurs,  appears to vary very  much  in diffiercnt
places.   For instance, in the Hospice  de la Mater-
nite of Paris, twins are stated by7 Mad. Boivin, to
average  about 1 in 132, and triplets 2 in 20,357 ;
while in the Dublin Lying-in Hospital,  twins were
found to occur as  about  1  to 00, and triplets  and
quadruplets as 1 to 4,300.*
   Nothing can be certainly known  as to the exist-
ence of  a second or third child  in  the uterus, until
the first  is born, excepting in some few instances,
where different parts of two children  have  been re-
cognized, at the same  time, in the  vagina.  It fol-
lows from this that the labour of  the first should be
conducted,  in all respects, as it would  under ordi-
nary circumstances, interfering or  not  interfering,
just as may be necessary, in accordance  with the
rules for managing the  various kinds of single la-
bour, already laid down.  When the first  child is
born, we at once know that there is another, when,
in placing  our left hand upon the abdomen, as has

  • In the Wellesley Institution the proportion of  twins has
been about one in sixty-four. 
ANOMALOUS LABOUR.--TWINS.         225
been already directed, we find  that the uterus has
very little diminished in size.  An examination will
then enable us to feel the membranes of the second
child, and its  presentation.  Very commonly the
uterus resumes its efforts in a few minutes, and, in
consequence of the passages being well dilated, the
second labour will  go on very speedily, if there be
nothing in the  presentation to prevent it.  Occa-
sionally, however,  there may be  a delay of hours
or even days between the two births, unless the lat-
ter be artificially  hastened. It  is not easy to lay
down a  rule as to when  we  should interfere, but
there is no necessity for  much haste  unless  some
untoward circumstance  arise.
  After the first birth has been concluded, we  may
put  on  a  binder,  with  moderate  tightness, and
when we have waited as long as (according to our
judgment) is sufficient to allow the womb to recover
from its fatigues,* it will be advisable to rupture the
second membranes.  After  this step,  should  pains
not return, a dose  of ergot may be given, and we
should not resort to the introduction of the hand in
a natural case, until we  ascertain  that these means
are  ineffectual.  Should  the second  child present
transversely, it  is better to introduce the  hand, and
turn at once; and the  same advice holds good in
case of any circumstance arising that  might endan-
ger the  mother, as convulsions,  hemorrhage,  syn-
cope, &c.  Occasionally, the second child requires

  * This period must  vary,  according to the circumstances of
the first labour, strength, and spirit of  the patient, &c, 
22C       DUBLIN PRACTICE OF M1DWIFEKY.

to be delivered with the forceps, in consequence  of
those symptoms presenting themselves, which, in an
ordinary case, would lead us to the use of that in-
strument.  When the first labour  has  been tedious
and  bad, or has required assistance,  it will  gene-
rally be  prudent to expedite the second.   In  short,
the rules to guide us in  giving assistance in twin
cases differ very little from those that ordinarily
apply in single labour.
   No attempt should ever be made to bring  away
the placenta, until after both children have been de-
livered : as there is often  but one  for the two  fictu-
ses, and  even if there were two perfectly separate,
removing the first,  while a child remained in utero,
would be leaving a bleeding surface with an uncon-
tracted  womb.   The  management of  the  after-
births, subsequently, is to  be conducted on the same
principles as in single labour.  When we  have oc-
casion to remove them, both should be taken  away
together, for the reason just now stated.
   It is a general rule to keep the mother, as long  as
possible, ignorant of the existence  of a second  child,
in order to prevent her from being dispirited, which
might interfere with the  further action of the ute-
rus.   All the rules appropriate  to  twin cases,  apply
equally when there  are three  or  more children  in
the womb.  The more numerous  the children, the
more easy may parturition  be expected  to  be, in
consequence of their diminished size. 
227
               CHAPTER XVII.

 ANOMALOUS LABOUR.--FOURTH ORDER.--PRESENTA-
                 TION OF FUNIS.

  This accident should rather be  called prolapsus
of the funis, as  it merely slips down  past  the pre-
sentation,  whatever  that  may  be.  The  peculiar
difficulties of the  case refer entirely to the child,
whose life is placed in extreme peril, from  the pro-
bability of such pressure  being exerted upon the
cord, as will stop circulation through it long before
respiration can  commence.  There is no danger to
the mother, and consequently no ground for inter-
ference, if from the  want of pulsation in the funis,
we ascertain that  the  child  is already dead, when
we discover the nature of the case.   Should  it be
otherwise, we must  endeavour to obviate  the inju-
rious  effects of pressure, which, however, is not
easy to be accomplished.
   The most feasible plan  is to endeavour to pass up
the cord above the presentation, and keep it there
during the pains, until the latter fills the pelvis, and
prevents it from again prolapsing.  Some  have re-
commended to  hook it upon a limb of the child, if
possible :  others to  enclose  it in a  bag, or pass  a
sponge after it, to keep it up.  Any of these means,
that are likely  to do no harm to the mother, should
be tried :  but I cannot say the same with respect to 
228       DUBLIN PRACTICE OF MIDWIFERY.

some instruments, that have  been  contrived for re-
turning the parts.  The chance of our saving  the
child by them is doubtful in the extreme ; and, upon
so slight a chance,  no prudent man will run the risk
of injuring the uterus, which must be  more or less
hazarded  by  the  use of those  machines.   Some
gentlemen have spoken of delivering by turning or
the forceps in funis presentations, but, I  should hope,
not seriously intending their suggestions to be adopt-
ed.  It must  be obvious to the most inexperienced,
that the danger of  pressure,  in either of these oper-
ations, would  be much greater than if the  simple
action of  the uterus  was trusted to.

   *#*  The proportion of funis presentations occur-
ing in  the  Wellesley Institution, during  the  years
1832 and  1833, was 2 in 839. 
229
              CHAPTER  XVIII.

 ANOMALOUS LABOUR.--FIFTH ORDER.--RUPTURE OF
               UTERUS OR VAGINA.

  This is probably the  most fatal complication of
labour that can occur.   It happens generally to in-
dividuals who have had  a number of children, and
in whom, consequently, the walls of the womb have
been thinned and weakened by repeated distension.
It is likely to occur when the pelvis  is deformed,
and, especially, when there is any sharp bony pro-
jection (e. g. a deformed sacral  promontory), by
pressure  against which the uterus may be injured.
The organ may also rupture itself upon  the  pro-
jecting limbs  of the child, in a preternatural presen-
tation, or it may be torn by the hand of the  opera-
tor  in turning.
  The usual time  for this accident to occur is in the
course of  a  tedious  labour, but it  has happened
when there was no unusual  difficulty, and even, in
some instances, long before the termination of preg-
nancy, so that it is very  probable that, in most cases
of rupture, there  exists  some previous disease  of
the  uterus, which renders  it particularly liable  to
laceration.
  The improper and violent use of the forceps has,
I believe, much oftener  than is supposed, produced
laceration of the  vagina.
          20 
230       DUPLIN PRACTICE OF MIDWIFERV
  When the  accident  happens during  childbirth,
the symptoms  arc  generally very remarkable.  A
severe labour pain will, probably,  suddenly cease,
and the patient, at the same  time, will be sensible of
something  giving way  internally.   The presenta-
tion,  unless  it be  firmly locked  in  the  pelvis, will
then immediately be found  to recede, often out of
reach  of the finger ;  at the same time  the limbs
may, perhaps, be felt through the  parietes of the
abdomen, and there will be  some hemorrhage  from
the  vagina.   threat  languor  and  prostration  of
strength soon follow, indicated by quick, weak, un-
steady pulse, laboured respiration, and cold  sweats.
At the  moment  of the accident, the stomach will
sometimes reject its contents, and shortly afterwards
there will be vomiting of the  brownish matter, so
well known from its resemblance to  colfee grounds :
the pains entirely cease from the time of the rup-
ture.  The situation of the  rupture is usually cither
transversely at the place where the cervix impinges
upon the promontory of the sacrum, or where the
cervix and  vagina join, in which  case  both vagina
and uterus  are often  involved  in the  rent;  it may
also happen at any part of  the fundus.*


  • Laceration of the uterus is not always accompanied by the
symptoms enumerated  in the  text.  It has occurred in New
York twice within the  past year, without any symptom  other
than extreme,  and rapidly increasing prostration.  In one of
these  cases,  though the rupture must have taken place while
the practitioner was in the room, the nature of the case, and the
cause of death were not suspected, till revealed by post mortem
examination.— Vide new York Med. On.:.—\.u. 
RUPTURE OF THE UTERUS.
231
   The treatment  generally adopted  in  these cases
is to deliver the woman as soon as possible.   If the
head  presents, and has  not receded,  this  may be
done  with  the forceps  or perforator,  whichever,
from  circumstances, may be considered most advis-
able.   Should  the child  have  partially escaped,
through the rent, into the  abdomen,  the hand must
be introduced, turning performed, and  delivery ac-
complished by the feet.  When the child has passed
entirely  out of the uterus, some practitioners  re-
commend that delivery should not be attempted, but
the further disposal of the fcetus  entrusted to na-
ture, there being a remote  probability of  its being
discharged, by an  ulcerative  process,  through  the
abdominal walls.   The choice  left  to  us is a mel-
ancholy one, and  I am not aware that much can be
said in favour of  either one plan or the other.*
   The subsequent treatment must be entirely guided
by circumstances, and  by the  general medical and
surgical  knowledge of the practitioner.  What is
to be  dreaded, is,  first,  the  sinking and death of  the
patient, in a few  hours, from  the violence of  the
shock; and subsequently,  if she rallies  from this,

  • From post mortem examination of two  cases  of ruptured
uterus, I am induced to believe, that where the child has passed
out of the uterus into  the  peritoneal  cavity, the attempt to
deliver by dragging it back, would be  extremely difficult, and
attended with great danger.  In both the cases alluded to, the
uterus was found alter death contracted  to the size  of a child's
head, and the rent so diminished in size, that a very considera-
ble extension of the laceration would  have been the inevitable
consequence of any attempt to drag the foetus through  the open-
ing.—Ed. 
232       DUBLIN PRACTICE OF MIDWIFERY.

peritoneal inflammation.   Until some degree of re-
action sets in, we shall probably find it necessary to
give stimulants ; afterwards, we must treat the (-ase
according to the symptoms.  The peritonitis is gen-
erally of  a low  kind, accompanied  with typhoid
symptoms, and will seldom bear the free use of the
lancet.  Leeches to the  abdomen, and  opium in
large doses, or calomel and opium, have,  perhaps,
more reasonable indications in  their favour than
any other plans.  I would feci particularly disposed
to avoid the use of any purgative measures, except-
ing mild enemata.
   The  chances  of the patient's escaping are, of
course,  very slight; but still instances of recovery
have occurred, and we should not altogether despair
as long as there is a spark of hope.

   Laceration of an over-distended bladder  is said
to have happened  during labour,  in consequence
of the attendant neglecting to  relieve retention of
urine ;  more usually, the injury done to the bladder
merely excites inflammation, which too often termi-
nates in sloughing and the production of a  fistula.
The first accident must be a very hopeless one, the
patient  having  scarcely a chance  of escaping  the
low peritonitis that must be expected to ensue.
   Ruptures of large blood-vessels in the abdomen,
and lacerations  of viscera, as  the  liver, cVc, have
been recorded.   The  symptoms will be  obscure,
and the nature of the case doubtful until  after the
death of the patient, and it is obvious  that there will
never be either opportunity or  use  for any medical
treatment. 
233
               CHAPTER XIX.

       MANAGEMENT OF PUERPERAL WOMEN.

  In order to comprehend  this subject, we must
have clear ideas with respect  to the state in which
a woman is situated after labour.  In the first place,
her muscular power has been exerted in a violent
and unusual manner probably for several hours, and
as a natural consequence  considerable  fatigue  pro-
duced ; secondly, her circulation  has been  a good
deal excited,  and a remarkable  change has taken
place in the relations of the abdominal viscera  to
each other and to their containing walls ; and, third-
ly, the  patient has been suffering more  or less men-
tal anxiety and  distress.
  All these circumstances manifestly require  rest,
both moral and physical;  and accordingly we must
enjoin perfect quietude, and  allow the woman  to
sleep, if she be inclined to do so.  The erect pos-
ture, and every thing stimulating, either in the way
of drink or food, must be positively  forbidden, as
from the state of the  circulation  and of the abdo-
men, as well  as of the nervous  system, there is a
peculiar  liability to inflammatory  or irritative ac-
tion.   Should the woman's  stomach  be empty, it
will  be well to give her  some cool gruel or whey,
with a little dry  toast: this will employ her diges-
tive  organs, and prevent  the very great annoyance 
234       DUBLIN' PRACTICE OF MIDWIFERY.

which is  sometimes experienced  from  flatulency.
The binder will probably require a little tightening
after the placenta has been  expelled : the  doubled
sheet may then  be  drawn  quietly from under the
woman's hips, so as to make her more comfortable,
and  a  dry  folded  napkin  applied  to  the  vulva.
These precautions having been attended  to, we may
take our leave, giving strict  directions that  she shall
not be moved at all for two or three hours, but that
if she feel well at   the end  of that  period, the left
side of the bed may be arranged  comfortably, and
she may be shifted quietly upon it, so as  to  admit of
the wet sheets, (Sec  being removed  from the place
where she was at first  lying.
   Within twelve hours we  should always  visit our
patient, and  wc have  then  to ascertain the state of
her tongue and pulse ;* whether there  be any pain
or tenderness in the abdomen ; whether  she has had
sleep, and  passed  urine;   and whether the after
pains have been severe,  or the discharge  copious.
Should matters be  going on well, we have nothing
to do until twenty-four or thirty hours  after deliv-
ery ; when,  if the bowels have not  been opened, a
mild aperient of castor oil or rhubarb should be
given, or an enema administered.f   A  light, non-

   • The pulse should have fallen by. this time from the elevation
caused by the labour to nearly its natural standard.  I  have, how-
ever, found it to remain quick, in irritable  women, for some days,
without any bad results.  These cases should be closely watched.
   t When women have piles, castor oil often produces much ir-
ritation, and a preferable substitute will be a couple of drachm*
of senna electuary, or some  of the  infusion of senna with carbo- 
         MANAGEMENT OF PUERPERAL WOMEN,      235

stimulant, but sufficiently nutrieious, diet should be
prescribed ; consisting, at first, of gruel, and tea or
cocoa with biscuits or toast.   On the third or fourth
day, if nothing  forbid, a  little chicken may be al-
lowed, and  half a glass of white wine diluted with
water ;*  after which, a gradual cautious return may
be made to the ordinary diet.
  The patient should not be  allowed to rise from
her bed  sooner  than the  third  or fourth day,  and
then only for  a  short time while  it is being made.
This restriction serves both to keep  the circulation
tranquil  and  to prevent  prolapsus  of the  uterus,
which is likely  to happen, unless the parts are al-
lowed time to regain their tone after the relaxation
which they have suffered during parturition.  In the
third week in summer, and probably the  fourth in
winter,  a drive  or walk in the open air may be  per-
mitted.  All these limitations of time must of course
be understood cumgrano salis, and acted upon with
reference  to  general  principles.  For instance, I
have known it  to be advisable to  give solid  food
from the very first to patients with whose  stomachs
slops -peculiarly disagreed.   But of these  matters,


nate of magnesia, already mentioned. In ordinary cases, I would
set my face entirely against the drastic purgatives sometimes em-
ployed.  Nothing could be better devised for exciting intestinal
irritation and fever than this unhappy practice.
  '* The wine here allowed is unnecessary.  The proportion of
American women  who  use wine habitually is happily so  small
that the adoption of any general rule, to give wine  during the
puerperal state, would be productive of the worst consequences.
—Ed. 
236       DUBLIN PRACTICE OF MIDWIFERY.

every practitioner must judge for himself; and in
an acquaintance with such peculiarities and excep-
tions, derived from observation, consists that prac-
tical  experience which  teaches,  but cannot  be
taught.
  There are two  secretions which play important
parts in the woman's constitution after delivery—
these are the lochia and the milk.   The lochia con-
sists at first merely of the blood which is squeezed
out of the enlarged  vessels by the contractions  of
the  uterus.  It  continues sanguineous  for some
days, then changes to a greenish scrum, finally  be-
comes paler, and decreases gradually, until in three
or four weeks (more  or less, in different women) it
altogether ceases.   Like every other secretion, it is
suppressed or diminished  by any accession of fever
or inflammation, and thus becomes a valuable diag-
nostic symptom of either of these states.
  The existence of the lochia requires strict atten-
tion  to cleanliness on the part of a puerperal woman
and  her attendants, as if  the discharge be allowed
to accumulate, it soon becomes putrid and  irritating.
The vulva should  be sponged  every day with luke-
warm water.
  [Dr. Dewees  advises to interfere with the lochial
flow if it continue free  longer than ten days.   In-
terference  with  this secretion  is  proper when it is
excessive  and obviously producing  bad effects,  on
the constitution, whether this happens on  the tenth
or twentieth day.  Profuse lochial discharge is very
generally dependent on debility and relaxation, and
here as in chronic leucorrhcea, to which it is  near 
        MANAGEMENT OF PUERPERAL WOMEN.       237

akin, the debility and the profuse discharge act  and
react as cause and eflect upon each other.   To such
cases tonics and the mineral acids are  appropriate.
I know of  no better form than, R. Rad, Columbo,
Cont.  3'ii.,  Cort Aurant, 3j. aqua bull., a pint.   A
wine glass full, to which elix. vitrol, gtt., x, is to be
added  is a  dose, to be taken once or twice  a day.*]
  Milk commences  to  be  secreted during  the  last
days of gestation, and often much earlier.   During
the   act of parturition, and for a few  hours after-
wards, a degree of fever exists, which  often  sus-
pends  the secretion for the  time ;  but  the  popular
notion, that it does not come until the  third day, is
quite unfounded, and leads to  injurious practical
results.  After the woman  has rested and  slept a
little, (say in ten or twelve hours,) the child may be
applied to her breasts, generally with much advan-
tage to herself and it.   The constant removal of the
milk as fast as it is secreted effectually prevents  ac-
cumulation in the gland, and the distension and fever
consequent upon it, which otherwise would  happen
about the third dayT, and the occurrence of which
has  given rise to the popular  prejudice alluded to.
If it be manifest, however,  that there  is no secre*
tion  in  the breast, it is  not   advisable  to keep  the
child applied, as its  determined efforts to  extract


  * Introducing this little prescription  gives me an opportunity
to pay a  tribute of respect, to the individual from whom I  first
had  it—that  most  able practitioner,  and  honourable  man,
Wright  Post, M. D., late Professor of Anatomy, in the College
of Physicians and Surgeons. 
238       DUDLIN PRACTICE OF MIDWIFERY.

something may have the eflect of excoriating the
nipples, and creating much after suffering.
  The milk, like the lochia, is  suppressed by fever
or inflammation ; and thus, by its  quantity, it often
affords  useful indications.   When a woman  does
not intend to nurse, her diet should  consist less of
fluids than under other circumstances ;  aperients
should also be exhibited more  freely; and  if the
breasts become hard and painful, they must be rub-
bed diligently with a little  sweet oil, or perhaps  it
may be necessary to have the milk drawn from them
by a breast pump.
   After-pains.—These are rare after first labours,
but very commonly occur after  subsequent  ones :
they are occasioned generally by the efforts of the
uterus to expel coagula of blood,  which, from time
to time collect in its  cavity.   They also seem to
depend sometimes  upon constipation.   In  some in-
stances, they continue from the time of delivery for
several  hours; in  others,  they do not commence
until twelve, twenty-four,  or  thirty  hours  have
elapsed.
   We may distinguish these pains from peritoneal
inflammation, by their remissions, by the abdomen
being free from remarkable  tenderness, by the se-
cretions of milk and  lochia being undisturbed, and
by the pulse being quiet and  indicating no fever,
and by their being excited by attempts to nurse.
   After-pains do  not  require  much treatment;  a
little friction over the  uterus, and a  mild aperient,
will often relieve them.  When they are severe and 
        MANAGEMENT OF PUERPERAL WOMEN.      239

prevent the woman from sleeping, it may7 be neces-
sary to give an anodyne ;*  but, as  the contractions
are a natural occurrence, and  intended  to  remove
coagula, which, if retained, might  be injurious, it is
as well, if we can so  manage, to avoid  a stoppage
of the uterine action by narcotics.

   Several  accidents  may happen  during  labour,
which, after its  completion,  require to  be  under-
stood and attended to by the  accoucheur, although
the treatment of many of them falls strictly within
the province of surgery.  Of these, we  shall  take
a brief notice.
   Lacerations of the Perineum  have been  already
alluded to :  they may occur merely as rents of the
posterior commissure  of  the  vulva, or they may
extend into the  rectum ; or,  lastly, the  head of the
child may be driven through the perineum, leaving
 the posterior  commissure entire,  and  constituting
 what has been termed the circular perforation.  In

   * Extracti opii aquosi gr. jss. in pilula ; vel tincturse opii, gtt.
 xxx. in haustu.
   [I often  combine an opiate and a  purgative, Castor oil -fss.
 with laudanum,  3ss.  It produces the very best effects ; given
 " hora swjth," it secures a ?ood night's sleep and  a free evacua-
 tion of the alimentary canal, with entire dissipation of the after-
 pains in the morning.  Ergot (5 grains or gtt. x. of the tincture)
 given every hour,  will often promote complete  contraction of
 the uterus, insure the evacuation  of any clots, and relieve the
 pains.  Dewees was very partial to the following mixture :—
 R. Pulv. Gum. Camphor, 3ii. Pulv. Gum Arabic, 3iii-—sachar-
 rum alb, 3i, aqua font §vi. m.  Dose, a table-spoonful every hour
 or two.—Ed.] 
 240      Dl'BLIN PRACTICE OF MIDWIFERY.

 the first case, little  treatment  is  required :  cleanli-
 ness should  be strictly attended to,  but there is no
 necessity for any dressing, as the sides of the wound
 are kept in  apposition by the  mere  approximation
 of  the thighs.  When the injury is  more  severe, it
 becomes a case  for surgical treatment,  and there-
 fore is beyond our present limits.
   Inflammation  of the Vagina sometimes follows a
 tedious labour, or even a natural one, when the wo-
 man sits up too  soon or too long at a time alter de-
 livery.   The symptoms  are beat and  soreness of
 the part, with a  sense of bearing down, and occa-
 sionally painful  and  frequent micturition.  It may
 end in suppuration, and even adhesion of the vagi-
 na ; or if the parts have, in the first instance, suffer-
 ed  much, there may result sloughing, and perhaps a
 fistulous communication with the bladder or rectum.
   The inflammation  must  be  treated  in the com-
 mencement upon ordinary7 principles.  The woman
 must be kept at rest, in the horizontal  posture, fo-
 mentations applied, and the other means suitable to
 the case in  a surgical  point of view diligently em-
 ployed.  Our attentions should  be redoubled, if we
 see any reason to dread sloughing, which we may
 be led to expect when the woman is of a broken-
 down, bad constitution.  In such a case, we should
 be  particularly  attentive  to the  drawing  off  the
 urine, which should never be allowed to accumu-
 late in the bladder.
  [If the inflammation  has been severe and espe-
cially if sloughing has taken place, attention should 
        MANAGEMENT OF PUERPERAL WOMEN.      241

be directed to the vagina, till  the process of cica-
trization is completed, to prevent contraction of the
canal or adhesion,  and a perfect occlusion.  For
this purpose a bougie (a full-sized  mould candle will
do very well,)  should  be passed  twice in every
twenty-four hours, in the early part of the case, and
subsequently a  sponge tent  worn.  In  a case  re-
ported by Professor Meigs,  from  neglect of these
precautions, universal adhesion of the vaginal wall
took place, and when the patient came  under Dr.
Meigs'  care  the  canal  was perfectly obliterated.
She was relieved by an operation performed by
Dr. Randolph.]
  Ecchymosis of the Labia.—This sometimes occurs
during a violent labour, in consequence  of a burst-
ing of some vessel, and consequent pouring  out  of
blood into the loose cellular  texture of which these
parts are composed.   A labium will  sometimes be-
come suddenly  almost as large as  the child's head,
and may even impede delivery.  In such a case it is
recommended, immediately after the occurrence, to
puncture the part,  and  allow the blood to escape
while it is yet fluid.  This should never be done,
however, after  coagulation  has taken place, as ad-
mission  of the  air then would  cause the blood to
become putrid, and  excite  a mischievous and un-
healthy  suppuration.  If we  leave the part untouch-
ed, absorption will in time be effected, and no inju-
rious consequence remain.*

  * Authors are not agreed as to the question of opening these
                 21 
242       DUPLIN PRACTICE OF MIDWIFERY.

   Retention  of Urine  sometimes  supervenes upon
a  perfectly natural labour  in an  irritable woman.
The urine must  be  drawn off twice a day with a
catheter, until the  bladder  regains its  tone, which
it  probably will in seven or eight days.   Should re-
tention continue after the dangers of the  puerperal
state have been passed, it may be  necessary to give
tonics (especially preparations of iron), and to apply
a blister  to the sacrum.   These  means  are usually
sufficient.
   Incontinence of Urine is also  an occasional con-
sequence of  labour;  but if there be no organic  in-
jury, it is not likely to  be troublesome.   The same
medical treatment will apply to  it as to retention.
tumours;  the better opinion seems to me to be, that if the blood
is fluid it  should always be evacuated, there is no fear of any
hemorrhage which plugging the vagina would not control. If,
however,  the blood be already coagulated, the propriety of open-
ing or not, depends mainly on the quantity effused.  If there
is but little, the present suffering is not great, and we may let it
alone, feeling confident that  the absorbents will remove it. If,
however,  the quantity  be  large,  I think an  opening should be
made;  and this for two reasons:  1st. the present suffering is in-
tense, and may produce the  worst effects ; cases are on record
■where delirium and death have resulted from the irritation urid
pain of one of these ecchymosis, 2d. the absorbents cannot gene-
rally be expected  to take  up a large quantity of effused M>od
from the labia, the skin will ulcerate and an imperfect opening be
made, when the patient, after enduring the most agonizing pain
will be found in a worse state than though an opening had  been
made in ihe first instance.  TIil- opening should be free, and ex-
tending the whole length of the thrombus, so  as to evacuate the
clots as speedily as possible.  The wound may be  dressed with
a poultice, made with weak chlorine solution—Eo. 
         MANAGEMENT OF PUERPERAL WOMEN.     243

   Piles  are  sometimes  productive  of very great
pain and inconvenience to puerperal women, the
pressure upon them  during labour  causing inflam-
mation and great tumefaction.   Warm fomentations
will often give sufficient relief, but occasionally it is
necessary to apply leeches.  Eight or ten  may be
put on,  and when they fall off, may be  succeeded
by a warm poultice of chamomile flowers, which
will encourage the  bleeding, and give much relief.
I have already alluded to the kind of aperients best
suited for piles, and mentioned that castor oil, con-
trary to what is  commonly supposed, is very likely
to irritate the extremity of the rectum.*
   Obstacles to nursing.—One  of the most formi-
dable of these arises  from  a deficiency of  nipple.
Owing to the tight  dresses worn by females, this
part is  sometimes  so  firmly compressed into  the
substance of the  breast, as to  offer nothing  for
the child's lips  to lay hold  of.   In  such a  case it
must be drawn out by the  breast pump, or by a
strong child, and the infant instantly applied.
   Sore Nipples.—The  nipples of some women  are
peculiarly tender, and liable to excoriation.   When
we know that this  is the  case before labour, we
should harden them by exposure to the air for some


  * When the inflammation has subsided, I  have seen much
benefit derived from the following liniment,  recommended by
Mr. Colles : a drachm of laudanum may be added to it with ad-
vantage.
  R Olei Olivaram, |ij. Liquoris Subacet. Plumbi, jj. M.  Fiat
linimentum. 
244       DUBLIN PRACTICE OF MIDWIFERY.

time everv morning, and by  the use  of a lotion  of
spirits and water.   The only effectual means of re-
lief, when excoriations do occur, is  the use  of the
nipple shield, whereby the exciting  cause (pressure
of the child's mouth) is removed.*   In addition  to
this, we may apply slightly  stimulating lotions,  as
sulphate of zinc solution,-}- or spirits  and water, or,
what answers very well, the black  wash.   Syphi-
litic sores, or aphthae, may be  communicated from
the  child's mouth  to  the nipples,  and, of course,
from their specific nature,  demand peculiar atten-
tion.
   [Sometimes we derive great advantage from pen-
cilling over  the  nipple  with  lunar caustic.   This
remedy, however, should be tried  cautiously, as  in
some cases it increases the  inflammation, nor  have
I been able to distinguish beforehand those in which
it was beneficial from those  in which it did harm.]

   * The best form of this useful instrument is that made of gum
elastic.
   t R  Sulphatis Zinci gr. viij.  Aqua Rosarum ^iv. M. Fiat
 lotio.
   The following, I believe, is a formula of Sir A. Cooper, and
 is very useful:—
   R Subborat. Sodae jij.  Cretan Precipitataj ^j.  Sp. Reclificali,
 Aquae Rosarum, aa | iij.  M. Fiat lotio. 
245
                 CHAPTER XX.

                PUERPERAL FEVER.

  Under this name authors have described several
modifications of disease, and even some totally dis-
tinct affections,  thereby causing so much confusion,
that many gentlemen have been induced to contrive,
in its stead, a variety of terms, by which they hoped
not only to designate a certain malady, but to con-
vey scientific allusions as  to  its nature.   In  the
complete attainment of these  objects, I think they
have all failed, and I shall therefore continue to em-
ploy the old term* as involving no peculiar theory,
and being now perfectly well understood to apply
to a certain range of very  fatal  nforbid  conditions
which occasionally follow parturition.
  Diseases popularly termed Puerperal Fevers, and
coming strictly  within  the  meaning which we wish
to apply to these words, may occur either sporadi-


  * It has always appeared  to me, that the more hieroglyphical
we can make our terms, the better, in so uncertain  a science as
medicine.  When a name contains a theory, it must lead us astray
as soon as the latter is changed; and  how long does any theory
hold its ground in pathology 1  If authors sought to obtain  and
teach correct ideas of  the nature of diseases under their old
names, in place of inventing new ones, we should have less of
that fighting about words, which is unquestionably the opprobrium
of medicine.
                21* 
246       DUBLIN PRACTICE OF MIDWIFERY.

cally, or as very destructive and general epidemics;
and under these different forms have  been repeat-
edlv described  with  variously modified  symptoms,
and as often treated  by excellent practitioners upon
diametrically opposite principles.   So  various, in-
deed, have been the accounts  of writers, that no
symptoms can  be fixed upon as having been com-
monly described  by  all,  excepting  fever, quick
pulse, and tenderness (often  very  indistinct)  in the
abdomen.  Amid these bewildering circumstances
we must seek our guide, both for theory and prac-
tice, in an  attentive  consideration  of the pathology
of the disease,  upon which  subject the profession
are much indebted to the researches of Dr.  S. Cu-
sack and Dr. Lee.  By both these gentlemen, the
affection is considered as an inflammation occurring
within the abdomen ; and  by the latter, it is  sup-
posed, that  the  various forms  which it  assumes,
" whether, inflammatory, congestive, or typhoid, in a
great measure depend on whether the serous, mus-
cular, or yenous tissue of the organ has become af-
fected."  This  proposition  is probably, to a certain
extent, correct; but as Dr. L.'s  divisions are rather
suited to the dissecting room than the sick chamber,
we shall take Dr.  Cusack's more practical classifica-
tion into three  species:—1. the Inflammatory; 2.
the Typhoid ;  and, 3.  the Mixed.
   1. The first  or inflammatory species differs but
little  from ordinary peritonitis.   It occurs  in pa-
tients of good constitution, and when epidemic, pre-
vails  simultaneously with  diseases  of a decidedly 
PUERPERAL FEVER.
247
sthenic character.   Its causes are exposure to cold,
irregularities in diet, and perhaps contagion.
  The symptoms are, first, a rigor seizing the pa-
tient, usually about the second, third, or fourth  day
after labour; if the abdomen  be carefully exam-
ined, some  tenderness will  immediately be found
over the uterus, which quickly  increases to severe
pain, and extends over  the whole  abdomen.   The
pain may be aggravated in paroxysms, but is never
absent, and the tenderness becomes in a short time
so exquisite, that the patient cannot bear even the
weight of the bed-clothes.  She lies upon her back
with her knees drawn up, so as to relax, as much as
possible,  the abdominal  walls; and,  in order to
avoid the pressure of the diaphragm, endeavours to
respire by means of the  intercostal muscles,  thus
giving to the breathing a very laboured character.
The rigors are succeeded by nausea, heat of  skin,
thirst, and often intense pain in the forehead.   The
countenance is expressive of great suffering.   The
pulse is  quick, sometimes full and  throbbing, at
others, hard and wiry, but  always incompressible.
The tongue is generally white and  creamy, but va-
ries  in its  appearance.  The bowels  are  usually
constipated,  the urine scanty7,  and the  milk  and
lochia suppressed.  If the disease be allowed to run
on,  the  belly  becomes tympanitic, diarrhoea  and
vomiting of  dark matter ensues,  the pulse becomes
feeble, the breathing hurried, sometimes with severe
pain in the chest, and death oecurs about the fourth
day, often much sooner.
  The disease is liable to be confounded with se- 
248       DUBLIN PRACTICE OF MIDWIFERY.

vere after pains, intestinal  irritation, and hysteric
tenderness of the uterus and abdomen.   From the
first, it is to  be  distinguished by its want of remis-
sions, by the tenderness on pressure, and by the se-
veritv of  the fever.  Intestinal irritation is  to be
known  chiefly  by the  previous marks  of derange-
ment of the chylopoietie viscera, and by  the ab-
sence of extreme tenderness on pressure.   In hys-
teric tenderness, it is often very difficult to discrim-
inate, the patient appearing to  suffer exquisite tor-
ture, and  screaming even before  our hand reaches
the surface  of  her body.   In these cases, however,
if we are able to divert away the woman's attention,
and still keeping  our  hand  upon the  abdomen, to
gradually increase  the  pressure, we  shall  find that
she  can easily bear what she  at  first  shrunk from
with terror.
   The  morbid appearances in  this species are pre-
cisely  similar  to those  observable  in peritonitis.
The peritoneum, especially near the uterus, is thick-
ened, vascular, and coated with lymph ; the viscera
are frequently agglutinated together, and there is an
effusion into the cavity (often in immense quantity)
of whey-coloured or sero-purulent fluid, mixed with
flakes or masses of lymph.   The omentum is some-
times inflamed, and there is a large  quantity of air
both in the  intestines and abdominal cavity.  In the
thoracic cavity there may be serous effusion into the
bronchial cellular tissue and  pleura, or a coating of
lymph upon the latter.
   2.  The typhoid form of the  disease occurs in pa-
tients of broken-down constitutions and  depressed 
PUERPERAL FEVER.
249
minds, living in unhealthy situations, and who pro-
bably have suffered hemorrhage or manual interfer-
ence with the interior of the uterus.   When epi-
demic, it appears to prevail in connection  with dis-
eases of an asthenic character, as typhus fever, ery-
sipelas, and diffuse inflammation; and, like these, it
often occasions sad ravages in hospitals.
  The symptoms are by no means so prominent  as
in the first species :  there is  often little  or no pain,
and scarcely any tenderness, except at  the com-
mencement, and  then perhaps only when we press
firmly upon the uterus.  The  disease usually com-
mences with a rigor, but even this is sometimes in-
distinct.  The pulse is quick and feeble,  and differs
from its character in the first species by being re-
markably compressible.  There is extreme weakness
and exhaustion, with want  of rest; of all which
the countenance is particularly expressive.   Indeed,
so remarkable is the anxiety apparent  in the pa-
tient's face from the very outset, that one can often
recognize  the disease  from  the  appearance of  it
alone.  The skin  is  also sallow and dirty-looking,
and seldom hot; towards  the close  there may be
petechias.  The respiration  is  hurried—the  lochia
and milk suppressed, or the former diminished and
foetid.  In the latter  stages there is often a feculent
diarrhoea.   The tongue is sometimes natural and
remarkably clean, or it may be of a bluish creamy
whiteness, or  even blackish.
  The patient quickly becomes weaker and weaker,
and the disease may proceed  to a fatal  termination
in a few hours, or it may hang on for twelve  or 
250      DUPLIN PRACTICE OF MIDWIFERY.

fourteen days.   In  some  instances,  1  have  had a
firm conviction that this form of fever had made its
commencement several days before parturition, and
that in many eases where it was supposed to be the
consequence, it was, in fact, the  cause  of difficult
labour.
   The  morbid  appearances in this species  differ
considerably from  those  observed in the first, but
still they are obviously the result  of a  kind of in-
flammation.  The effusion into the peritoneal cavity
is by no means  so great as in  the former affection,
nor are there any adhesions or  extravasations of
lymph.   The fluid effused is sometimes a brownish,
dirty-looking serum; at others, of an oily, semi-pu-
rulent character.   In the subserous  and pelvic cel-
lular tissue, and  between the  broad ligaments, a
reddish serum or a gelatinous fluid  is deposited in
considerable quantity.  The same  deposits  often
exist in the uterine  substance, which may be soft-
ened and altered  in texture, so as to present a gan-
grenous appearance, and may contain depositions of
pus.  The internal coat of the  womb is also some-
times softened in patches, and of a dark  or ash-
grey colour.   Similar changes  may occasionally be
observed in the coats  of the intestines.   The ova-
ries are frequently enlarged and changed into  cysts
of pus, and may  undergo a process of softening  to
such  a  degree, as not to admit of being handled
without  being destroyed.   The  absorbents  and
veins of the uterus, in some  cases, are found  filled
with pus ;  and  abscesses and disorganisation may
occur simultaneously in distant organs, as the lungs, 
PUERPERAL FEVER.
251
spleen, liver, joints, eyes, brain, &c. ; the disease in
these  melancholy  examples  strikingly  resembling
that  form of  diffuse inflammation  which  follows
dissection wounds,  or operations  performed  upon
unhealthy subjects during the prevalence of erysip-
elas.   Dr. Lee has divided  the morbid appearances
just described into three sections,  considering that
the disease may distinctly affect the  appendages of
the uterus, its muscular  tissue, or its veins and. ab-
sorbents.  He has not, however, been able to point
out any means of diagnosis between these, nor any
difference in the effects of  remedies, or in the ordi-
nary fatal results.   His division, in fact,  is founded
upon  morbid  anatomy, not upon pathology, and
therefore is  not of use in practice.
   3. There  is decidedly a mixed species of disease,
what, in fact, we might expect to  meet with in  an
individual of strong constitution, at a time when the
" constitutio anni" was of an asthenic type.
   The  symptoms are  a mixture of those of the
other two :  considerable pain  and  tenderness often
existing, with a pulse  not possessing the wiry hard-
ness or incompressibility of the inflammatory spe-
cies ; much  debility and little relief following the
employment of the lancet; and the blood neither
presenting the highly inflammatory appearance of
the first form,  nor the broken-down, scarcely coagu-
lating "quality of the second.
   The morbid appearances  generally indicate  in-
flammation of the peritoneum, but  wanting the very
adhesive  character of the  first species, and often
presenting at the same time a degree of the subse- 
252       DUBLIN PRACTICE OF MIDWIFERY.

rous infiltration  and tendency to  alteration in the
uterine appendages which  characterize the  typhoid
disease.
   Some difference of opinion has existed as to the
contagious or non-contagious nature  of puerperal
fever.   Like every question  of the kind, it is one
extremely difficult to come to any conclusion about.
But so many instances  have  been recorded of the
disease following a particular  nurse or accouchcr,
that it would be now highly culpable  in any prac-
titioner not to  adopt  the most strict precautions
against the risk of his carrying infection from one
patient to another.  After  seeing  a  case of this
fever,  the  clothes  should  always be  changed, the
most careful  ablutions performed,  and no  accou-
cheur  should  personally interfere in  the opening
of the bodies of victims to the complaint.  Should
a run of fever continue to affect the patients of any
individual, notwithstanding attention to these  mat-
ters, it becomes  his bounden duty7 to abstain tempo-
rarily from practice, and, if possible, to remove for
a time from his  ordinary residence.
   The treatment of puerperal fever, of course, varies
very much according to the species.
   In  the inflammatory form, antiphlogistic treat-
ment is decidedly indicated  in the commencement,
and  the lancet  should be  our sheet  anehor.   As
much blood (probably from  twelve  to twenty-four
ounces) must be taken from the arm  as will produce
a decided effect  upon  the  circulation.   To do this
most efficiently,  a large orifice should be made  in a
vein, while the patient is in a recumbent posture, its 
                 PUERPERAL FEVER.             253

 effects upon the pulse and countenance being care-
 fully  watched.   Dr.  Cusack very  justly  remarks,
 that placing the woman in the erect  posture when
 we are going to bleed  her will generally produce
 syncope, quite independently  of the abstraction of
 blood, and may prevent the useful  employment of
 this remedy.  We must be guided, with  respect  to
 a repetition of venesection, by the effect of the first,
 and by the  appearance  of the  blood.   The  latter,
 and the compressibility  or non-compressibility  of
 the pulse, afford very valuable indications.   When
 there is any doubt about a second blood-letting, we
 may,  as an  intermediate measure, apply leeches  to
 the abdomen.  Venesection,  when  it is proper,
 should always be adopted as early as possible in the
 complaint, as the lapse of a very  brief space  of
 time may render its employment worse than useless.
 As long, however, as the  pulse  retained  its incom-
pressibilily,  I should  not  be prevented from using
 the lancet, even  by  the existence of considerable
 debility; the former  symptom, I think, giving the
 truest indication upon this point.
  After bleeding, whether we think it  advisable to
 apply leeches or not,  we shall  find great  advantage
 from  a fomentation  of the whole  abdomen with
 spirits of turpentine,* or the  application of a bag
 of scalded bran, or  chamomile  flowers  as hot  as


  *  To apply this, a piece  of flannel  may be wrung out of  hot
 water, and an ounce or two of the turpentine sprinkled  upon it.
 It causes great pain, of which the patient should be apprised, and
 desired to remove it as soon as the smarting becomes very severe
             22 
254       DUBLIN PRACTICE OF MIDWIFERY.

they can be borne.   Either of these latter are in-
finitely preferable to poultices, from  their lightness
and cleanliness.   The turpentine  has often a pecu-
liarly good eflect, removing  distressing  flatulency,
and  sometimes  producing  evacuations  from  the
bowels.  If constipation exists, a  smart purgative,
as castor oil and spirits of turpentine (half an ounce
of each), or a bolus of jalap and calomel (ten grains
of the former, and five  of the latter), may be ad-
ministered,  and  followed  by an enema.   Should
the bolus be given, and not act quickly,  it  must be
assisted by a purgative mixture (inf. senna-,  Arc.)
If the stomach be irritable, it may be more  advisa-
ble  to  give  the purgative  in the form of pills.*
When the constipation  has  been  relieved, the in-
testinal canal should  not  be further  irritated by-
cathartics.  After bleeding, and freeing the  bowels,
the  next  remedies,  upon which  our dependence
should be placed, are decidedly calomel and opium.
The  former  should be  given in doses  of two or
three grains  every second hour, until  the  system
is influenced, combining one-sixth  or one-fourth of
a grain of opium, should  the bowels  be irritable.
At night, ten grains  of  Dover's powder will often
be found  to  produce sleep,  and do much  service.
When the mouth becomes affected, the prognosis is
almost always favourable,  and we  should  continue
the action by smaller doses of mercury.


  * R Extract. Colocynth. comp. ^ss., Calomclanos, gr. x., Olei
Caryophill. gs. iii. Fi. massa, et divide in pilulas decern, suman*
tur duae 2da q.q. hora ad effectum. 
PUERPERAL FEVER.             255
   I have no great opinion of the use of blisters in
 abdominal  inflammations,  especially  in  the  first
 stages, as they then  very effectually deprive us  of
 one of our  best  guides, by masking the pain  and
 tenderness  upon  pressure.   In the  latter  stages,
 however, they are often of service.
   The regimen, in this species, must,  of course, be
 rigidly antiphlogistic ; and, should  the disease sub-
 side, the strictest  precautions  must be  adopted to
 prevent relapse, to which there is  a considerable
 tendency.
   In the second species, bleeding is always injurious,
 and often hastens a fatal termination.
   The medicines upon which most reliance  can be
 placed in this very intractable malady are mercury
 and opium; and, as a very great source of suffering
 exists  in the patient's  restlessness and want of sleep,
 the latter may be given in considerable doses ;  for
 example, a grain every  three or four hours, in com-
 bination with from two to four grains of calomel,
 until the  patient sleeps, or  an effect is produced
 upon the system by the mercury.  According to the
 observations of Drs. Graves and  Stokes,*  opium
 appears to exercise a  beneficial  influence in several
 low  forms of inflammation,  and there is  a good
 deal of encouragement  for its  free use in this dis-
ease.  If  the bowels are  constipated, or we have
reason  to suppose them to be loaded, a mild aperient
 must be given ; but  it should  be  of a warm and
simply  laxative kind, as the rhubarb draught already
* Vide Dublin Hosp. Reports, vol. v. 
256       DUPLIN PRACTICE OF MIDWIFERY.
mentioned.*   Spirits of turpentine has been recom-
mended by  some  gentlemen, and it will sometimes
be found  of use by  acting as an aperient, and, at
the same time, stimulating and  restoring a healthy
tone  to the mucous membrane.f  We should be ex-
tremely cautious about giving any drastic purgative,
lest it might increase the debility, and accelerate the
approach  of diarrhoea, which is often a verv trou-
blesome  symptom.  When the  latter  sets in, wc
must endeavour to  check it  by enemata of starch
and  laudanum.  The application of turpentine, ex-
ternally, will often be of service : and we may, also,
in the progress of  the  complaint, employ blisters
with more advantage than in  the inflammatory spe-
cies.
   The dietetic and general  management of the pa-
tient is of much importance.  She should, if  possi-
ble,  be placed in an  open airy room ; wine must be
given, diluted with water, or in arrow-root, so as
cautiously to support the strength,  taking care, at
the same  time, not to add to the gastric  derange-
ment.   Cold chicken broth may be allowed  as or-
dinary drink, and  will be often  found to  agree re-
markably well with  the stomach.
   Should a rally be  made, we shall be obliged to
assist the patient's  recovery by light  tonics, and,


  • Vide p. 125.
  t R Sp. Terebinthinrp rect. rvj., Aquae Cinnamomi  rvj.,
Syrupi Zingiberis jj. M. Fiat hauitio. 2da quaque hora su-
mend. 
PUERPERAL FEVER.
257
perhaps, by sulphate of quinine.   At  all times we
must be carefully on the watch for a relapse.
  The third or mixed species of puerperal fever re-
quires  a  modified  and cautious  treatment.   Our
principal reliance must be upon calomel and opium;
but, although general  blood-letting is  seldom safe,
we  shall frequently find much  advantage in the ap-
plication of leeches (two or three dozen) to the hy-
pogastrium, repeating them, according to the degree
of pain and tenderness, and the manner in which
the  loss of blood is borne.
  [In an epidemic which raged at Keil in 1834, 35,
and 36, Michaelis used  ice both externally and in-
ternally, with excellent effect.   The cases in which
he gave it with success were  marked by burning
pain and heat in the bowels, thirst, painful eructa-
tions, and  tenderness at the epigastrium.  The brain
was clear—no delirium.  The  ice was  given by the
mouth, in  bits the size of the finger, every half hour
or oftener, it was also applied over the abdomen in
a large bullock's bladder,  extending  from the epi-
gastrium to the pelvis, in a layer half an inch thick.
This application was  in  some cases continued for
three days, the bladder being changed  as soon as
the  ice melted.   It was very grateful to the patient,
and Michoelis thinks that it cured some cases where
effusion had actually taken place, into the peritoneal
cavity.  The use of ice was not persisted in, unless
it was  grateful to the patient.  The  symptoms of
amendment were a sudden and  very great  fall in
the  frequency of the pulse, a peaceful sleep,  relief
from the painful eructations, and diminished disten-
            22* 
258       DUBLIN PRACTICE OF MIDWIFERY.

sion of the bowels.  A profuse watery diarrlnra,
occurring w ith these favourable changes, seemed to
him to be critical.  The  authority  of  Michulis
would justify the use of ice, and in a case marked
by burning pain and  urgent thirst, if the ice was
grateful to the patient, I should  expect good eth cts
from it.   It ought to be tried at any rate.]
   In the  treatment of all  these species, we  are to
recollect that  the one frequently runs into the other,
and  that -they must always be  managed accord-
ing to the symptoms,,and not upon any preconceived
notion respecting their-type.   To  no malady, in-
deed, is "the excellent advice of  Sydenham more ap-
propiate, " to  find out, 'in  the first place, the genius
of epidemic diseases, which, though they may seem
alike to the unwary, because  in some sort  they do
agree, to outward appearance, yet, if seriously con-
sidered, are very different."
   Emetics, antfmonial  preparations,  and various
other remedies of all  kinds, have, as  might have
been expected  in  so fatal"a disease, been recom-
mended for the treatment of puerperal  fever ; but,
my object being simply to give a plain statement of
what I conceive to be  useful in practice, I think it
would be exceeding my limits to enter into the con-
sideration of speculations  of this  kind, which are
not supported by solid  practical'foundations.
   [Within the last few  years  the attention of the
profession  has been   specially directed by Mar-
shall Hall, and others, to  a form  of puerperal  dis-
ease dependent on intestinal irritation.   This may
readily be  mistaken  by the  unwary for  puerperal 
                PUERPERAL FEVER.              259

fever, its  true  nature and  appropriate  treatment
ought to  be studied  with care.  The  puerperal
state, though not a state of disease, is one of great
susceptibility to the action of morbific  agents, and
hence it often  happens, that  causes of irritation
which the system is able to resist during pregnancy,
will produce the most serious, and even fatal effects,
if their action is allowed to continue during the pu-
erperal state.
  Now, one of  the sources of irritation to which
women  are  most  frequently exposed, is the fcecal
accumulations  which  are so apt  to  occur during
pregnancy.
  Again, susceptibility to  irritation is always aug-
mented  by exhaustion, (within certain  limits) par-
ticularly if it be  from loss of blood.  Now, taking
these premises together, it  is  easy to see that  in-
testinal  accumulations, may excite in the suscepti-
ble system of the parturient female, a vast  amount
of irritation, and  this will be  most apt  to  happen
when the strength is  broken  down,  and the vital
energies exhausted by a tedious labour,  by uterine
hemorrhage, or  by some pre-existing state of dis-
ease  ; to distinguish this irritation  from  inflamma-
tion—this irritative fever  from  puerperal fever, is
exceedingly difficult.  In both  we have  a chill, fol-
lowed by heat of skin, a rapid pulse, pain and ten-
derness in the abdomen, in both the tongue  is white
and loaded, and there is headach.  Not only does this
similarly exist in  the  irritatory symptoms,  but the
effect of one remedy, and that the one most  likely to
be tried, will, very probably, mislead us.  Suppose 
 260       DUBLIN PRACTICE OF MIDWIFERY.

 we are called to a  woman on the  third or  fourth
 day after delivery,  we find that she has bad a chill,
 that the skin is now hot, the  pulse 150 and tolerably
 firm, there is throbbing pain in the head, and  ten-
 derness on pressure over the abdomen, we  diagnos-
 ticate  puerperal fever, and resolve  to bleed, say 2(J
 ounces.   The patient feels  a  little faint  from the
 bleeding, she rallies, and  the symptoms are surpri-
 singly7 ameliorated, the pain  in the head is gone, the
 abdomen is less tender, the skin covered with a free
 perspiration.   The bleeding seems to have produced
 the best effects.  But next day she  will  be  wi>r>e, a
 second bleeding may be judged  necessary  to extin-
 guish  the disease; the symptoms again abate, but in
 a few hours they  return  with redoubled  violence,
 and if another bleeding is tried, a  few  ounces will
 sink the  patient into a collapse  from  which she
 never  rallies.
   Now, I will not say, as  Hall does, that a majority
 of the  fatal cases  of puerperal disease are of this
 character, and fatal because  thus  treated, neither
 will I say that such cases never occur.   / know that
 they do.
   The following diagnostic  marks will  enable the
 attentive observer to avoid confounding these  two
 cases.   The attack of the  irritative  fever is oftener
 sudden, the pain, particularly the throbbing pain, in
 the head, occurs immediately  after the chill,  it is
 often more distressing than the abdominal  tender-
 ness,  the pulse attains its  maximum of  rapidity
sooner, and it is more apt  to vary, as, indeed, do all
the symptoms, from hour to hour.   The  patient ap- 
PUERPERAL FEVER.
261
pearing better and worse, two or three'times during
the day.  If exhaustion is playing a part in the dis-
ease, the cerebral symptoms will be much aggrava-
ted by raising the head from the pillow.
  In irritative fever, from foecal  accumulations, the
tongue is more loaded, the abdomen universally soft,
puffy, and full, the pain is  scarce  ever confined to
one spot, which, in the beginning of puerperal fever,
it almost always  is.  If  these symptoms, or most of
them, attend a case, intestinal irritation  should  be
apprehended.  Puerperal fever  is very generally
insidious  in its approaches; when,  therefore, the
symptoms are developed rapidly, and openly,  their
very violence should  lead us to suspect irritation.
In a  doubtful case, it is very good practice to order
a large enema of  soap  suds, salt and water, or the
like, (not molasses, as  it colours the discharges).
This is a good remedy, and that, whether the  case
be puerperal  fever or mere  irritation; but it is  most
valuable as a diagnostic.  By the nature of the dis-
charges, and the  effect of a free  evacuation  of the
lower bowels upon the symptoms, we judge of the
nature of the disease.   If black foetid scybala are
discharged  with  some relief to the sense of fullness
in the abdomen, we should not think of depletion
till the bowels are thoroughly evacuated.   This may
be best done by castor oil and laudanum, or we may
give  at bed time  Pulv. Doveri grs. x.—Pil Hydrarg-
yri. grs. xx., to be followed in the morning by a large
dose of rhubarb  and magnesia,  or castor oil.  By
these means assisted by repeated enemata the  bow-
els should be thoroughly evacuated.   This done we 
262       DUBLIN PRACTICE OF MIDWIFERY.

resort  to  anodymes, of  which  hyosciamus  and
camphor, one  grain of each, in a pill to  be taken
frequentlv, is one of the best I know.  Host, and  a
nutrieious, but non-stimulating diet, will complete the
cure.   In fact, the great difficulty in  this east, is in
the diagnosis, if no mistake  be made there,  the
practitioner can hardly go wrong in the treatment.] 
263
               CHAPTER XXI.

     ORDINARY FEVERS OF PUERPERAL WOMEN.

  The irritability  of the  nervous system and  of
certain organs, always more or less dependent upon
the puerperal condition,  render women liable  to a
number of febrile affections, besides the formidable
disease treated of in the last chapter.
  One of the most common of these is the Ephe-
mera, or Weed.   This fever sets in generally during
the first three or four days after parturition, with a
severe rigor.  It consists of a cold, hot, and sweat-
ing stage, and may terminate in twenty-four hours,
having but one paroxysm.   The rigor is often very
severe and long  continued.  During  the  hot stage
there is intense headach, intolerance of light, quick
but  otherwise good pulse,  great  thirst, white and
coated  tongue.   Sometimes there  is slight abdomi-
nal tenderness, and the  bowels are generally con-
fined.  The sweating  in the third stage is profuse,
and the sy7mptoms continue very much as  in the
second.  After some hours, the symptoms  begin  to
subside, the patient probably falls asleep, and awakes
eonvalescent.  In other  cases, the duration of the
fever is not so short;  other paroxysms (though not
so violent as the  first.)  succeed, and the disease may
hang  on  for eight or  ten days,  constituting what
may be called Intestinal fever.  Weed may be dis- 
264       DUBLIN PRACTICE OK MIDWIFERY.

tinguished from  puerperal  fever  by a want of the
tenderness so remarkable in the  inflammatory form
of that  disease,  by the regularity of its  stages, its
history, and by the general contrast that will be ob-
served upon a careful examination of all the  symp-
toms.
  The causes of the ephemera,  or intestinal fever,
are to be found  in an irritated state of the intesti-
nal mucous  membrane and  derangement of tin* he-
patic system, usually  occasioned by  irregularities
of diet, exposure to cold, \c   Among  the lower
classes of  people, nothing  is more common than
to find weed excited by drinking porter  or  spirits
shortly  after  delivery; and corresponding irregu-
larities  among  the  rich  are  attended by similar
results.
   From what has been said of the causes, the treat-
ment must be  obvious.  Should it have arisen from
the taking of  improper food, and  our attention  be
directed to this circumstance at an early period, wc
may  hope to cut short the complaint by the admin-
istration of  a mild emetic of  hipp >.*   Afterwards,
or, without  using the  emetic, should we not have
seen the patient in the commencement, we must set
the bowels and hepatic system right by the admin-
istration of a purgative, containing some mercurial:
•three grains of calomel, or live grains of hydrargy-
rum cum creta, with  perhaps a little antimonial pow-
der, may be given, and followed by a senna mixture
or  a rhubarb draught, according to the circum-

          •  Hippo is the Irish for Ipecac.—Ed. 
MILIARY FEVER.
265
stances of the case.  When we see a patient during
the rigor, we must  endeavour to  restore warmth
and bring on the hot stage by giving warm diluents,
and applying heat  to  the  feet.  In  the  sweating
stage, we must ventilate the room and  lighten the
bedclothes, without, however, exposing  the woman
to any risk of cold.  If the  headach  be severe, or
any thing more than a very slight  abdominal ten-
derness exist, it will  be erring  on the safe side to
apply leeches respectively  either to the  head or
belly.  Should the fever not terminate at once, our
further attentions must be directed  to the re-estab-
lishment of a healthy tone in the bowels, by careful
watching of the secretions, and by the enforcement
of a mild  unirritating regimen.   In the  progress of
intestinal fever, the bowels  may become loose, and
the abdomen somewhat tender and tumid, the case,
in fact, very much resembling  the remittent fever
of children.  Change of air, and the continued use
of  mild  alterative  mercurials  (as  the hyd.  cum
creta*) with light bitters (as the infusion of Colom-
bo), when the tongue begins to clean, will be the
remedies most likely to serve.
   It is remarkable  that the milk and  lochia may
continue  to be secreted during  the existence of this
fever.  It is  almost  needless to  say, that  the most
careful attention must be paid  to any symptoms of
local mischief that may show  themselves, either in
the abdomen or head.

  * R  Pil. Rhei comp. ^ss., Hyd. cum Creta 3 j. Fiat massa,
et divide in pilulas x., sum. ij. 2da quaque nocte.
               23 
266       DLPLIN PRACTICE OF MIDWIFERY.

  Miliary Fever.—When the ephemera, or intesti-
nal fever, ha9 been mismanaged, the patient being
kept in a heated, ill-ventilated apartment,  and the
bowels not set to rights,  a  miliary eruption occa-
sionally7 supervenes.
  This eruption consists of a number  of small pa-
pulae, resembling millet  seeds,  upon  the  apex of
which little vesicles form, containing a fluid at  first
straw-coloured,  and subsequently becoming white
or yellow.   In  two or three days these1 scab  and
desquamate,   and other  crops  probably  succeed.
The papulae first appear  upon  the fort head, neck,
and breast—rarely  upon  the face.  Two varieties,
a red and white, are described, of which the former
is said to be the mildest.  Before  the  eruption the
skin becomes rough, and  there  is a sensation in  it
of prickling heat: after it has appeared, there arc
frequently other marks of derangement  of the mu-
cous membrane, as aphthae  in  the mouth,  and  red-
edged tongue.   The patient  is  generally bathed in
a profuse acid perspiration.
  The treatment is that recommended in  intestinal
fever, but,  as there is usually  more debility, bark
and mineral acids will probably be required in the
latter stages.  For further information upon miliary
fever, which is not a peculiarly puerperal disease, re-
ference must be made to systematic works upon the
practice of physic.
  Milk Fever.—When the milk begins to  be secre-
ted copiously, there is  always some degree of febrile
excitement.   Should the milk  be allowed to accu-
mulate, in consequence of the woman  declining to 
MILK FEVER.
267
nurse, or the child  being improperly withheld, this
excitement becomes an actual fever, ushered in by
rigors,  and  followed  by hot and sweating stages,
w ith all the et cetera  described  under  the head  of
ephemera.   In  addition, there is a distended and
very painful state of the breasts.
  A smart purgative will be required to allay the
fever, but  the  natural and obvious remedy is,  of
course, to remove the offending secretion.   For this
purpose, the child should be applied early, or, if that
be  not practicable,  the  breast  must be  diligently
and gently rubbed  with a  soft  hand,  and a little
sweet oil, until the milk runs from it;  or the breast
pump may be  employed  to draw it.   Where the
woman  does not intend to nurse, it is  better to
avoid the latter, as it rather  excites a continuance of
the secretion.
  The danger in this fever is, that it may  terminate
in mammary abscess, a most painful and distressing
complaint.   When we have reason  to dread its su-
pervention, from the severity of  the fever, the most
effectual treatment is to nauseate the  patient with
tartar emetic.  A grain or two of this  medicine
may be given  in  the  purgative  mixture which we
usually have occasion to exhibit  at the commence-
ment, and if that  does  not succeed, it  may be sub-
sequently given in solution, in doses of an eighth or
sixteenth of a grain, every  half  hour,  until nausea
is produced.  When a patient is not about to nurse,
purgatives  must  be occasionally used, until the se-
cretion altogether ceases, and she must be  cautioned
to remain quiet, and avoid putting on stays, or any 
268        DUBLIN PRACTICE OF MIDWIFERY.

other tight dress, that may press  upon the mamma ,
while they are  in an excited condition.   If a mam-
mary  abscess be unavoidable,  we must  promote
suppuration by fomentations, \c"  according to the
plans laid  down by surgical.writers.


  * The best mode of fomontating the breast is by placing upon
it a piece of  flannel wrung out of hot  water,  and over thatn
wooden bowl (somewhat larger than the gland) which has been
heated  in boiling  water; by this plan  a sort of steam balh ii
formed, and all injurious pressure avoided. 
269
               CHAPTER XXII.

               PHLEGMASIA DOLENS.

   This painful affection generally attacks  women
 between the tenth and sixteenth days after delivery,
 seldom earlier, but sometimes at a much later pe-
 riod.   Its subjects are generally persons of broken-
 down constitutions, and  it frequently attacks those
 who have suffered  from hemorrhage  or   manual
 interference with the interior of the uterus,  and, in
 whom, before its invasion, there are manifest signs
 of irritation of that organ.
  The disease  is usually ushered in by distinct fe-
 brile symptoms ; there is a rigor, followed by heat,
 thirst, loaded tongue, full pulse, and headach.   The
 cause of these symptoms is soon  revealed,  by the
 occurrence of  pain  and stiffness in one  of the
 groins, upper part of the  thigh, or labium, or the
 pain may  first be felt in the  knee or calf of  the leg.
 This is  rapidly succeeded  by tumefaction, which
 spreads  from the point first attacked,  and, within
 twenty-four or forty-eight hours, the limb is some-
 times increased  to nearly  twice its  original size.
 There is  then  exquisite pain, aggravated  by the
 slightest  attempt  at motion.  The limb  is tense,
white, and shining, is elastic to the touch, and  pits
very little  upon pressure,  but gives  to the hand
passed over it  a sense of irregularity, as if  it con-
                23* 
270       DUBLIN PRACTICE OF MIDWIFERY.

tained numerous  little depressions  under the tense
integument.  The swelling,  in some instances, goes
on slowlv, not arriving  at its maximum for se\eral
days.  When the whole extremity is swelled,  the
violence of the pain abates, but  it  is still very se-
vere upon the least effort at  motion, and the patient
loses all command over  the limb.   The temperature
is increased, and there is a good  deal of pain upon
pressure, which is  said to be  greater  along  the
course of the  veins, but I  cannot  say that  I have
observed this to be always  the case.  At this time,
there is a good deal of  fever,  with  a  quick, feeble
pulse, white tongue, and pale face.   The  lochia arc
suppressed, or diminished and fetid, and the urine is
muddy.  The patient suffers greatly from want of
sleep.  In six or eight days  (more  or less  in differ-
ent cases), the febrile symptoms begin to abate,  and
the swelling slowly diminishes;  first,  in  the  thigh,
and afterwards, in the  leg  and  foot.   As tumefac-
tion decreases, the veins, absorbents, and lymphatic
glands may sometimes be discovered,  enlarged  and
indurated, and the limb  begins to pit upon pressure,
more than it formerly  did.  The  patient remains
weak and  feeble, with  very little  power over her
leg, which feels  heavy,  stiff, and benumbed.  The
disease is generally, at first, confined to one extrem-
ity  and  labium, but it frequently extends  to the
other.   The  ultimate recovery  is  very  slow,  and
there may be a fatal termination, the  patient being
worn down by the protracted constitutional disturb-
ance, or by extensive  suppurations  and purulent 
PHLEGMASIA  DOLENS.
271
depot's,  which  occasionally  form in  the  affected
limb.
  The pathology of phlegmasia dolens is  still ex-
tremely obscure.  By the older writers it was sup-
posed to be an irregular deposit of the milk  (depot
du lait)  ; by others, an extravasation  of lymph, in
consequence of rupture of  the lymphatics ; and, by
some, a general  inflammatory  state  of  the  same
class of vessels.   None of these hypotheses account
for the  symptoms, nor are they supported by post
mortem  observations.  I  cannot  avoid expressing
the same opinion with respect to Dr.  Davis's idea,
that the disease  is  phlebitis of  the  crural  veins.
Phlegmasia dolens is well known not to be  in gene-
ral a fatal disease, and it is equally notorious,  that
phlebitis in any  part of the body is particularly
mortal.  Besides this objection, I cannot  see  that
the phenomena of the disease are  at all explainable
upon the  idea of its being venous  inflammation.
In the generality of cases of the latter malady, there
js nothing  corresponding to the  peculiar  firm swel-
ling of  phlegmasia dolens, and  an attentive  exami-
nation of Dr. Lee's cases  of  actual  phlebitis  will
show that  they were very distinguishable from the
other disease.  I do not  mean to deny, however,
that inflammation and  suppuration of the veins is
often to be found upon examination  of the  bodies
of those who have died of phlegmasia dolens, but it
appears to me that the evidence already in existence,
docs not prove that this inflammation is the cause
of the  swelled leg, but merely  that it supervenes, in
certain cases, upon that disease.  The  disease ap- 
272       DUBLIN PRACTICE OF MIDWIFERY-
pears to me to  consist  in  an  inflammation of the
cellular tissue,  occasioning an  effusion of coagula-
ting lvmph ;  but  bow the  inflammation  is excited,
or why it produces  those peculiar effects,  has  not
yet been discovered.
   The prognosis, when  the disease is uncomplicated,
is favourable, but recovery is always slow and very-
protracted.
   The treatment in the acute state  must be con-
ducted upon the antiphlogistic  plan.   The nature of
the  fever  and  circumstances of the  patient, how-
ever, generally forbid the use of the lancet, and we
usually find it advisable to  trust to the application
of leeches to the groin  and to those parts where the
pain is chiefly seated.'   Two or three  dozen may be
applied at first, and subsequently a smaller  number
repeated, if necessary.  The bleeding may be encour-
aged by warm  fomentation with decoction of poppy
heads or infusion of chamomile, which latter measure
of itself does great service.  In some rare cases, more
benefit will be derived from  the use of evaporating
lotions.   As the bowels are  frequently constipated,
we shall probably have  occasion to employ an ape-
rient, but it should be of a mild warm kind ;f  and
it is not necessary that its effects should be  very

  • This restriction from bleeding is too absolute.  Dr. Dewees
recommends a free use of the lancet in this disease, bleeding so
as decidedly to affect the pulse, and repeating the operation if the
pulse indicate it.   Blundell says, if the patient is robust, a bleed-
ing to 16 ounces will do  good.—Ed.
  t As the infusion of senna, or the rhubarb draught, already spe-
cified. 
PHLEGMASIA DOLENS.            273
powerful.   As the  patient's  nights  are generally
sleepless, we shall find great  advantage from giving
ten grains of Dover's powder and  two  or three of
calomel at bed-time.   I think it is generally advisa-
ble to give calomel and  antimonial powder,  so as
slightly to  affect  the  mouth, but  I  should by  no
means recommend any attempt at speedy salivation.
A grain of each three times  a day, with the  addi-
tion of two or three grains of  Dover's  powder,
should the bowels not be confined, will  be quite
sufficient.  The regimen  should  be  antiphlogistic,
and strict  rest enjoined.  After  the  inflammation
has subsided, we  must alter  our hand, and endea-
vour judiciously to improve the tone  of the consti-
tution.   A  light nutritious diet may  be allowed,
change of air, or at all  events free ventilation ob-
tained, and the  digestive  organs  improved by the
use of light bitters and mineral acids.*   While we
are acting  in this way, however, we shall frequently
have to attend to  recurring signs  of local inflam-
mation, and should always meet them by the appli-
cation of leeches.   The  limb must be still kept at
perfect rest, in a  horizontal position,  but  when  it
is able to bear slight frictions with the hand, these will
be found  serviceable, as will also sponging with
tepid salt water: at a later  period bandaging and
strapping the  limb with adhesive plaster  may be
used.   We shall often have occasion for all our in-
genuity in contriving  plans of treatment, as the fee-

   * R Inf. Cascarillae, Mist. Camphora, aa. |iij., Soda? Subcarb.
jss., Sp. Ammon. aromat grs. xxx. M. Sum. §j. ter quotidie. 
27 4       DUBLIN PRACTICE OF MIDWIFERY.

ble state of  the  part  may continue  for months or
even years.   When depositions  of pus arc ascer-
tained to  exist in any part of the  extremity, free
incisions  are  required to give exit to the matter,
the more particularly as it is  generally  diffused
through the  cellular  and  other tissues, and seldom
confined by a regular cyst.   These cases of abscess
are attended usually with very low typhoid fever,
and  frequently  require  the  exhibition  of  wine,
opium, camphor, quinine, and ammonia. 
275
              CHAPTER XXIII.

               PUERPERAL MANIA,

  This occurs in two forms, the maniacal and mel-
ancholic, and makes its appearance, generally, with-
in the first few days after labour.  A similar disease
may also happen when the woman has been ex-
hausted by a continuance of the process of nursing
longer than is suitable to her strength.   The disease
is most likely to attack persons of a nervous sus-
ceptible temperament, and whose minds have been
shaken by depressing  passions, or  other causes of
mental  emotion.   " A large  proportion of cases,"
Dr.  Gooch  states, " have occurred in  patients  in
whose families disordered mind  had  already ap-
peared."
  With respect to the cause, nothing  more explicit
can be stated than the opinion of the same  distin-
guished writer, that it exists in the peculiar nervous
excitement which, more  or less, accompanies all the
actions of the generative system.
   [In some cases a fright experienced during gesta-
tion, will seem to have given a shock to the mind,
the effects of which will hang about the patient du-
ring the remainder of gestation,  and after  labour
burst  forth  in  the form of puerperal  mania.  All
such  cases  of  fright during gestation should be
carefully  watched.] 
276      DUBLIN PRACTICE OF MIDWIFERY.

   The attack is sometimes  quite sudden, but more
generally  the  patient may  be observed  for some
time previously to  be irritable and  peevish, [there
is a quick sharpness in the  voice, a wild expression
of the eye, the manner  is abrupt and  agitated, she
sleeps badly, or she may be] melancholy and gloomy,
with  a pulse somewhat  quickened,  and  evident
marks of disorder  of  the digestive organs, as furred
tongue, yellow conjunctiva, and costive bowels.
  [The influence  of disorder of  the  digestive or-
gans, as a prc-disposing cause of  puerperal mania,
is very well illustrated by a  case  of  Dr. (looch's.
" The patient bad  the jaundice at  the  time of her
first confinement, and became  maniacal; she had a
slight degree of  it during her second  confinement,
and suffered from  the same  disease; she was com-
pletely  jaundiced  before  her  third  confinement,
but  it was  removed  by purgatives before  labour,
and she this time escaped her  mental  derange-
ment."*]
  The  derangement  of mind is  very various; in
one case the patient being gloomy and desponding,
while in another she is  so violent  as to require the
employment of coercion, talking and moving about
incessantly, and  scarcely ever sleeping.   In many-
instances, there is  a very strong disposition to com-
mit suicide.
  [The connection of the disease with irritation of
the genital  apparatus  is frequently manifested  by
the character of the  mental disease.  The thoughts

  • Gooch on women, case 1st, p. 108.—Phil. Edition.—Ed. 
PUERPERAL  MANIA.
277
run all the while upon the generative functions, the
conduct is excessively indecent,  and the  language
shockingly obscene.]
  The bodily symptoms  are those already men-
tioned, denoting  derangement of the  chylopoietic
viscera.  The pulse is quickened, but not usually to
any remarkable degree ; and it has been remarked
by Dr. Gooch, that a  very rapid pulse is a particu-
larly unfavourable sign.   The face is most com-
monly pale, and  there does not exist, in  ordinary
cases, any evidence of inflammation or congestion
of the brain.
  [There are three forms of mental  disease from
which it is necessary to distinguish puerperal mania,
1st. phrenitis, 2d.  inflammatory headache, 3rd.  de-
lirium tremens.  From phrenitis we distinguish it
by the absence of those evidences  of  vascular ac-
tivity which abound in that  disease, as full, bound-
ing, hard pulse, hot,  dry skin,  flushed face, throb-
bing pain in the head, giddiness, ringing in the ears,
and  other  manifestations of  cerebral  congestion.
Phrenitis, too, is a very rare disease.  Inflammatory
headach is not very uncommon^but it is rarely at-
tended with delirium, and  never begins  with it.
When the mind is disturbed in these cases it is ob-
viously from the excitement, the pain, and the fever.
Delirium tremens  occurs earlier  than puerperal
mania, often in  a few hours, always  in  a day or
two, while  puerperal mania rarely attacks before
the third day, and often not till the second  week.
Puerperal mania sometimes  occurs suddenly, deli-
rium tremens never.   The profuse sweatings of the
                 24 
278       DUPLIN PRACTICE OF MIDWIFERY.

latter disease are very characteristic, and exceed
any thing we are likely to meet with in puerperal
mania, though there, a free perspiration is not un-
common.   The habits of the patient will, of course,
be a good guide,  if they can be discovered, but in
this case, as in that of doubtful pregnancy,  the prac-
titioner must often look for that which he dares not
say he suspects.   It is very easy in all  these cases
to attach too much importance to moral evidence,
and scarcely possible to attach  too little.]
  The  prognosis is  generally favourable, but  in
some cases,  especially those  in which  there  is a
quick weak  pulse, with  extreme  watchfulness, a
state of exhaustion may be produced that will ulti-
mately  prove fatal.   The probability of complete
mental recovery is also  considerable, and there are
not many chances in favour of a return  of the dis-
ease in future labours.
  [To this favourable prognosis a decided exception
must be made of those cases which depend on here-
ditary taint.  Here the disease will  usually return
with every confinement, and if the patient continue
to bear children the repeated  accessions of puerpe-
ral mania, will, probably, so  thoroughly excite the
hereditary pre-disposition, as   in  the end to induce
confirmed and permanent insanity.]
  The treatment of puerperal mania must  be both
medical and moral.  The former requires very nice
discrimination, in order  to adapt our measures to
the exigencies of  each  particular  case.   General
blood-letting is very seldom admissible, and never
required,  unless there exist manifest tokens of con- 
PUERPERAL MANIA.
279
gestion or inflammation of the parts within the cra-
nium.   Even where these exist to  a certain extent,
it will be better, if  possible, to  meet them by local
than by constitutional depletion, and the  utmost or-
dinarily required is  the application of a few leeches
to the temples.  Attention to the  intestinal  canal
will always be requisite, but the kind and degree of
it must depend upon the  peculiar  circumstances  of
the case.   If there be a loaded tongue, a yellow eye,
and an offensive breath, all indicating the stomach
as the seat of irritation, a mild emetic of hippo will
often be of signal service.   This may  be followed
by a purgative, or, where the  former is not admissi-
ble, the latter may7 be administered at  once, and
should be of such a nature as  will produce evacua-
tions  without exciting much secretion  from the
mucous membrane.*  From the want of sleep suf-
fered by the patient, it is obvious that narcotics are
indicated, and accordingly we shall find our most
valuable remedies  in that class of medicines.   It
will be of course advisable to see  that there is no
great vascular excitement before we use  them, and
it will generally be  necessary  to premise laxatives.


  *  Dr. Gooch recommends for this  purpose the aloetic pill, or
compound decoction of  aloes.  I must here acknowledge  that
gentleman's excellent paper as the source from which the above
brief sketch of puerperal mania was  chiefly drawn.   To  that
essay, as indeed to the whole of his writings, the reader's atten-
tion may be directed, upon his own principle, as to the work  of
" a master mind, which we return to again and again, not merely
for the  knowledge which it contains, but  to observe how that
mind worked." 
 280      DUPLIN PRACTICE OF MIDWIFERY.

 The black drop will be found to be one of the best
 forms in which we  can administer opium.   A  full
 dose  (say twelve drops) may be given,and repented
 in an hour or two if it fail to produce sleep.   Small-
 er doses may be subsequently employed, to keep up
 the calm produced  by the  first.  Should the stom-
 ach bear it, the Dover's powder will also  be found
 very  serviceable, and if it be necessary to vary  the
 medicine, extract of hyoscyamus and camphor may
 be given together,  in a dose of five grains of each.
 In the latter stages  of the complaint, when the vas-
 cular excitement has entirely subsided, it will be  ne-
 cessary to have recourse to light bitters and mineral
 acids, for  the  purpose of improving  the patient's
 general health.
  The  diet ought always  to be sufficiently nutri-
 tious ; of course, it must be of a light and unheal-
 ing kind, and given  with due  regard to the disor-
 dered state  of the  digestive organs.  In some  in-
 stances wine may be  beneficial; its use, of  course,
 to be regulated according  to  the judgment of the
 practitioner. When the disease occurs in individu-
 als weakened by protracted nursing, there is a still
 more  imperative demand upon our discretion, in the
 avoidance  of every  thing  that may  unnecessarily
 lower the strength.
  The moral management  should  be  intrusted  to
persons accustomed to the  care of the insane.   In
the  first  instance, the  patient should  be put under
the  charge of a nurse of this description, by whom
she  should  be  closely watched, and  every  instru-
ment  that might be employed for  the  purpose of 
PUERPERAL MANIA.
281
 suicide, must be carefully put out of reach.   When
 the disease is likely to be  protracted, it  becomes a
 question as to whether it may be advisable to place
 the woman completely in the hands of a physician
 who makes  it his business  to treat  insanity.  On
 this point, of course, no general rules can  be  laid
 down; the taking of such  a step, and the mode of
 taking it, must  altogether depend upon the circum-
 stances of the case.   Dr. Gooch forbids all inter-
 course with the husband ; but I lately heard of a
 case in which this rule was not adhered to,  and yet
 rather good effects attended its violation.
   [Preventive   Treatment.—Whenever,   from  the
 constitution of the patient, from hereditary taint, or
 from any other cause, we have reason to apprehend
 puerperal mania, the greatest possible care should
 be taken to  remove  all exciting  causes.   The  ali-
 mentary canal should be thoroughly cleansed before
 delivery, and its secretions, if vitiated, corrected.
 Every form and variety  of  mental and  moral irri-
 tation should be guarded against, and the first  be-
 ginnings  of restlessness, want of sleep, or mental
 agitation, met with opiates and sedatives.  If there
 is  much debility a  supporting plan will be necessary,
 nothing is  more  likely to  excite puerperal mania
 than exhaustion.   After  delivery great  tact is re-
 quired, to decide  as to when, and under what re-
 strictions, the patient should  see  company.  If she
 is  too much secluded, she is  delivered over defence-
less (if I may say  so) to  the  attacks of her  excited
imagination.  If, on the contrary, she see her friends
too soon, or under improper circumstances, their
             24* 
282       DUBLIN PRACTICE OF MIDWIFERY.

conversation will prove a stimulant, which will com-
pletely overset  her mind.  To avoid both extremes
is not always easy ;  that end is best gained by af-
fording to the patient, at as early a period  as possi-
ble,  such company  as will pleasantly occupy,  but
never excite her  mind.  Quiet  conversation, made
up  of small  and pleasant details,  is the  charm by
which such imaginative beings are often won from
the dominion of fancy, and restored  to that of rea-
son.
   A great deal may  be done  by giving  constant
employment, even carried to fatigue, in the ordinary,
every-day duties of house-keeping, before delivery.
In one case, where I had every  reason, except here-
ditary pre-disposition, to apprehend puerperal mania,
I think the patient's escaping an attack was mainly
owing to her having taken an active part in the  du-
ties of her establishment.]
   Actual Phrenitis  occasionally occurs during  the
puerperal state, and requires a  treatment  of course
essentially different  from that just  laid down.  In-
stead  of the supporting and tranquillizing system
generally  adapted  to  puerperal  mania,  the most
active depletion will be required in phrenitis,  and
will too often fail  of success.   The treat ment of
this formidable disease do s  not come within  my
purpose, and it  is only mentioned, to remind  the
reader of the  necessity of discriminating justly be-
tween it and puerperal mania. 
STILL-BORN CHILDREN.
283
NOTE ON THE MEANS OE RESUSCITATING STILL-BORN
                  CHILDREN.
  In addition to the measures  recommended  for
this purpose at p. 131., viz. tickling the mouth and
fauces, rubbing and gently slapping the chest, and
allowing the funis to bleed, we are advised by most
obstetric authors to employ the warm bath and ar-
tificial  inflation  of  the  lungs.  Recent enquiries,
however, have thrown considerable doubt upon the
propriety  of adopting either of  these measures.
According to Dr. Edward's experiments, the warm
bath must act injuriously, by excluding the  atmos-
pheric air, which he found to play a most important
part in the removal of asphyxia.  Again, the obser-
vations of MM.  Leroy and Majendie  prove " that
brisk inflation of air into the trachea killed rabbits,
foxes, goats, sheep, and other  animals,  even when
the force employed was that of an expiration from
the human lungs," and that " from  the  records kept
in the city  of Paris of the  results of means  em-
ployed  for the  recovery of persons drowned, the
greater prevalence of the practice of insufflation
has been coincident with a decrease of the number
restored to life."*   Mr. Porter, who performed ex-
periments similar to those of Leroy, and  with  like

  • Review of Dr.  Kay's work on Asphyxia in Med. Chir. Rev.
for July, 1831. 
284        DUBLIN PRACTICE OF MIDWIFERY.

results, before he knew of the investigations of that
gentleman, mentioned  to me the fact that insinua-
tion of cold air from a bellows, in the event of the
person's resuscitation,  seldom fails to produce dan-
gerous bronchitis.   From a  consideration of these
circumstances, I would  recommend  heat  to be ap-
plied to a still-born infant,  by holding it before a
fire upon a person's lap: the chest  and abdomen to
be  well rubbed with  warm,  dry flannel; and the
nostrils and  fauces  to be  tickled with  a feather
dipped  in  spirits.   The lungs may be  filled once
or  twice, by the operator applying his lips,  with a
bit of silk or  muslin  intervening (for  the sake of
cleanliness) to those  of the child, and gently breath-
ing into its mouth.   While doing this,  the nostrils
must be held between  the finger and  thumb of one
hand, and the fingers of  the other should be placed
upon the pit of the stomach, so as to prevent the air
from passing into that  organ.  When the chest has
been distended, it  may be  compressed  gently with
the hand, so as again to empty it, and the  inflation
may be repeated once or twice.   It should  not,  I
think, be done much oftener,  and always with the
greatest gentleness.  The trachea pipe, which  cer-
tain  teachers have recommended  to be  carried  by
every accoucheur,  should, in my opinion, never be
resorted to. 
APPENDIX A.
                   Vide p. 109

The  Editor here presents for  the use of  his own
  students, the  Classification of Labours which  he
  adopts in his Lectures.

  Classification  of Labour.—There is an almost
infinite  variety  in the classifications  adopted by
celebrated men.  I note only  the most generally
adopted.
  Hippocrates divided labours into natural  and pre-
ternatural.  This division is adopted by Merriman,
Conquest, Blake, Velpeau  and Dewees.   Baude-
locque makes three classes—natural, manual, and
instrumental, he  is followed by Dubois, Boivin, La
Chapelle, Desormeaux, and by  the French writers
generally.   Denman  makes four  classes—natural,
difficult, preternatural, and anomalous  or complex.
To this classification Hamilton,  Maunsell, and  most
of the British writers adhere.  Blundell adds a fifth
class of flooding labours.  Dr. Davis makes  four
classes—natural, preternatural, complex, and instru-
mental.  Ashwell three—natural,  preternatural, and
complex.  Burns augments the  number to six—nat-
ural, premature,  preternatural, tedious, instrumental,
and complex.
  I adopt the classification of Ashwell, but  I  do
not like  his nomenclature, though  it is the one very 
2S6
APPENDIX.
 generally, indeed almost universally adopted.  The
 term, natural, is used as svnonymus with  regular,
 easy, or, as Merriman  has  hellenised it, Eutochia.
 As opposed to this, the term preternatural is applied
 to footling and other like cases.  Now this  nomen-
 clature is obviously improper.   Is not labour always
 a natural process ?   Is  it not a  natural function of
 the uterus, just as  much  so as menstruation  ?  Yet
 who ever thinks of speaking of preternatural men-
 struation?   Is not a footling  case just as natural,
 just as much the product of nature, as a vertex pre-
 sentation ?  The one is usual, the other unusual, but
 to  neither can  the  term preternatural  be  applied
 without a verbal absurdity.
   But my  objection to the terms  natural and pre-
 ternatural, goes  deeper than to  their mere verbal
 accuracy, 1 think they have a bad  practical tendency.
 If a man is taught to think certain  forms of  labour
 preternatural, he will be unwilling  to leave them  to
 nature, or to allow nature to have  anything  to do
 with them.   These terms tend  to diminish our con-
 fidence in, and our reliance upon, that best of mid-
 wives, Dame  Nature, and anything  that does this,
 that thrusts nature back, and art  forward, that sub-
 stitutes a fussing, meddling,  mischievous "obstetric
 operator," in the place of Benignant Nature, imposes
 upon him any of her duties, or trusts him with the
 performance of any7 of her functions, will  always
 find in mc an earnest, if not a vigorous  opponent.
 But if wc discard the terms natural and preternatural,
 what others  shall we adopt in their place?   The
choice is not difficult; to  make it we have  only  to 
APPENDIX.
287
 enquire what do we actually mean by natural—evi-
 dently we mean regular—very well, then say regu-
 lar ; instead of preternatural say irregular,  to Ash-
 well's term for  the third class I do not object, we
 mean complex, let us therefore say complex.
   I arrange labours then into three classes.
   1. Regular.—Where the head  presents,  and no
 important complicating circumstance occurs.
   2. Irregular.—Where some  part other than the
 head presents, without any complication.
   3. Complex.—Where labour in its progress is at-
 tended by some important circumstance, essentially
 complicating the process.
   Proceeding to sub-division—of  the first  class I
 make two orders.
   Easy.—Where the process is completed with or-
 dinary facility.
   Difficult.—Where the labour  is attended with
 unusual difficulty7, from  some cause not essentially
 complicating it.
   Of the second class I make four orders.
   1. Where the breech, the knees,  or the feet  pre-
 sent.
   2. Presentations of the shoulder, elbow, or hand.
   3. Presentations of the trunk, whether by its an-
terior, its posterior, or one of its lateral surfaces.
  4. 'W'here  two parts present,  as the head  and
hand.
  Of the third  class I make eight orders, according
to the complicating cause.
   1. Labour with convulsions.
  2. Labour with hemorrhage. 
288
APPFVDIX.
3. Labour with presenting placenta.
4. Labour with retained placenta.
5. Labour with prolapsed cord.
6. Labour with plurality of children.
7. Labour with ruptured uterus.
8. Labour with inverted uterus. 
INDEX.
Abortion        -    -    189
Accidental hemorrhage    200
Accoucheur, duties of     118
Affections of mind in la-
    bour   -     -    -    149
After-birth       -    -     73
After-pains      -    -    238
Allantois   -     -    -     77
Amnion    ...     G7
Anomalous labour    -    215
Apoplexy during labour   222
Arm presentation    -    180
Articulations of pelvis      18
Asphyxia of infants  -    132
Auscultation, rules  for
    practising    -    -  88-91
Axis of pelvis    -    -     24
----of uterus              61

Ballottement     -    -     93
Bearing of pelvis     -     23
Bed, guarding of     -    120
Binder    -    -    -    132
Bladder, rupture of   -    232
Bleeding in labour    -    142
Breech presentation   -    176 j
Brim of pelvis   -     -     20
Bruit plaeentaire     -     88

Caesarean operation   -     168
Carunculse myrtiformes     46
Catheter   -    -    -     44
Cavity of pelvis      -     22
-----of uterus      -     48
Cervix uteri     -    -     48
---------, changes in      92
Chorion   -               67
Clitoris     -    -    -     44
Conception      -    -     55
Contents of womb    -     64
Consultation    -     153-156
                25
Convulsions     -    -    215
Cord, umbilical -    -     71
----, tying and division of 131
Corpus luteum  -    -     51
Craniotomy     -    -    164
Cross birth      -    -    174
Crotchet    -    -   ,.-'... 164

Death of child, signs of    155
      , sudden, after labour 221
                           64
                           25
                           13
                          140
                           95
                          144
                          131

                          109
                           94

                          118
Deeidua
Deformities
Description of pelvis  -
Difficult labour,
Diseases of pregnancy
Disproportion  of pelvis
Division of funis
Divisions and definitions
    of labour
Duration of pregnancy
Duties of accoucheur in
    natural labour

Early  rupture of  mem-
    branes
Ecchymosis of labia,  -
Effects of gravidity
Ephemera   -
Ergot  of rye
Examination, external
Expulsion of placenta
Extraction of placenta

Face presentation
---- to pubis
 Fallopian  tubes  -
 False pains
  ----  pelvis
 Fevers, ordinary
 ------, puerperal
 ------, intestinal
138
241
 51
263
146
 92
116
210

137
136
  50
103
  13
263
245
263 
290
INDEX.
Fevers, miliary  -
-------.  milk
Fillet
Fatal heart, sounds of
i'u'ius, positions of
---—,  head of
------------movements of
 ----—.  deviations  from
          standard
-------,  pelvic extremity of
-------, Shoulders of  -
----;—.  development of
—-r-—:, circulation  of -
-----r-,  weight of "
Fontanelles,    .-  .  -
-----:—'■—  presentation
F.lulling presentation
Forceps, reasons for using
 ———, mode  of using
---■---, comparison with
             vectis
Fo<>a naviculars
Fourcheite
Fundus uteri
Funis umbilicalis  "
----, division of
---- presentation
----, shortness of

Generation, external or-
    gans of
Generation, internal or-
    gans of
Glandulac nahothi
Gravid  uterus
Gravidity, effects of  -
Guarding bed

Ileal, measurements of
----. movements of
—~,  deviations from
          standard
----,  transmission of -
----, hand presenting with
----, hydrocephalic -
----, perforation of
Hemorrhage
------------,  accidental
—■----------,  unavoidable
'Jt>ti  Hemorrhage, after birth
266:               of child     207
lfil!-------------, after expulsion
 90               of placenta   211
 2s--------------, internal      — I—
 29; Hour-glass contraction      210
 32: Hymen     -    -    -      16
 32
 31
 33
 69
 70
 71
 30
136
180
155
15.H

n;:i
 46
 46
 4H
 71
131
227
119
 43

 46
 1!)
 til)
 51
120

 30
 32

 32
 35
138
115
164
1*H
200
2')3
242
Incontinence of urine
Induciion of premature
    labour
Inertness of uterus
Inflammation of vagina
Internal lu-nuu rhni^e  -
Intestinal lever  -
Introduction of the catheter  II
Inversion of the uterus   213
171
115
240
21J
2i;:<
Labia
Labour, natural -
------, divisions of
------, signs of -
----1—, stages of -
------, dillicult  -
------, dangerous symp-
          toms in
Labour, induction of pre-
    mature
------, preternatural
      , anomalous
13,
Laceration of perineum
Large pelvis
Licjuor amnii
Lochia
Lowder's lever   -

Management of puerperal
    women
Marks of preseniatioiis
Measurements of pelvis
                head
211
ins
I "9
110
112
140

151

171
171
21")
239
 26
 lis
236
162
 23
175
Mechanism of parturition
Membranes, early rupture
    of     ...
Menstruation
Miliary fever
Milk   ---.
----fever  ...
Miscarriage
 3'»

i:w
 63
266
237
266
189 
IND
                          Page
Mons veneris     -    -     43
Morsus diaboli   -    -     50
Obliquity of the uterus	149
Obstetric position	120
--------operations	158
Omphalo-mesenteric ves-	
sels	72
Opium in difficult labour	143-6
--------hemorrhage	213
--------convulsions	220
	219
	
Organs of generation, ex-	
ternal - - -	13
ternal -	46
Os tincae	49
--------, changes in -	92
Outlet of pelvis -	21
Ovaries	50
Ovum	67
Pains, false	103
Pelvimeters	26
Pelvis, description of -	13
Perforation	164
Perforator, reasons for	
using	156
Perineum	46
--------, support of -	127
--------, lacerations of	239
Phlegmasia dolens	269
Phrenitis -	282
Piles	243
--------,  management of  131
--------,  retention of      208
Placental  soufflet      -     88
Plugging  vagina      -    196
Plurality of children  -    224
ex.                      291
                         Page
Position    ...      35
-------of fcetus      -     28
------, obstetric      -     120
Pregnancy, signs of   -     81
----------, duration of      94
----------, diseases of      95
Presentation   -    35-124-175
------------ef Fontanelle 136
------------of feet and
               breech     126
------------, face    -     137
Presentation, arm and
    shoulder    -     -     180
------------, placenta     203
------------, funis   -     227
Pressure on uterus    -     130
Preternatural labour       174
Prognosis in labour   -     123
Puberty     ...      55
Puerperal state, manage-
    ment of     -    -     233
--------fever   -    -     245
--------mania  -    -     275

Gluantity of menses   -      54
Quickening     -    -      86

Reckoning      -    -      94
Resuscitation of still-born
    children     -    -     283
Retention of placenta      208
--------of urine     -     212
Rigidity of soft parts -     141
Rupture of uterus,    -     229
---------- bladder   -     232
----------blood-vessels   232

Secale cornutum      -     146
Shortness of funis    -     149
Shoulder presentation      180
Show      -    -    -     113
Sigaultian operation       167
Signs of pregnancy   -      81
--------labour       -     110
--------child's death      155
Soft parts, rigidity of -     141
--------, tumours and dis-
    eases of     -     -     144
Sore nipples     -     -     243
Nates, transmission of      40
 ----, presentation of      175
Is'ausea of pregnant women 95
Natural  labour   -    -    108
-------------, varieties of 136
Nipples, sore     -    -    243
Nursing, obstacles to  -    243
Nymphae   ...     44 
292
INDEX.
Sounds of fcrtal heart
Spontaneous evolution  41
Slaves of labour
Still-born children     132
Sudden death
Supporting perineum
Suppression of urine

Turning
Twins     ...

Umbilical cord
Unavoidable hemorrhage
Urachus
Urethra
Urine, incontinence of
------, retention of
------, suppression of
Uterus
Pa.:.' 90 1 si i	Uterus,	gravid	-
		pressure on	
112 J->3 1		inertness of inversion of rupture of	
	1		
221	i		
127	'		
159	Vairina	.	.
		inflammation	of
	»		
IM1	Varieties of natural labou		
224	Vectis	-	.
	Vernix caseosa -		.
71	Vesicul	a nmbilicalis	.
203	Vesicul	a: (iriatiinie	.
11 212	Vitelline pedicle		-
	Waters		
212	Weed	.	
l.V.)	Womb,	, contents of	.
48			
HE END.
^33 8  5^' 
 
vnouvn inoioiw to A070011 tuMBiiom owoiodw «© ""'
MDICINI (NATIONAL MtlAIT OI MIOICINI NATIONAl UIIAtT












;p ]  A^,\# J   *^/f



VNOI1VN INOIOIW 10 1ITMII IVNOIIVN INOIOIW iO AIVI



^ }         *      ""•       '

I* :  rtf
y l  \A s Ay 3  \A* J
MDICINI N ATION Al II II AIT 0» Ml 01 C I Nl NATIONAL UIIAII
Itjk
?  ^Kv.
X>)

VN0I1VN INOIOIW tO 11*1111 IVNOIIVN INOIOIW 10 AIVI
y I
a>f^i'4t>i
01^ • ^Ctfr i  -  v  ^ r «
IIDICINI NATIONAL UIIAlr Of MIDICINI NATIONAl IIIIAIY
\
I  /Vl
VN0I1VN INOIOIW 10 11*1111 IVNOIIVN INOIOIW 4 O AIVI

i  \Ai
y
IIDICINI NATIONAL IIIIAIY 01 MIDICINI NATIONAL UIIAlr


5J  y*£\\(S I  A£\ 
11*1111 IVNOIIVN INOIOIW JO 11*1111 IVNOIIVN INOIOIW JO A!
>r oAt I
<J Hz  i
IIAIY OF MIOICINI NATIONAl IIIIAIY OF MIDICINI  NATIONAL Llll
'AA  •
t-   1
> AIVIII1 IVNOIIVN iNOIOIW JO U«llll IVNOIIVN INOIOiW JO A!
) AIVIII1 IVNOIIVN INOIOIW JO 11*1111 IVNOIIVN INOIOIW JO A
IIAIY OF MIDICINI NATIONAL IIIIAIY OF MIOICINI  NATIONAL llll
IIAIY OF MIDICINI NATIONAl LIIIAIY OF MIOICINI  NATIONAl Llll 

NuTn,Nn.L U8RAnY <* MEDICINE
nlm ommDizt, s